The era of warfarin as the principal oral anticoagulant is drawing to a close as a result of the introduction of direct oral anticoagulants. Direct oral anticoagulants are associated with reduced bleeding and similar or better efficacy than warfarin. Furthermore, the lack of need for monitoring results in a strong preference of patients for these medications. The use of the direct oral anticoagulant is supported by both clinical trial data and experience from large population studies. Bleeding is frequently cited as a concern with direct oral anticoagulants despite high-quality evidence that this complication is both more frequent, and more morbid, with warfarin. Although an antidote has been introduced for dabigatran, there is still no widely available reversal agent for the Xa inhibitors. Idarucizumab should be used in patients with major or life-threatening bleeding who are taking dabigatran. Patients with mechanical heart valves or those with potent procoagulant states such as antiphospholipid antibody syndrome, heparin-induced thrombocytopenia, or cancer-associated thrombosis should not be treated with direct oral anticoagulants outside the context of a study.

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Contribution: M.C. is responsible for all components of the material.

Conflict-of-interest disclosure: M.C. serves as the Chair, Data and Safety Monitoring Board, Bayer Pediatric Program and receives research funding from Bayer. M.C. also received research funding from Leo Pharma, honoraria from Pfizer, and consultancy fees from Shinogi.

Correspondence: Mark Crowther, St. Joseph’s Hospital, McMaster University, 50 Charlton Ave E, Room L208, Hamilton, ON L8N 4A6, Canada; e-mail: crowthrm@mcmaster.ca.