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Direct oral anticoagulants (DOACs), also sometimes called ‘NOACs’ (variably for novel, new, or non-vitamin K antagonist oral anticoagulants), represent an increasingly applied form of anticoagulant therapy for an ever-expanding range of indications.1,2 Routine haemostasis (coagulation) assays are variably sensitive to DOACs,3,4 and cannot be reliably used for measuring their concentration. Although routine monitoring of DOACs is not generally required, there are many plausible situations in which knowledge of patient’s anticoagulant status may be clinically useful, including unconscious patients presenting as a trauma and bleeding, or patients presenting for emergency surgery, known or unknown to be on an anticoagulant, as well as patients developing thrombosis while on treatment and women with possible pregnancy whereby the effect of these drugs on the foetus is still unknown.3,4 Accordingly, sensitive and specific methods for assessing DOACs are increasingly employed in clinical practice. DOACs mainly segregate into one of two agent classes, namely anti-thrombin (anti-activated factor II; anti-FIIa, such as dabigatran) and anti-activated factor X (anti-FXa, such as rivaroxaban, apixaban, edoxaban). Like most tests of haemostasis, laboratory-based assays typically utilize citrate anticoagulated plasma to measure DOAC activity.3,4 The most commonly applied tests respectively are laboratory-performed direct thrombin inhibitor and chromogenic anti-FXa assays.3,4 Point-of-care (POC) tests represent an additional strategy for measuring DOACs. Proponents of POC testing cite faster test times at ‘bedside’, potentially useful for emergency or surgical use where despatch to a laboratory and availability of finally issued results may exceed clinical desirability. Sometimes, specific laboratory tests for DOACs may also only be available on restricted days or times or at central sites. There are several current and emerging strategies for DOAC testing, including POC.3–11 However, the research group headed by Harenberg has taken a unique strategy to develop a POC for DOAC testing using urine as the biological material and amethod they have called ‘DOACDipstick’.5 The basis for the test is that some 30 to 80% of DOACs are excreted into the urine, and that sensitive and specific tests for either anti-FIIa or anti-FXa in urine can therefore be developed. With this assay, the dipstick contains amatrix where specific enzymes and substrates directed against DOACs are immobilized to enable detection of both types of agents (anti-FIIa or anti-FXa) on the same dipstick, at the same time, but using separate pads. The dipstick also contains additional pads to control for colour of urine and assess urine creatinine concentration, which respectively help to avoid false positives and identify impaired renal function. It is therefore of interest that the Harenberg group have published the results of a multicentre trial on the methodology in the current issue of the journal.11 This report provides important confirmatory evidence on the reliability of this POC system to specifically identify (or exclude) the presence of current anti-FIIa or anti-FXaDOACs in urine,with different operators and remarkably high negative and positive predictive value. This article represents the last in a series of publications by the authors around this technique,5,11 and importantly identifies a milestone in this journey, initially conceived as an idea in 2013.12,13 Like all journeys related to the field of haemostasis, this will no doubt be one that continues. ‘Stagnation’ reflects a dangerous term in haemostasis. Pathophysiologically, stagnation in blood flowmay lead to thrombosis according to the classical Virchow’s triad. Metaphorically, stagnation in innovation leads to a separate kind of arrest, namely that of progress. The journey of anticoagulation therapy is itself interesting and on-going. DOACs represent the new kid on the antithrombotic block, with four such agents now imbedded in clinical practice, but several others are potentially

The Pointy End of Point-of-Care Testing for Direct Oral Anticoagulants