Oral anticoagulation: a critique of recent advances and controversies

• Warfarin is the most commonly used oral anticoagulant for thrombotic disorders.
• Genotype-guided dosing of warfarin may have clinical utility.
• New oral anticoagulants have benefits, as well as drawbacks.
• Methods are needed for stratification between the new and established anticoagulants.

There have recently been significant advances in the field of oral anticoagulation, but these have also led to many controversies. Warfarin is still the commonest drug used for clotting disorders but its use is complicated owing to wide inter-individual variability in dose requirement and its narrow therapeutic index. Warfarin dose requirement can be influenced by both genetic and environmental factors. Two recent randomized controlled trials (RCTs) came to different conclusion regarding the utility of genotype-guided dosing; we critically explore the reasons for the differences. The new generation of oral anticoagulants have been demonstrated to be as efficacious as warfarin, but further work is needed to evaluate their safety in real clinical settings.