For patients requiring administration of inhibitors or inducers of P-gp or strong inhibitors or inducers of CYP enzymes, the ASH guideline panel suggests using an alternative anticoagulant (such as VKA or LMWH) rather than a DOAC for the treatment of VTE (conditional recommendation based on very low cer- tainty in the evidence about effects ). Summary of the evidence. DOAC absorption is mediated by P-gp proteins, and, therefore, P-gp inhibitors potentially increase DOAC absorption and effect, whereas P-gp inducers potentially decrease DOAC absorption and effect. Furthermore, CYP3A4 Table 2. Interpretation of strong and conditional recommendations Implications for Strong recommendation Conditional recommendation Patients Most individuals in this situation would want the recommended course of action, and only a small proportion would not. The majority of individuals in this situation would want the suggested course of action, but many would not. Decision aids may be useful in helping patients to make decisions consistent with their individual risks, values, and preferences. Clinicians Most individuals should follow the recommended course of action. Formal decision aids are not likely to be needed to help individual patients make decisions consistent with their values and preferences. Different choices will be appropriate for individual patients; clinicians must help each patient arrive at a management decision consistent with the patient s values and preferences. Decision aids may be useful in helping individuals to make decisions consistent with their individual risks, values, and preferences. Policy makers The recommendation can be adopted as policy in most situations. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Policy-making will require substantial debate and involvement of various stakeholders. Performance measures should assess whether decision-making is appropriate. 