📊 BOB ICB DOAC Clinical Logic Flowcharts v11.91

Visual reference for NHS Buckinghamshire, Oxfordshire and Berkshire West ICB decision pathways in DRA (Updated to March 2026 Guidance)

🧪 Test Suite (181 Cases) 🔬 Interactive Playground 📊 Visual Flowcharts ← Back to DRA App

1. High-Level Patient Evaluation Pipeline & CrCl Gate Cockcroft-Gault & Safety Gate

Every patient row imported from the strict 27-column EMIS CSV (A–AA) is evaluated sequentially. If baseline renal monitoring (SCr or Weight) is missing, Cockcroft-Gault CrCl evaluates to null, triggering an immediate Early Return that suppresses false dose recommendations.

Clinical Safety Rule (Gate 1): When crcl === null, the engine terminates evaluation before reaching any drug or VTE branch. It raises Missing SCr & Weight, sets status to Tech Recall, and suppresses recommended dose to —.

flowchart TD
    classDef gate fill:#7c3aed,stroke:#a78bfa,stroke-width:2px,color:#fff;
    classDef action fill:#1e293b,stroke:#475569,stroke-width:1px,color:#e2e8f0;
    classDef decision fill:#0f172a,stroke:#38bdf8,stroke-width:2px,color:#fff;
    classDef tech fill:#581c87,stroke:#c084fc,stroke-width:1px,color:#f3e8ff;
    classDef review fill:#7f1d1d,stroke:#f87171,stroke-width:1px,color:#fee2e2;
    classDef ok fill:#14532d,stroke:#4ade80,stroke-width:1px,color:#dcfce7;
    classDef specialist fill:#4c1d95,stroke:#c084fc,stroke-width:2px,color:#f3e8ff;

    START(["Patient Record (27-Col EMIS CSV A–AA)"]) --> PARSE["Parse Demographics, Drug, Dose, Indication, Labs, Reviews, A&G (Col Y), Codes"]
    
    PARSE --> CG["Calculate Cockcroft-Gault CrCl:
((140 - Age) * Weight) / (72 * (SCr / 88.4)) * (0.85 if Female)"]

    CG --> GATE1{"Is CrCl == null?
(Weight or SCr Missing?)"}:::gate

    GATE1 -- "YES (Missing Data)" --> EARLY_RETURN["EARLY RETURN (Line 139)
- Flag: Missing SCr & Weight
- Recommended Dose: '—'
- Status: Tech Recall"]:::tech
    
    EARLY_RETURN --> OUTER_CHECKS["Outer Safety Checks
(Bloods Due, Hepatic, FBC, Interactions)"]

    GATE1 -- "NO (CrCl Calculated)" --> WT_CHECK{"Weight Evaluation
(BOB 2026 Categories)"}:::decision

    WT_CHECK -- "Wt < 40 kg or > 150 kg" --> FLAG_WT_SEVERE["Flag: DOAC not recommended
(Warfarin or spec. advice)"]:::review
    FLAG_WT_SEVERE --> WT_ASSESSED{"Reviewed within 12m?"}:::decision

    WT_CHECK -- "Wt > 120 kg" --> FLAG_WT120["Flag: CrCl may be overestimated
(actual wt used)"]:::action
    FLAG_WT120 --> DOAC_WT_GATE{"DOAC Check:
Edoxaban / Dabigatran?"}:::decision
    DOAC_WT_GATE -- "Yes" --> FLAG_EDOX_DAB_WT["Flag: Weight >120kg — avoid
Edoxaban/Dabigatran per BOB guidance"]:::review
    DOAC_WT_GATE -- "No (Apix/Rivar)" --> WT_ASSESSED
    FLAG_EDOX_DAB_WT --> WT_ASSESSED

    WT_CHECK -- "Wt 40–49 kg" --> DAB_50_CHECK{"Prescribed DOAC:
Dabigatran?"}:::decision
    DAB_50_CHECK -- "Yes (Dabigatran)" --> FLAG_DAB_50["Flag: Weight <50kg — consider 110mg BD
if high bleed risk per BOB guidance"]:::review
    FLAG_DAB_50 --> WT_ASSESSED
    DAB_50_CHECK -- "No (Apix/Rivar/Edox)" --> DRUG_ROUTER{"Select Prescribed DOAC"}:::decision

