Appropriate Dosing of Novel Anticoagulants

An 80-year-old female with a history of atrial fibrillation on warfarin is seen by you in follow-up after her second emergency room visit for epistaxis in the setting of a supratherapeutic INR. As you review her laboratory data, you note that she is infrequently in therapeutic range despite careful monitoring, including home INR measurements. She expresses concern about her stroke risk while subtherapeutic and frustration with her repeated emergency room visits. She has seen commercials about other anticoagulants and is wondering whether there might be an alternative to warfarin.

Her medical history is notable only for non-valvular, paroxysmal atrial fibrillation and hypertension. She is currently managed with metoprolol succinate, hydrochlorothiazide, dronedarone, and warfarin. On exam, she is a well-appearing, petite female (5'4", 50kg) with an irregularly, irregular rhythm without murmurs. Laboratory studies from her recent emergency room visit showed a hemoglobin of 12.2 gm/dL and creatinine of 1.0 mg/dL, both stable from prior values. She has no history of liver disease. A 12-lead ECG reveals atrial fibrillation with a regular rate.

What would you recommend for anticoagulation in this patient?

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