Direct Oral Anticoagulants in the Elderly for AF and VTE | Ten Points to Remember

May 25, 2015   |  Geoffrey D. Barnes, MD, MSc, FACC
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Authors:
Sharma M, Cornelius VR, Patel JP, Davies JG, Molokhia M.
Citation:
Efficacy and Harms of Direct Oral Anticoagulants in the Elderly for Stroke Prevention in Atrial Fibrillation and Secondary Prevention of Venous Thromboembolism: Systematic Review and Meta-Analysis. Circulation 2015;May 20:[Epub ahead of print].

The following are 10 key points to remember from this systematic review and meta-analysis of direct oral anticoagulant (DOAC) use in elderly patients (≥75 years) with atrial fibrillation (AF) or venous thromboembolism:

  1. Efficacy in managing thrombotic risks for each of the DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) was similar or superior to vitamin K antagonists (VKAs) in elderly patients.
  2. As compared to VKA therapy, a nonsignificantly higher risk of major bleeding in the elderly was seen with dabigatran 150 mg (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.97-1.44), but not with dabigatran 110 mg.
  3. As compared to VKA therapy, a higher risk of gastrointestinal bleeding in the elderly was seen with dabigatran 150 mg (OR, 1.78; 95% CI, 1.35-2.35) and dabigatran 110 mg (OR, 1.40; 95% CI 1.04-1.90).
  4. As compared to VKA therapy, a lower risk of intracranial hemorrhage in the elderly was seen with dabigatran 150 mg (OR, 0.43; 95% CI, 0.26-0.72) and dabigatran 110 mg (OR, 0.36; 95% CI, 0.22-0.61).
  5. As compared to VKA therapy, a lower risk of major bleeding in the elderly was seen with apixaban (OR, 0.63; 95% CI, 0.51-0.77), edoxaban 60 mg (OR, 0.81; 95% CI, 0.67-0.98), and edoxaban 30 mg (OR, 0.46; 95% CI, 0.38-0.57).
  6. As compared to VKA therapy, rivaroxaban had a similar risk of major bleeding in the elderly (OR, 1.04; 95% CI, 0.86-1.26).
  7. Similar risks of major bleeding, gastrointestinal bleeding, and intracranial hemorrhage were seen in the overall population as in the elderly subpopulation.
  8. Findings of this meta-analysis were largely dominated by the individual large randomized trials for stroke prevention in AF.
  9. The authors were unable to combine findings of different DOACs given significant heterogeneity in the findings, perhaps related to study design or individual drug characteristics.
  10. While the risk of intracranial hemorrhage was uniformly reduced in DOAC-treated patients as compared to VKA, the risk of other major bleeding varied between the various DOAC agents in elderly patients.

Keywords: Aged, Anticoagulants, Atrial Fibrillation, Benzimidazoles, beta-Alanine, Geriatrics, Intracranial Hemorrhages, Morpholines, Pyrazoles, Pyridines, Pyridones, Secondary Prevention, Stroke, Thiophenes, Thiazoles, Venous Thromboembolism, Vitamin K


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