Direct oral anticoagulants (DOACs) appropriate dosing after more than 15 years of introduction to clinical practice is baffling to the healthcare provider. The stroke prevention in high-risk patients with atrial fibrillation set ahead by all DOACs to multiple aims: lower risk of intracranial hemorrhage, lesser drug, and food interactions, and more stable blood levels compared to warfarin.1 Due to pharmacokinetic considerations, Multiple factors should be considered for the appropriate use of DOACs in different indications. The labeled dose varies based on indications, age, weight, BMI, and kidney function, Apixaban doses were differ in Randomized clinical Trial for variable indications (Fig. 1).2 For patients who are elderly, renal impaired, and underweight different dosages should be reduced according to ARISTOTLE tial criteria, but not other indications. Those factors make it cumbersome process to daily practice.

Never though, Many RWD studies showed persistent inappropriate doses prescribed in practice range from 10-40 %2 mostly underdoing is more common in this prescribing pattern in DOAC-20-40 % while overdosing is usually 5-15 %. Apixaban is the most reported DAOC to inappropriate dosing, underdoing is the most common and ranges from 19-40 % in different countries and practice models.3,4 Local reports from Saudi Arabia range the practice to around 20-30 % as well.5

Although The long-term effect of inappropriate dosing is DOACs is debatable, one study showed different outcomes ranging from no difference to increased mortality in inappropriate dosing of Apixaban6. EHRA/ESC quality indicators released in 2020 highlighted the appropriateness of dosing in the clinical setting of stroke prevention in AF as a primary quality indicator, AF 2023 guidelines endorder bu ACC had new recommendations specific for inaapropraite dosing in Atrial fibrillation pobulation considering is as harmful practice.1,7, 8, 9, 10

The pharmacist's role in improving the DOAC dosing in different care settings is evolving,8 but up till now a limited number of studies were able to evaluate the pharmacist's role in the management of the Apixaban in patients with non-valvular atrial fibrillation (NVAF) in Saudi Arabia.1,4, 5, 6, 7, 8,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29

Our study aims to evaluate the impact of adding a rounding clinical pharmacist to the Cardiology teams (Multidisciplinary approach). This approach provides clinical pharmacy consultations on prescription appropriateness and clinical outcomes 1year after.