    WT_CHECK -- "Standard (50–120 kg)" --> DRUG_ROUTER

    WT_ASSESSED -- "Yes" --> FLAG_WT_MUTED["Flag: Weight review verified (Muted)"]:::action
    WT_ASSESSED -- "No" --> FLAG_WT_REV["Flag: Weight alert active (Status -> CP Review)"]:::review
    FLAG_WT_MUTED --> DRUG_ROUTER
    FLAG_WT_REV --> DRUG_ROUTER

    DRUG_ROUTER -- "Apixaban" --> APIX["Apixaban Sub-Engine"]:::action
    DRUG_ROUTER -- "Rivaroxaban" --> RIV["Rivaroxaban Sub-Engine"]:::action
    DRUG_ROUTER -- "Edoxaban" --> EDOX["Edoxaban Sub-Engine"]:::action
    DRUG_ROUTER -- "Dabigatran" --> DAB["Dabigatran Sub-Engine"]:::action

    APIX --> OUTER_CHECKS
    RIV --> OUTER_CHECKS
    EDOX --> OUTER_CHECKS
    DAB --> OUTER_CHECKS

    OUTER_CHECKS --> AG_GATE{"Advice & Guidance Gate:
A&G Date (Col Y) ==
Anticoag Rev Date (Col T)?"}:::decision
    AG_GATE -- "Yes (Same Date Match)" --> SPEC_ROUTE["Route to Awaiting Specialist
(CP Review Suppressed into Specialist)
Tech Recall maintained if due"]:::specialist
    AG_GATE -- "No / Unmatched" --> BADGE_SYNTHESIS["Synthesise Final Status Badges & Flags
(Tech Recall · Awaiting Specialist · CP Review · GP Review · Dose OK)"]:::gate
    SPEC_ROUTE --> BADGE_SYNTHESIS

2. Apixaban Clinical Decision Tree AF (3 Criteria) & VTE Duration Logic

In AF, Apixaban dosing uses the BNF/SmPC 3-criteria rule (Age ≥80, Weight ≤60kg, SCr ≥133 µmol/L; ≥2 met = 2.5mg BD). In VTE, full dose (5mg BD) is evaluated against diagnosis date (≤6 months = acute phase; >6 months = review step-down/stopping).

flowchart TD
    classDef decision fill:#0f172a,stroke:#38bdf8,stroke-width:2px,color:#fff;
    classDef review fill:#7f1d1d,stroke:#f87171,stroke-width:1px,color:#fee2e2;
    classDef ok fill:#14532d,stroke:#4ade80,stroke-width:1px,color:#dcfce7;
    classDef contra fill:#991b1b,stroke:#ef4444,stroke-width:2px,color:#fff;

    APIX_START(["Apixaban Evaluation"]) --> IND_CHECK{"Indication"}:::decision

    IND_CHECK -- "AF" --> AF_CRCL{"CrCl (ml/min)"}:::decision
    
    AF_CRCL -- "CrCl < 15" --> APIX_AF_ESRD["Rec: Avoid (Spec. Advice)
Flag: CrCl <15 — avoid
Status: CP Review"]:::contra
    
    AF_CRCL -- "CrCl 15–29" --> APIX_AF_RENAL["Rec: 2.5mg BD
Reduction Flag: CrCl 15–29 -> 2.5mg BD"]:::action
    APIX_AF_RENAL --> APIX_AF_RENAL_DOSE{"Prescribed Dose?"}:::decision
    APIX_AF_RENAL_DOSE -- "== 2.5mg" --> APIX_AF_RENAL_OK["Status: Dose OK
Chip: Green .chip.assessed"]:::ok
    APIX_AF_RENAL_DOSE -- "!= 2.5mg" --> APIX_AF_RENAL_WRONG["Flag: Wrong Dose / Above max dose (pulsing purple)
Reduction Flag: Pink .chip.flag
Status: CP Review"]:::review

    AF_CRCL -- "CrCl >= 30" --> APIX_SCORE["Score 3 Reduction Criteria:
1. Age >= 80
2. Weight <= 60 kg
3. SCr >= 133 µmol/L"]:::decision
    
    APIX_SCORE -- "Score >= 2" --> APIX_REC_25["Rec: 2.5mg BD
Reduction Flag: >=2 reduction criteria met"]:::action
    APIX_REC_25 --> APIX_25_DOSE{"Prescribed Dose?"}:::decision
    APIX_25_DOSE -- "== 2.5mg" --> APIX_25_OK["Status: Dose OK
Chip: Green .chip.assessed"]:::ok
    APIX_25_DOSE -- "!= 2.5mg" --> APIX_25_MISMATCH["Flag: Wrong Dose / Above max dose (pulsing purple)
Reduction Flag: Pink .chip.flag
Status: CP Review"]:::review

