The challenges and limitations of widespread direct oral anticoagulant treatment: practical suggestions for their best use

For many decades vitamin K antagonists (VKA), whilst extremely effective but associated with significant drawbacks, were the only drugs available for chronic anticoagulation. However, recently, novel direct oral anticoagulant drugs, completely different to VKA and at least as effective and safe as VKA, have been introduced in clinical practice and their use is becoming increasingly more widespread. Their availability can extend effective anticoagulant treatment to a larger number of subjects requiring anticoagulation and substantially improve the quality of life of many patients. However, these drugs and their use also have limitations. The aim of this article is to analyze these limitations and the challenges potentially associated with their use, a move crucial to promote proper, effective and safe use of the drugs in everyday practice.