Optimizing the use of anticoagulants (heparins and oral anticoagulants) in the elderly

As longevity constantly increases, the number of elderly patients (75 years and older) who require anticoagulation likewise rises steadily. Managing elderly patients receiving anticoagulants is challenging because those patients are at high risk of both thrombosis and bleeding. Moreover, older patients are commonly frail: they have substantial chronic co-morbid conditions including renal impairment and frequent acute illnesses and are often polymedicated. There remains a clear need to optimize the use of anticoagulant drugs in these patients, especially at full anticoagulant dose. In the last decade, efforts have been made to better understand the inter-individual variability in the response of elderly patients to traditional anticoagulants including heparin derivatives (unfractionated heparin, low molecular weight heparins and fondaparinux) and vitamin K antagonists. Moreover, their safety profile has been evaluated in different settings in the elderly, assisting in minimizing risks related to their use. Emergence of new oral anticoagulants (dabigatran, rivaroxaban, apixaban), which appear to be much more convenient, is promising. Even though some elderly patients were included in pivotal clinical trials evaluating these new anticoagulants, the safety of these drugs remains uncertain in real life.