The following is a summary of “Benefits and Harms of Standard Versus Reduced‐Dose Direct Oral Anticoagulant Therapy for Older Adults With Multiple Morbidities and Atrial Fibrillation,” published in the November 2023 issue of Cardiology by Hayes et al.

Within the realm of older adults residing in nursing homes and grappling with nonvalvular atrial fibrillation, the utilization of reduced-dose direct oral anticoagulants (DOACs) presents a complex landscape. In this retrospective cohort study that tapped into US Medicare claims associated with Minimum Data Set records between 2013 and 2017, researchers explored dosing strategies and their impacts on this demographic marked by multiple morbidities. Among the substantial cohort of 21,878 DOAC initiators identified aged ≥65 years, nearly half were subjected to reduced dosing strategies.

Intriguingly, delving deeper into the inverse probability of treatment weights revealed a notable trend: those individuals who were prescribed standard dosages exhibited a discernibly higher rate of bleeding events compared to their counterparts receiving reduced-dose DOACs. This discrepancy was particularly pronounced in certain subsets of this elderly population, notably among those over 80 years and individuals with a body mass index <30 kg/m2. The disparity in bleeding rates between standard and reduced dosing strategies calls attention to a nuanced consideration regarding selecting the appropriate DOAC dosage, mainly when dealing with specific age groups and body compositions.

Despite this notable difference in bleeding events, their extensive analysis unveiled no significant disparities in mortality or thrombotic events between those prescribed standard versus reduced-dose DOAC therapy. The absence of substantial differences in mortality or thrombotic events raises pertinent questions about the clinical implications of DOAC dosing strategies in this elderly population. While bleeding risk seemed more prominently associated with standard dosing, the overall clinical effectiveness in preventing thrombotic events or reducing mortality did not significantly vary between the two dosing strategies.

These findings, gleaned from a comprehensive nationwide study conducted among nursing home residents grappling with nonvalvular atrial fibrillation, offer crucial insights into the complex interplay between DOAC dosing strategies, patient outcomes, and the prevalence of multiple morbidities. The discernible discrepancy in bleeding rates and the consistent effectiveness in averting thrombotic events and mortality across both dosing strategies underscores the potential advantages of leaning towards reduced-dose DOACs for older adults with multiple comorbidities. This study underscores the necessity for tailored dosing strategies that account for age-related factors and individual characteristics, advocating for a personalized approach in prescribing DOAC therapy within this vulnerable demographic.

Source: ahajournals.org/doi/10.1161/JAHA.122.029865