Presentation Details
| DOAC’s in the elderly Abhinav Paknikar1, Keerti Chakravarthy1, Fakiha Siddiqui2, Atul Laddu1, Jawed Fareed2, Aarushi Dua1, Anish Joshi1. 1Global Thrombosis Forum, Suwanee, GA, USA.2Loyola University, Chicago, IL, USA |
Abstract
Background DOACs are routinely prescribed in the elderly to manage non-valvular atrial fibrillation and stroke prophylaxis. DOACs reduce the risk of stroke and systemic thromboembolism, without increasing the risk of major bleeding, with a favorable risk profile. Fluctuations in renal function, comorbidities, and concomitant antiplatelet use may necessitate more individualized dosing strategies with these agents. Objectives/methods We researched the use of DOACs and the challenges in their use in the elderly by reviewing the available literature. Results Age and AF The incidence of AF in the elderly population shows an increase in all the races studied (Figure 1) The Framingham Heart Study group had shown age to be the greatest risk factor for AF, surpassing other risk factors, including male sex, obesity, diabetes, smoking, hypertension, heart failure, and coronary artery disease. The quality of life is poor, with a larger number of hospitalizations, and more cardiovascular events in elderly patients with AF, compared to patients younger than 75 years old. Older age can increase the risk of stroke/systemic embolism, one of the most common complications of AF. Types of DOACs Factor Xa Inhibitors : Rivaroxaban and Apixaban Direct Thrombin Inhibitor (DTI) : Dabigatran Mechanism of action of DOACs (Figure 2) Apixaban, Rivaroxaban and Edoxaban inhibit Factor Xa Dabigatran inhibits Factor IIA. Indications of DOACs Provide both clinicians and patients with safer, more effective, and convenient therapeutic alternatives in thromboembolic conditions. Prevention and treatment of thrombosis in cardiovascular conditions including DVT and PE, atrial fibrillation, and recurrent thrombotic stroke. When should DOACs be avoided? Patients with severe hepatic disease in which warfarin is the only recommended anticoagulant. Dabigatran, apixaban, and edoxaban are viable options in patients with moderate hepatic impairment and do not require dose adjustments. Rivaroxaban should be avoided in patients with advanced renal insufficiency, apixaban is the drug of choice in this population Challenges for the use of DOACs in the elderly Often forget to take medications resulting in altered drug levels and efficacy. Accidental overdose of anticoagulants resulting in excessive risk of bleeding. Polypharmacy & Drug Interaction Altered Pharmacokinetics: Renal function declines with age, affecting excretion and causing a longer half life and elevated bleeding risk High risk of falls due to multiple reasons including stroke, imbalance, visual difficulties, arthritis, and frailty, resulting in increased risk of bleeding. Advantages of DOACs over warfarin No need for regular INR checks No dietary restrictions Stable and predictable dosage Fewer drug interactions Disadvantages of DOACs over warfarin High cost Absence of tests to measure drug levels or effect. Lack of universal reversal agents/antidotes Conclusions DOACs significantly reduce the risk of stroke and systemic thromboembolism in elderly patients, without increasing the risk of major bleeding. DOACs are safe and effective for use in the elderly but should be used with great caution. DOACs offer various practical advantages over warfarin in the elderly.
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