Which anticoagulant is safest for frail elderly patients with nonvalvular A-fib?
In a retrospective study comparing direct oral anticoagulants vs warfarin in this population, apixaban’s adverse event rate was lower regardless of frailty status.
PRACTICE CHANGER
Consider apixaban, which demonstrated a lower adverse event (AE) rate than warfarin regardless of frailty status, for anticoagulation treatment of older patients with nonvalvular atrial fibrillation (AF); by comparison, AE rates for dabigatran and rivaroxaban were lower vs warfarin only among nonfrail individuals.
STRENGTH OF RECOMMENDATION
C: Based on a retrospective observational cohort study.1
Kim DH, Pawar A, Gagne JJ, et al. Frailty and clinical outcomes of direct oral anticoagulants versus warfarin in older adults with atrial fibrillation: a cohort study. Ann Intern Med. 2021;174:1214-1223. doi: 10.7326/M20-7141
Additionally, the study collected data on each of the DOAC–warfarin cohorts for < 90 days. Trials to address long-term outcomes are warranted.
Finally, there was no control group in comparison with anticoagulation. It is possible that choosing not to use an anticoagulant is the best choice for frail elderly patients.
CHALLENGES TO IMPLEMENTATION
Doctors need a practical frailty scale, patients need an affordable Rx
Frailty is not often considered a measurable trait. The approach used in the study to determine the CFI is not a practical clinical tool. Studies comparing a frailty calculation software application or an easily implementable survey may help bring this clinically impactful information to the hands of primary care physicians. The Clinical Frailty Scale—a brief, 7-point scale based on the physician’s clinical impression of the patient—has been found to correlate with other established frailty measures18 and might be an option for busy clinicians. However, the current study did not utilize this measurement, and the validity of its use by primary care physicians in the outpatient setting requires further study.
In addition, cost may be a barrier for patients younger than 65 years or for those older than 65 years who do not qualify for Medicare or do not have Medicare Part D. The average monthly cost of the DOACs ranges from $560 for dabigatran19 to $600 for rivaroxaban20 and $623 for apixaban.21 As always, the choice of anticoagulant therapy is a clinical judgment and a joint decision of the patient and physician.