    APIX_SCORE -- "Score < 2" --> APIX_REC_5["Rec: 5mg BD (Standard AF)"]:::action
    APIX_REC_5 --> APIX_5_DOSE{"Prescribed Dose?"}:::decision
    APIX_5_DOSE -- "== 5mg" --> APIX_5_OK["Status: Dose OK"]:::ok
    APIX_5_DOSE -- "< 5mg" --> APIX_5_UNDER["Flag: Below 5mg BD
Status: CP Review"]:::review
    APIX_5_DOSE -- "> 5mg" --> APIX_5_OVER["Flag: Above max dose
Status: CP Review"]:::review

    IND_CHECK -- "VTE" --> VTE_DOSE{"Prescribed Dose?"}:::decision

    VTE_DOSE -- "2.5mg BD" --> VTE_25_EXT{"Extended Phase Assessed
within 12m?"}:::decision
    VTE_25_EXT -- "Yes" --> VTE_25_OK["Rec: 2.5mg BD (Extended prevention)
Flag: Extended phase reviewed
Status: Dose OK"]:::ok
    VTE_25_EXT -- "No" --> VTE_25_UNCONF["Rec: 2.5mg BD (Extended prevention)
Flag: Extended phase — confirm phase & duration
Status: CP Review"]:::review

    VTE_DOSE -- "5mg BD" --> VTE_5_DATE{"Diagnosis Date Available?"}:::decision
    VTE_5_DATE -- "No Date" --> VTE_5_NODATE["Rec: 5mg BD (Confirm duration)
Flag: VTE full dose — confirm planned duration
Status: CP Review"]:::review
    VTE_5_DATE -- "Date Present" --> VTE_5_AGE{"Months Since Diagnosis?"}:::decision
    VTE_5_AGE -- "> 6 Months" --> VTE_5_OVER6M["Rec: 5mg BD (Review duration/step-down)
Flag: VTE full dose >6m — review step-down/stopping
Status: CP Review"]:::review
    VTE_5_AGE -- "<= 6 Months" --> VTE_5_ACUTE["Rec: 5mg BD (Acute phase)
Flag: VTE acute phase (Diagnosed Date)
Status: Dose OK"]:::ok

    VTE_DOSE -- "10mg BD" --> VTE_10_CHECK["Rec: 10mg BD (Initial 7 days only)
Flag: 10mg BD — verify within initial 7 days
Status: CP Review"]:::review

    VTE_25_OK & VTE_25_UNCONF & VTE_5_NODATE & VTE_5_OVER6M & VTE_5_ACUTE & VTE_10_CHECK --> VTE_CRCL_OVERRIDE{"CrCl < 15 ml/min?"}:::decision
    VTE_CRCL_OVERRIDE -- "Yes" --> VTE_CRCL_ESRD["Rec: Avoid (Spec. Advice)
Flag: CrCl <15 — avoid
Status: CP Review"]:::contra
    VTE_CRCL_OVERRIDE -- "No" --> APIX_OUT(["To Outer Monitoring Layer"])

3. Rivaroxaban, Edoxaban & Dabigatran Pathways

Renal thresholds and duration logic for the other three DOACs. Note the specific Edoxaban AF restriction (CrCl ≥95 ml/min is not recommended due to reduced efficacy) and Dabigatran Age ≥80 automatic reduction.

flowchart TD
    classDef decision fill:#0f172a,stroke:#38bdf8,stroke-width:2px,color:#fff;
    classDef review fill:#7f1d1d,stroke:#f87171,stroke-width:1px,color:#fee2e2;
    classDef ok fill:#14532d,stroke:#4ade80,stroke-width:1px,color:#dcfce7;
    classDef contra fill:#991b1b,stroke:#ef4444,stroke-width:2px,color:#fff;
    classDef warn fill:#78350f,stroke:#fb923c,stroke-width:1px,color:#ffedd5;

    subgraph RIVAROXABAN ["RIVAROXABAN"]
        RIV_IND{"Indication"}:::decision
        RIV_IND -- "AF" --> RIV_AF_CRCL{"CrCl (ml/min)"}:::decision
        RIV_AF_CRCL -- "< 15" --> RIV_AF_C15["Rec: Avoid (Contraindicated)"]:::contra
        RIV_AF_CRCL -- "15–49" --> RIV_AF_C50["Rec: 15mg OD (Renal reduction)
Dose == 15 -> Dose OK (Green assessed chip)
Dose != 15 -> CP Review (Pink flag + Above max dose)"]:::warn
        RIV_AF_CRCL -- ">= 50" --> RIV_AF_STD["Rec: 20mg OD (Standard AF)
Dose != 20 -> CP Review"]:::ok

