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Clinician Article

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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.

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• Sharma M
• Cornelius VR
• Patel JP
• Davies JG
• Molokhia M

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Clinical Comments

Gastroenterology

Helpful information regarding risk for GI bleeding associated with DOACs, although this was just a secondary endpoint in this otherwise well done systematic review.

Gastroenterology

As a gastroenterologist, it is important to know the bleeding risks with newer anticoagulant medications, especially since traditional reversal agents are not as effective.

General Internal Medicine-Primary Care(US)

A meta-analysis that shows how much we know and don`t know about the use of DOACs in the elderly population. Patients >75 are highly affected by acute thromboembolic events, but we still don`t have enough data about the effects of these new agents in this population. This study attempted to fill those gaps. The methodology used is strong and comprehensive. It shows that the current data are insufficient to draw conclusions about the bleeding risk for these agents in the elderly. The study pointed out the following: the new agents are not inferior to VKA therapy; dabigatran is associated with a higher risk for GI bleeding in the elderly; and dabigatran, apixaban, and rivaroxaban have a protective effect against intracranial bleeding. These conclusions are still limited by the poor data available in this age group. The current analysis shows the importance of developing specific age-related trials. We still need to be cautious at the time of prescribing these agents.

Geriatrics

The new information that many clinicians may not know is the comparison between the "novel" anticoagulants and warfarin, with the caveat that the validity of the comparison between the novel anticoagulants is limited by the significant heterogeneity between studies. This study provides a useful review that confirms that the novel anticoagulants have an equal risk for major bleeding as warfarin. This may help to reassure clinicians still wary of their use in older patients.

Geriatrics

Very important question as we continue to learn more about these agents. We make these decisions on an almost daily basis right now.

Hematology

This paper modestly advances the field. Most AF patients were elderly, with a mean age ~72 years.

Hematology

Confirms the previously established efficacy and safety data in afib in the elderly.

Internal Medicine

In this systematic review, the authors attempt to determine whether subgroups of elderly patients had the same benefits as younger patients. Their review was limited because the included studies were NOT designed to balance the elderly among group; groups were often quite imbalanced. The authors also point out that without patient-level data, we do not know whether renal failure (a very important cause of bleeding in these patients) was balanced. Several of their analyses had unexplained heterogeneity. Given the different drugs and doses, the authors were right to separate them; however, this meant that the results were primarily based on a few large studies. In the end, I am not sure that anything here should change how I practice as a hospitalist for elderly patients requiring anticoagulation.

Internal Medicine

A commendable attempt, however, a study-level meta-analysis might not be the best approach to address this important question about the role of NOACs in elderly patients. Limitations: lack of adequate number of trials, methodologic and statistical heterogeneity, use of substratified analysis from individual trials limiting power and adequate randomization.