| Labile INR, inability to check INR regularly | Dabigatran Rivaroxaban Apixaban Edoxaban |
| History or high risk of Intracranial hemorrhage | Dabigatran Rivaroxaban Apixaban Edoxaban |
| Stroke or systemic embolism while on Vitamin K antagonists | Dabigatran 150 mg BID Apixaban |
| Renal Function impairement eGFR < 15 ML/min/1.73m2 eGFR 15 - 30 ML/min/1.73m2 eGFR 30 - 50 ML/min/1.73m2 | Vitamin K antagonists Rivaroxaban 15 mg OD Apixaban 2.5 mg BID Edoxaban 30 mg OD Dabigatran 110 mg BID* Rivaroxaban 15 mg OD Apixaban Edoxaban 30 mg OD |
| History or high risk of bleeding | Dabigatran 110 mg BID Apixaban Edoxaban 30 mg OD |
| HAS-BLED score ≥ 3 | Dabigatran 110 mg BID Apixaban Edoxaban 30 mg OD |
| Elderly > 80 years | Dabigatran 110 mg BID Rivaroxaban Apixaban |
| Nasogastric tube due to dysphagia | Rivaroxaban |
| Need for a reversal agent | Dabigatran |