        RIV_IND -- "VTE" --> RIV_VTE_DOSE{"Dose"}:::decision
        RIV_VTE_DOSE -- "10mg OD" --> RIV_VTE_10["10mg OD (Extended prevention)"]:::action
        RIV_VTE_DOSE -- "20mg OD" --> RIV_VTE_20["20mg OD Full Dose
Check >6m duration / confirm duration"]:::action
        RIV_VTE_DOSE -- "15mg OD" --> RIV_VTE_15{"CrCl 15–49?"}:::decision
        RIV_VTE_15 -- "Yes" --> RIV_VTE_15_RENAL["15mg OD (Renal reduction confirmed)
Green assessed chip (.chip.assessed)"]:::action
        RIV_VTE_15 -- "No" --> RIV_VTE_15_ACUTE["15mg BD (Initial 21 days) or 20mg OD
Flag: Confirm acute-phase/renal"]:::warn
    end

    subgraph EDOXABAN ["EDOXABAN"]
        EDOX_CRCL{"CrCl & Weight"}:::decision
        EDOX_CRCL -- "AF & CrCl >= 95" --> EDOX_HIGH["Flag: CrCl >=95 not recommended
Status: CP Review"]:::warn
        EDOX_CRCL -- "CrCl < 15" --> EDOX_C15["Rec: Avoid (Contraindicated)"]:::contra
        EDOX_CRCL -- "CrCl 15–50 OR Wt <= 60kg" --> EDOX_30["Rec: 30mg OD (Reduction criteria met)
Dose == 30 -> Dose OK (Green assessed chip)
Dose != 30 -> CP Review (Pink flag + Above max dose)"]:::warn
        EDOX_CRCL -- "CrCl > 50 & Wt > 60kg" --> EDOX_60["Rec: 60mg OD (Standard)
Dose != 60 -> CP Review"]:::ok
    end

    subgraph DABIGATRAN ["DABIGATRAN"]
        DAB_IND{"Indication"}:::decision
        DAB_IND -- "AF" --> DAB_AF_CRCL{"CrCl & Age"}:::decision
        DAB_AF_CRCL -- "CrCl < 30" --> DAB_AF_C30["Rec: Avoid (Contraindicated)"]:::contra
        DAB_AF_CRCL -- "Age >= 80 OR CrCl 30–49" --> DAB_AF_110["Rec: 110mg BD (Age/Renal reduction)
Dose == 110 -> Dose OK (Green assessed chip)
Dose != 110 -> CP Review (Pink flag + Above max dose)"]:::warn
        DAB_AF_CRCL -- "Age < 80 & CrCl >= 50" --> DAB_AF_150["Rec: 150mg BD (Standard AF)"]:::ok
        DAB_IND -- "VTE" --> DAB_VTE_CRCL{"CrCl Check"}:::decision
        DAB_VTE_CRCL -- "CrCl < 30" --> DAB_VTE_C30["Rec: Avoid (Contraindicated)
CP Review (CrCl <30 — avoid)"]:::contra
        DAB_VTE_CRCL -- "CrCl >= 30" --> DAB_VTE_CRIT{"Age >= 80 OR CrCl < 50?"}:::decision
        DAB_VTE_CRIT -- "Yes" --> DAB_VTE_110["Rec: 110mg BD (Reduction criteria met)
Dose == 110 -> Dose OK (Green assessed chip)
Dose != 110 -> CP Review (Pink flag)"]:::warn
        DAB_VTE_CRIT -- "No" --> DAB_VTE_150["Rec: 150mg BD (Standard VTE after parenteral)"]:::ok
    end

4. Outer Monitoring, Frailty, Intervals & Escalation Layer

Evaluates blood monitoring intervals, frailty capping (max 4 months if eFI >0.12 or Age ≥75), abnormal biochemistry (ALT >2× ULN, Bilirubin >1.5× ULN, Anaemia, Thrombocytopenia), and EMIS GP communication coding.

