Direct oral anticoagulants in patients with venous thromboembolism: current challenges in everyday practice

Direct oral anticoagulants (DOACs) have transformed venous thromboembolism (VTE) treatment by offering predictable pharmacokinetics and eliminating routine monitoring requirements. Despite robust clinical trial evidence supporting their efficacy, real‑world implementation continues to present challenges in special populations. This review synthesizes recent evidence on DOAC usage in VTE patients, with emphasis on current challenges encountered in everyday clinical practice, including special populations, treatment adherence, bleeding management, and emerging dosing strategies. A literature search was conducted across PubMed, MEDLINE, and Cochrane databases for peer‑reviewed articles published in the last 5 years using the following search terms: "direct oral anticoagulants," "DOACs," "venous thromboembolism," "VTE," "deep vein thrombosis," and "pulmonary embolism." Inclusion criteria prioritized randomized controlled trials, meta‑analyses, systematic reviews, and observational studies. Current evidence demonstrates DOACs as first‑line therapy for most VTE patients, with clinical challenges remaining in patients with obesity, severe renal impairment, cancer‑associated thrombosis, and unusual site thrombosis. Network meta‑analyses reveal comparable efficacy among DOACs, with apixaban demonstrating favorable bleeding profiles. Adherence significantly impacts outcomes, with consistently high adherence reducing recurrent VTE risk. Reversal agents have improved management of DOAC‑associated bleeding. DOACs represent the standard of care for VTE treatment, with increasing real‑world evidence supporting their safety and efficacy. Clinicians must navigate persistent challenges in special populations through individualized risk‑benefit assessment. Encouraging physicians to focus both on patient education to optimize adherence and on provider awareness of emerging evidence on dose modifications and reversal strategies is imperative to proper and effective implementation of DOACs in these groups.