Practical use of Direct Oral Anti Coagulants (DOACs) in the older persons with atrial fibrillation.

Bo, Mario; Marchionni, Niccolò

doi:10.1016/j.ejim.2019.10.026

Cited by 21 publications

(30 citation statements)

References 90 publications

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“…However, the issue is whether the proposed "target spot" strategy might be the best research avenue to pursue to further reduce strategy, and prescription of the most appropriate drug at the correct dose according to the patient's clinical characteristics. [4][5][6] In fact, the relationship between anticoagulant activity and the risk of bleeding and ischemic adverse events varies somehow among different DOAC molecules, and in any case is similar to that presented in the authors' figure. 7 Despite the fact that DOACs "have a direct effect on the hemostatic system in a bidirectional manner as has been shown for dabigatran and edoxaban (i.e, too much effect results in bleeding, too little effect in thromboembolism)," LETTER TO THE EDITOR (RR 1.18, 95% CI 0.98-1.42; p for interaction <0.001).…”

Section: Comment On the Article By Toorop Et Al: "The Relationship Bsupporting

confidence: 82%

Comment on the article by Toorop et al.: “The relationship between DOAC levels and clinical outcomes: The measures tell the tale”

Brunetti

2021

Journal of Thrombosis and Haemostasis

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We read with great interest in your journal the paper by Toorop et al., 1 who argue that "it may be worthwhile to study the relationship between direct oral anticoagulant (DOAC) concentrations and patient-important outcomes." Although we agree that research on DOAC plasma level variability according to clinical factors and its association with relevant outcomes could be informative, we would like to put the proposal by Toorop et al. in a more appropriate clinical perspective.According to the article, this research topic would be of interest because "the overall major bleeding (MB) risk for DOAC use in observational studies remains 1% to 3% per year because of a large proportion of major extracranial bleeds." 1 This figure might look not so large compared to the rate of MB in the general population and in older subjects, which represents the majority of people receiving DOAC therapy, at least for stroke prevention in atrial fibrillation (AF). In a large study including 359,166 people without cardiovascular (CV) disease and not receiving antithrombotic therapies, the reported annual rate of MBs in subjects aged 70-79 years was 2.3% and 1.6% in men and women, respectively. 2 Therefore, when put in

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Section: Comment On the Article By Toorop Et Al: "The Relationship Bsupporting

confidence: 82%

Comment on the article by Toorop et al.: “The relationship between DOAC levels and clinical outcomes: The measures tell the tale”

Brunetti

2021

Journal of Thrombosis and Haemostasis

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“…Furthermore, several meta-analyses seem to confirm DOACs’ clinical benefit compared with VKAs also in older patients ( Bo and Marchionni, 2020 ). In a meta-analysis including patients treated for acute VTE and stroke prevention in AF, DOACs showed equal efficacy to VKAs in the subgroup of patients aged ≥75 years.…”

Section: Direct Oral Anticoagulants In Special Populationsmentioning

confidence: 98%

Direct Oral Anticoagulants: From Randomized Clinical Trials to Real-World Clinical Practice

et al. 2021

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Direct oral anticoagulants (DOACs) are a more manageable alternative than vitamin K antagonists (VKAs) to prevent stroke in patients with nonvalvular atrial fibrillation and to prevent and treat venous thromboembolism. Despite their widespread use in clinical practice, there are still some unresolved issues on optimizing their use in particular clinical settings. Herein, we reviewed the current clinical evidence on uses of DOACs from pharmacology and clinical indications to safety and practical issues such as drugs and food interactions. Dabigatran is the DOAC most affected by interactions with drugs and food, although all DOACs demonstrate a favorable pharmacokinetic profile. Management issues associated with perioperative procedures, bleeding treatment, and special populations (pregnancy, renal and hepatic impairment, elderly, and oncologic patients) have been discussed. Literature evidence shows that DOACs are at least as effective as VKAs, with a favorable safety profile; data are particularly encouraging in using low doses of edoxaban in elderly patients, and edoxaban and rivaroxaban in the treatment of venous thromboembolism in oncologic patients. In the next year, DOAC clinical indications are likely to be further extended.

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“…Moreover, mortality in individuals not prescribed OAC is markedly higher than in those receiving OAC therapy, and not accounted for by an excess of thrombo-embolic fatal events, but rather reflecting the higher proportion of oldest old with complex comorbidities and poor health status in the untreated population [9]. Despite evidence demonstrating the greater net clinical benefit of direct oral anticoagulants over vitamin K antagonists in older AF patients [10,11] some of these patients are at risk of increased short-term all-cause mortality, thereby diluting the undisputable benefit of OACs. In the absence of validated methods, loss of functional independence and severe frailty, anemia, and short estimated life expectancy may assist physicians to identify those older in-patients who may have an uncertain net clinical benefit from OAC [11].…”

Section: To the Editormentioning

confidence: 99%

“…Despite evidence demonstrating the greater net clinical benefit of direct oral anticoagulants over vitamin K antagonists in older AF patients [10,11] some of these patients are at risk of increased short-term all-cause mortality, thereby diluting the undisputable benefit of OACs. In the absence of validated methods, loss of functional independence and severe frailty, anemia, and short estimated life expectancy may assist physicians to identify those older in-patients who may have an uncertain net clinical benefit from OAC [11].…”

Section: To the Editormentioning

confidence: 99%

Underuse of anticoagulant therapy in hospitalized older patients: comment on the article of Wojszel et al.

Brunetti²,

Gibello

2020

J Thromb Thrombolysis

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Practical use of Direct Oral Anti Coagulants (DOACs) in the older persons with atrial fibrillation.

Cited by 21 publications

References 90 publications

Comment on the article by Toorop et al.: “The relationship between DOAC levels and clinical outcomes: The measures tell the tale”

Comment on the article by Toorop et al.: “The relationship between DOAC levels and clinical outcomes: The measures tell the tale”

Direct Oral Anticoagulants: From Randomized Clinical Trials to Real-World Clinical Practice

Underuse of anticoagulant therapy in hospitalized older patients: comment on the article of Wojszel et al.

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