flowchart TD
    classDef gate fill:#7c3aed,stroke:#a78bfa,stroke-width:2px,color:#fff;
    classDef tech fill:#581c87,stroke:#c084fc,stroke-width:1px,color:#f3e8ff;
    classDef review fill:#7f1d1d,stroke:#f87171,stroke-width:1px,color:#fee2e2;
    classDef ok fill:#14532d,stroke:#4ade80,stroke-width:1px,color:#dcfce7;
    classDef caution fill:#78350f,stroke:#fb923c,stroke-width:1px,color:#ffedd5;
    classDef specialist fill:#4c1d95,stroke:#c084fc,stroke-width:2px,color:#f3e8ff;

    CHECK_START(["Outer Safety Checks Pipeline"]) --> FRAIL_CHECK{"Frailty Assessment
(eFI score or text)"}

    FRAIL_CHECK -- "Frail (eFI > 0.12)" --> FRAIL_INTV["4-month Monitoring Cap
(No visible flag or GP note)"]:::caution
    FRAIL_CHECK -- "Fit (eFI <= 0.12) / None" --> CRCL_INTV{"CrCl Level"}

    CRCL_INTV -- "CrCl < 60 ml/min" --> CALC_INTV["Interval: CrCl / 10 months
(1 to 6 months)"]
    CRCL_INTV -- "CrCl >= 60 ml/min" --> STD_INTV["Interval: 12 months standard"]

    CALC_INTV & STD_INTV --> AGE_CAP{"Age >= 75?"}
    AGE_CAP -- "Yes" --> CAP_4M["Cap interval at 4 months max"]:::caution
    AGE_CAP -- "No" --> FINAL_INTV["Set Monitoring Interval"]
    CAP_4M --> FINAL_INTV
    FRAIL_INTV --> FINAL_INTV

    FINAL_INTV --> BLOOD_EVAL["Evaluate Blood Statuses vs Interval:
- U&E (Serum Creatinine)
- LFT (ALT & Bilirubin)
- FBC (Haemoglobin & Platelets)"]

    BLOOD_EVAL --> BLOOD_GATE{"Any Bloods Due OR
Weight == null OR
CrCl == null?"}:::gate

    BLOOD_GATE -- "Yes" --> ADD_TECH["Add Status: Tech Recall
Flag: 'Incomplete monitoring — dose unverified'"]:::tech
    BLOOD_GATE -- "No" --> LAB_VALUES["Check Specific Lab Values"]
    ADD_TECH --> LAB_VALUES

    LAB_VALUES --> ALT_CHECK{"ALT > 2x ULN (>90) OR
Bili > 1.5x ULN (>31.5)?"}
    ALT_CHECK -- "Yes" --> HEPATIC_FLAG["Flag: Hepatic Impairment Alert
Status elevated to GP Review"]:::caution
    ALT_CHECK -- "No" --> FBC_CHECK{"Anaemia (Hb <130 M, <120 F) OR
Platelets < 100?"}

    FBC_CHECK -- "Yes" --> FBC_FLAG["Flag: Anaemia / Thrombocytopenia
Status elevated to GP Review"]:::caution
    FBC_CHECK -- "No" --> INTERACT_CHECK{"Interacting Drug (Col R)?"}

    INTERACT_CHECK -- "Yes" --> INT_REV{"Reviewed within 12m &
Prescribed on/before Review Date?"}
    INT_REV -- "Yes" --> INT_MUTED["Flag: Interaction reviewed (Assessed)"]:::ok
    INT_REV -- "No (New / Added Post-Review)" --> INT_ACTIVE["Flag: Interact: [Drug Name] (post-review)
Status elevated to CP Review"]:::review

    INTERACT_CHECK -- "No" --> GP_ESCALATION{"GP Contact Coded in EMIS
within last 3 months?"}
    INT_MUTED & INT_ACTIVE & HEPATIC_FLAG & FBC_FLAG --> GP_ESCALATION

    GP_ESCALATION -- "Yes (Recent GP Contact)" --> MUTE_GP["Flag: GP Contacted re: Bloods
Review elevated to GP Caution"]:::ok
    GP_ESCALATION -- "No" --> AG_CHECK{"Advice & Guidance (Col Y)
matches Anticoag Rev Date (Col T)?"}:::decision
    MUTE_GP --> AG_CHECK

