The direct oral anticoagulants (DOACs) offer distinct advantages over warfarin – among them, dose adjustment is only needed in cases of impaired renal function, advanced age, low body weight, or potential for drug-drug interactions. Incidentally, these factors (ie, older age or chronic kidney disease) can also increase the risk of ischemic stroke and of bleeding. Thus, the safety and efficacy profile of DOACs vs warfarin in the subgroup of patients on a reduced dose of the former could be different from that seen in the general population. This situation has not been previously well described as these patients are mostly under-represented in the landmark large randomized trials that led to the approval of these drugs.

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