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Direct oral anticoagulants versus warfarin: is new always better than the old?

Lookup NU author(s): Professor Sir John BurnORCiD



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


About 1.4 British million people are at risk of strokes due to non-valvular atrial fibrillation (AF) necessitating long-term anticoagulation. The vitamin K antagonist, warfarin, has a long half-life and narrow therapeutic range necessitating regular monitoring and is a common cause of iatrogenic hospital admission. Direct-acting oral anticoagulants (DOACs), dabigatran, rivaroxaban, apixaban and edoxaban are not required to have monitoring but are sensitive to changes in renal function and are associated with poorer adherence. There are good grounds to believe that DOACs are not always superior to warfarin in routine practice particularly with an older population. Much higher levels of therapeutic effectiveness can be achieved using a simple genotype guidance to identify those who are highly sensitive and by adoption of home monitoring. These adjustments could make warfarin the preferred drug for most people and would reduce the dramatic rise in health service expenditure.This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

Publication metadata

Author(s): Burn J, Pirmohamed M

Publication type: Article

Publication status: Published

Journal: Open Heart

Year: 2018

Volume: 5

Online publication date: 01/03/2018

Acceptance date: 29/12/2017

Date deposited: 07/03/2018

ISSN (electronic): 2053-3624

Publisher: BMJ


DOI: 10.1136/openhrt-2017-000712


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