    AG_CHECK -- "Yes (Same Day Match)" --> AG_SPEC["Triaged to Awaiting Specialist
• CP Review suppressed
• Flag: Awaiting Specialist (Xd ago)
• Tech Recall active if due"]:::specialist
    AG_CHECK -- "No / Differing Dates" --> COMPOSE_BADGES["Final Output Badges:
• Tech Recall (Purple)
• Awaiting Specialist (Purple / Lavender)
• CP Review (Red)
• GP Review (Amber)
• Dose OK (Green)"]
    AG_SPEC --> COMPOSE_BADGES

5. Quick Reference Decision Matrix

Verified Dose Reduction Indicator (v11.90): When DOAC reduction criteria are met and the patient's currently prescribed DOAC strength matches the recommended reduced dose (e.g. Apixaban 2.5mg BD, Rivaroxaban 15mg OD, Edoxaban 30mg OD, Dabigatran 110mg BD), the reduction flag is classified as a Green assessed chip (.chip.assessed). This immediately reassures pharmacy technicians in the Ready to Complete tab that the patient has already undergone appropriate clinical dose titration in line with national and BOB ICB guidelines. If the prescribed dose exceeds the recommendation (e.g. patient remains on 5mg BD despite reduction criteria), the reduction flag remains Pink (.chip.flag) and is paired with a pulsing purple Above max dose alert in CP Review.

Condition / Check	Trigger Logic	Engine Action	Status Badge & Chip Indicator
Missing SCr or Weight	`crcl === null`	Immediate early return. Recommended dose suppressed (`—`). Downstream logic bypassed.	Tech Recall .chip.tech
Weight Extremes	`wt < 50kg` or `wt > 120kg`	Flags extreme weight; prompts CP review unless reviewed within past 12 months.	CP Review (or Assessed if reviewed)
Drug Interactions	Interacting drug in Col R	Flags for CP review. Assessed if reviewed within 12m and added on/before review date. Flags if added post-review.	CP Review (or Assessed if reviewed)
Advice & Guidance / Specialist	`adviceGuidanceDate === doacReviewDate` (Col Y == Col T)	Triages patient into dedicated “Awaiting Specialist” tab and status. CP Review is suppressed into Awaiting Specialist. Tech Recall remains active if bloods or weight are due.	Awaiting Specialist .chip.specialist
Apixaban AF (≥2 Criteria or Renal)	Age ≥80, Wt ≤60kg, SCr ≥133 (or CrCl 15–29)	Mandates 2.5mg BD. • Prescribed 2.5mg BD: Verified reduction confirmed. • Prescribed 5mg BD: Unreduced regimen flagged.	• On 2.5mg BD: Dose OK + ≥2 reduction criteria met / CrCl 15–29 -> 2.5mg BD • On 5mg BD: CP Review + Reduction flag + Above max dose
Rivaroxaban AF (Renal Reduction)	CrCl 15–49 ml/min	Mandates 15mg OD. • Prescribed 15mg OD: Verified reduction confirmed. • Prescribed 20mg OD: Unreduced regimen flagged.	• On 15mg OD: Dose OK + CrCl <50 -> 15mg OD • On 20mg OD: CP Review + CrCl <50 -> 15mg OD + Above max dose
Edoxaban AF/VTE (Reduction Criteria)	CrCl ≤50 ml/min or Wt ≤60kg	Mandates 30mg OD. • Prescribed 30mg OD: Verified reduction confirmed. • Prescribed 60mg OD: Unreduced regimen flagged.	• On 30mg OD: Dose OK + Reduction criteria -> 30mg OD • On 60mg OD: CP Review + Reduction criteria -> 30mg OD + Above max dose
Dabigatran AF/VTE (Reduction Criteria)	Age ≥80 years or CrCl 30–49 ml/min	Recommends 110mg BD. • Prescribed 110mg BD: Verified reduction confirmed. • Prescribed 150mg BD: Unreduced regimen flagged.	• On 110mg BD: Dose OK + Age ≥80 / CrCl <50 -> 110mg BD • On 150mg BD: CP Review + Age ≥80 / CrCl <50 -> 110mg BD + Above max dose
VTE Duration >6 Months	Full dose (5mg Apix / 20mg Riv) >6m	Prompts clinician to review step-down to extended prevention dose or cessation.	CP Review .chip.flag
Hepatic Elevation	ALT >90 U/L or Bili >31.5 µmol/L	Flags liver enzymes >2× / >1.5× ULN. Contraindicated in Child-Pugh B/C.	GP Review .chip.warn
Haematology / Bleed Risk	Hb <130 (M) / <120 (F) or Plt <100	Flags anaemia or thrombocytopenia for clinical GP review.	GP Review .chip.warn