[Anticoagulation of older patients: what is new?]

Area of Science:

• Geriatric Medicine
• Pharmacology
• Cardiology

Background:

• Vitamin-K antagonists (VKA) are standard oral anticoagulants but pose challenges for older patients, including bleeding risks and drug interactions.
• Newer oral anticoagulants (NOA), such as direct thrombin inhibitors and direct factor Xa inhibitors, offer simpler management with fixed doses and no routine monitoring.

Purpose of the Study:

• To review the efficacy and safety of NOA in older populations, particularly in the context of atrial fibrillation and venous thromboembolic disease.
• To highlight the specific considerations for NOA use in the elderly, including renal function and potential adverse events.

Main Methods:

• Review of randomized trials comparing NOA with heparins and VKA.
• Analysis of subgroup data focusing on patients aged 75 and older.
• Examination of pharmacokinetic data related to renal elimination and dosing adjustments.

Main Results:

• NOA demonstrate non-inferiority to heparins and VKA in treating venous thromboembolic disease and preventing embolisms in atrial fibrillation.
• Subgroup analyses in atrial fibrillation show similar efficacy across age groups, but dabigatran may increase bleeding risk in those over 75, especially at higher doses.
• All NOA are renally eliminated, requiring dose reduction in moderate renal impairment and contraindication in severe impairment; dabigatran and apixaban doses also need adjustment in older individuals.

Conclusions:

• NOA represent a viable alternative to VKA for anticoagulation in older adults, offering simplified management.
• Careful consideration of renal function, age-specific dosing (dabigatran, apixaban), and potential bleeding risks is crucial.
• Further research is needed to address drug interactions, develop specific monitoring tests, and establish antidotes for NOA-related bleeding complications.