As the population ages, the management of atrial fibrillation (Afib) in older adults becomes increasingly important. Anticoagulation therapy plays a crucial role in reducing the risk of stroke and other cardiovascular events in these patients. However, there is a lack of consensus regarding the choice of oral anticoagulants (OACs) in this population. In this article, we will critically analyze a recent study that compared the effectiveness and outcomes of different OACs in older adults with Afib.
The study, published in JAMA Network Open, analyzed Medicare records to evaluate the patient-centered outcomes associated with different OACs in older adults with Afib. The researchers found that apixaban (Eliquis) was associated with better outcomes compared to other common OACs in this population. Specifically, rivaroxaban (Xarelto) was linked to a significantly increased risk of prolonged hospital stays or stays in skilled nursing facilities. Additionally, rivaroxaban demonstrated a higher composite risk of stroke, systemic embolism, major bleeding, or death, as well as higher total costs compared to apixaban. Similarly, warfarin use was associated with increased risks compared to apixaban, both in terms of healthcare facility stays and combined clinical events.
One notable finding of the study was the greater relative reductions in home time lost in frail older adults who were on apixaban compared to rivaroxaban or warfarin. This indicates that apixaban may be the preferred OAC for this subgroup of patients. Frail individuals often require more rehospitalizations and are more likely to be discharged to a location other than home. Therefore, the use of apixaban could potentially reduce healthcare costs and improve patient outcomes in this vulnerable population.
The study also examined the cost-effectiveness of different OACs. Apixaban was associated with a lower annual cost compared to rivaroxaban, primarily driven by the cost of the medication itself. However, even after excluding the cost of the OAC, apixaban had lower overall costs compared to rivaroxaban. Warfarin, on the other hand, had the lowest costs overall. These findings suggest that while apixaban may be more expensive upfront, it may provide cost savings in the long term, considering the reduced risks of adverse events and hospitalizations.
Despite the increasing willingness of older adults with Afib to initiate and adhere to anticoagulant therapy, there is still underutilization of these medications in this population. This is particularly true for frail individuals, who often face greater barriers to accessing appropriate care. It is important to address these treatment gaps and ensure that older adults with Afib, especially those who are frail, receive optimal anticoagulation therapy to reduce their risk of thromboembolism and other adverse outcomes.
It is important to acknowledge the limitations of this study. The researchers relied on prescription claims data, which may not capture all relevant clinical variables. Unmeasured confounding factors may have influenced the results, despite efforts at statistical adjustment. Laboratory test results and use of over-the-counter medications were not available, which could potentially impact medication interactions and dosing. Furthermore, the study did not include comparisons with other direct oral anticoagulants (DOACs) such as dabigatran and edoxaban, which are less frequently used in clinical practice.
Future research should focus on evaluating the impact of inappropriate dosing and potentially reducing doses of DOACs in frail older adults with Afib. Additionally, studies should aim to include a more diverse population, including those with other indications for anticoagulation therapy apart from ischemic stroke, such as venous thromboembolism or joint replacement.
The study provides valuable insights into the choice of OACs for older adults with Afib, particularly in the context of frailty. Apixaban appears to be the preferred anticoagulant in this population, offering better patient-centered outcomes and cost-effectiveness compared to rivaroxaban and warfarin. It is essential to consider the specific needs of older adults with Afib, especially those who are frail, to ensure they receive appropriate anticoagulation therapy. Further research is needed to address the limitations of this study and assess the impact of dosing on the efficacy and safety of different DOACs in frail older adults with Afib.