Two recent studies suggest that direct oral anticoagulants (DOACs) have the potential to significantly boost the prevention of thromboembolic events in older persons with atrial fibrillation (AF) as these agents have an improved safety profile and relatively simple mode of administration.

The first is a retrospective cohort study that was carried out utilizing administrative claims data from Optum′s Clinformatics Data Mart. 381,488 participants who were 65 or older had AF, and were at high risk of having an ischemic stroke were included in the study. The study evaluated changes in OAC initiation and DOAC uptake from 2010 to 2020 in elderly participants with new AF who were at increased risk of stroke.

The findings suggested that the rate of OAC initiation within a year of an occurrence of AF increased from 20.2% in 2010 to 32.9% in 2020. The rate of DOAC uptake rose from 1.1% to 30.9%. Lower probabilities of OAC initiation were associated with advanced age, dementia, frailty, and anaemia. OAC nonadherence dropped from 52.2% to 39.0% of the population.

The second article is a meta-analysis, which included 106 observational studies written in English between 2008 and 2020. It evaluated the results or risk factors for DOAC misuse (under and overdose) in adults with AF. The key results included overdosing, which was connected to a higher risk of significant bleeding, as was expected, and off-label underdosing, which was connected to no influence on stroke outcomes, stroke/systemic embolism, and stroke. Additionally, underdosing was linked to a null effect on bleeding consequences (perhaps unexpected), but an elevated risk of all-cause mortality. Increased age, a history of mild bleeding, hypertension, congestive heart failure, and low creatinine clearance were all risk factors for underdosing.

In conclusion, research points to the advantages of OACs, especially DOACs, for frail patients with AF and suggests that DOACs may reduce the incidence of intracranial bleeding in older persons who fall. 

(Source:  https://www.medscape.com/viewarticle/986128?src=#vp_1)