Direct Oral Anticoagulants in the Elderly for AF and VTE | Ten Points to Remember
- Sharma M, Cornelius VR, Patel JP, Davies JG, Molokhia M.
- 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:
- 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.
- 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.
- 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).
- 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).
- 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).
- 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).
- Similar risks of major bleeding, gastrointestinal bleeding, and intracranial hemorrhage were seen in the overall population as in the elderly subpopulation.
- Findings of this meta-analysis were largely dominated by the individual large randomized trials for stroke prevention in AF.
- 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.
- 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.
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