Illustration of human blood cells

One direct-acting anticoagulant stands out as the least likely to cause dangerous bleeding in elderly patients with atrial fibrillation, according to a new study. But other new research questions the need for these drugs in nursing home residents who have advanced dementia.

A large, multinational cohort study compared the use of apixaban (Eliquis), dabigatran, edoxaban and rivaroxaban in more than 500,000 patients with Afib. Apixaban was associated with lower risk for gastrointestinal bleeding than the three comparison drugs. Notably, this was true for patients 80 years old and older, and those with chronic kidney disease.

The results indicate that apixaban might be preferable to the other DOACs, but consideration of all potential risks and benefits would be needed, the authors wrote in the Annals of Internal Medicine

Nursing home use

In the case of nursing home residents with advanced dementia, the benefits of these drugs may be relatively small, another study published in JAGS suggests.

Using Minimum Data Set and Medicare claims, the investigators followed outcomes in more than 14,800 long-stay nursing home residents between 2013 and 2018 with advanced dementia and Afib. Residents with venous thromboembolism and valvular heart disease were excluded. 

Based on quarterly measurements of anticoagulation exposure, direct-acting blood thinners were associated with a decreased risk of death. While more than 50% of patients in both groups died within a year, median survival was 76 days longer for individuals taking anticoagulants. There was not a significant association with stroke risk — but there was an increased risk of bleeding. 

“Persons with advanced dementia and [Afib] derive clinically modest life prolongation from anticoagulation, at the cost of elevated risk of bleeding,” investigators concluded. “The relevance of this benefit is unclear in a group with high dementia-related mortality and for whom the primary goal is often comfort.”

In 2019, the American Heart Association and other groups recommended DOACs over warfarin for treatment of Afib. DOACs have a relatively low risk of side effects and, unlike with warfarin, there is no need for blood test monitoring.

More clinicians appear to be using direct-acting anticoagulants to treat U.S. nursing home residents with atrial fibrillation, a 2019 study found. The uptick in use coincided with declining warfarin use, the investigators reported.

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