Assessment of the risk of complications associated with the use of direct oral anticoagulants in elderly patients with polypharmacy

Introduction. The use of direct oral anticoagulants (DOACs) in elderly patients is associated with an increased risk of complications compared to the general population. First of all, this is due to the presence of risk factors – modifiable and nonmodifiable. The main modifiable risk factors for DOAC-related hemorrhagic complications are polypharmacy and adverse drug interactions. Consideration of renal function is also important. The study of these issues is extremely important for finding a balance in the benefit-harm ratio in the treatment of elderly patients.

Aim. Assessment of risk factors for the development of DOAC-related complications in elderly patients with polypharmacy.

Materials and methods . A retrospective single-center study involved 503 patients who were followed-up for April–September 2024. Patients were treated with DOACs for persistent atrial fibrillation, while they did not have severe hemorrhagic complications (exclusion criterion). A questionnaire survey was used, during which data on medications taken, the duration of anticoagulant treatment, and renal function were collected.

Results . The independent factors associated with DOAC-related complications in the study cohort were polypharmacy (concomitant use of over 6 medications) and a reduced glomerular filtration rate of less than 45 ml/min/1,73 m2. Furthermore, a correlation between an increased risk of hemorrhagic complications and the concomitant intake of DOACs with specific drugs that affect the anticoagulant’s pharmacokinetics was identified.

Conclusion. When prescribing DOACs to elderly patients with the risk factors described above, the benefit-harm ratio for the prescribed anticoagulant should be carefully evaluated, the risk of bleeding should be predicted, and adverse drug interactions should be avoided in patients with polypharmacy.

1. Lubbe A.L., van Rijn M., Groen W.G. et al. The quality of geriatric rehabilitation from the patients’ perspective: a scoping review // Age Ageing. 2023;52(3):afad032. DOI: 10.1093/ageing/afad032.

2. Ellis G., Sevdalis N. Understanding and improving multidisciplinary team working in geriatric medicine // Age Ageing. 2019;48(4):498-505. DOI: 10.1093/ageing/afz021.

3. Joosten L.P.T., van Doorn S., van de Ven P.M. et al. Safety of switching from a vitamin K antagonist to a non-vitamin K antagonist oral anticoagulant in frail older patients with atrial fi brillation: Results of the FRAIL-AF randomized controlled trial // Circulation. 2024;149(4):279-289. DOI: 10.1161/CIRCULA-TIONAHA.123.066485.

4. Saczynski J.S., Sanghai S.R., Kiefe C.I. et al. Geriatric elements and oral anticoagulant prescribing in older atrial fi brillation patients: SAGE-AF // J. Am. Geriatr. Soc. 2020;68(1):147-154. DOI: 10.1111/jgs.16178.

5. Okumura K., Akao M., Yoshida T. et al.; ELDER-CARE-AF Committees and Investigators. Low-dose edoxaban in very elderly patients with atrial fi brillation // N. Engl. J. Med. 2020;383(18):1735-1745. DOI: 10.1056/NEJMoa2012883.

6. Debette S., Mazighi M., Bijlenga P. et al. ESO guideline for the management of extracranial and intracranial artery dissection // Eur. Stroke J. 2021;6(3):XXXIX-LXXXVIII. DOI: 10.1177/23969873211046475.

7. Polidori M.C., Alves M., Bahat G. et al.; Special Interest Group “Cardiovascular Diseases” of the EuGMS. Atrial fibrillation: a geriatric perspective on the 2020 ESC guidelines // Eur. Geriatr. Med. 2022;13(1):5-18. DOI: 10.1007/s41999-021-00537-w.

8. Demelo-Rodriguez P., Galeano-Valle F., Proietti M. Use of oral anticoagulant drugs in patients with pulmonary hypertension // Heart Fail Clin. 2023;19(1):97-106. DOI: 10.1016/j.hfc.2022.08.018.