Dabigatran 150 mg reduced the risk of stroke or systemic embolism by 34% compared to VKA in elderly patients, while apixaban reduced it by 30%.
Systematic Review (n=31,418)
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Yes
Do direct oral anticoagulants improve efficacy and bleeding outcomes compared to vitamin K antagonists in elderly patients (≥75 years) with atrial fibrillation or venous thromboembolism?
In patients ≥75 years, DOACs are as effective as VKAs for preventing thrombosis, but dabigatran is associated with higher GI bleeding risk, whereas apixaban and edoxaban may reduce major bleeding.
Effect estimate: OR 0.66 for dabigatran 150 mg; OR 0.70 for apixaban (95% CI 0.49–0.90 for dabigatran 150 mg; 0.52–0.93 for apixaban)
p-value: P=0.009 for dabigatran; P=0.01 for apixaban
Background— Evidence regarding the use of direct oral anticoagulants (DOACs) in the elderly, particularly bleeding risks, is unclear despite the presence of greater comorbidities, polypharmacy, and altered pharmacokinetics in this age group. Methods and Results— We performed a systematic review and meta-analysis of randomized trials of DOACs (dabigatran, apixaban, rivaroxaban, and edoxaban) for efficacy and bleeding outcomes in comparison with vitamin K antagonists (VKA) in elderly participants (aged ≥75 years) treated for acute venous thromboembolism or stroke prevention in atrial fibrillation. Nineteen studies were eligible for inclusion, but only 11 reported data specifically for elderly participants. The efficacy in managing thrombotic risks for each DOAC was similar or superior to VKA in elderly patients. A nonsignificantly higher risk of major bleeding than with VKA was observed with dabigatran 150 mg (odds ratio, 1.18; 95% confidence interval, 0.97–1.44) but not with the 110-mg dose. Significantly higher gastrointestinal bleeding risks with dabigatran 150 mg (1.78, 1.35–2.35) and dabigatran 110 mg (1.40, 1.04–1.90) and lower intracranial bleeding risks than VKA for dabigatran 150 mg (0.43, 0.26–0.72) and dabigatran 110 mg (0.36, 0.22–0.61) were also observed. A significantly lower major bleeding risk in comparison with VKA was observed for apixaban (0.63, 0.51–0.77), edoxaban 60 mg (0.81, 0.67–0.98), and 30 mg (0.46, 0.38–0.57), whereas rivaroxaban showed similar risks. Conclusions— DOACs demonstrated at least equal efficacy to VKA in managing thrombotic risks in the elderly, but bleeding patterns were distinct. In particular, dabigatran was associated with a higher risk of gastrointestinal bleeding than VKA. Insufficient published data for apixaban, edoxaban, and rivaroxaban indicate that further work is needed to clarify the bleeding risks of these DOACs in the elderly. Systematic Review Registration— http://www.crd.york.ac.uk/PROSPERO . Unique identifier: PROSPERO CRD42014007171/
Sharma et al. (Wed,) conducted a systematic review in Atrial Fibrillation and Venous Thromboembolism (n=31,418). Direct Oral Anticoagulants (DOACs) vs. Vitamin K Antagonists (VKA) was evaluated on Reducing risk of stroke or systemic embolism in AF and recurrent VTE (OR 0.66 for dabigatran 150 mg; OR 0.70 for apixaban, 95% CI 0.49–0.90 for dabigatran 150 mg; 0.52–0.93 for apixaban, p=P=0.009 for dabigatran; P=0.01 for apixaban). Dabigatran 150 mg reduced the risk of stroke or systemic embolism by 34% compared to VKA in elderly patients, while apixaban reduced it by 30%.