Although many physicians are hesitant to use novel oral anticoagulants in older adults because currently no antidote is clinically available, these agents offer several advantages. There are few drug/drug or drug/food interactions and no need for routine laboratory monitoring (often challenging for older adults with mobility issues) with the new agents.
In ARISTOTLE, the dosing of apixaban was prespecified as 2.5 mg (rather than 5 mg) twice daily for patients older than 80 years. At this lower apixaban dose, there was no significant difference in major bleeding events between warfarin and apixaban in older adults.[3] In the RE-LY trial, the higher 150-mg twice-daily dose of dabigatran had slightly higher rates of major bleeding than warfarin among older adults; the 110-mg twice-daily dose had similar bleeding rates to warfarin in this subgroup.[4,5]
Rivaroxaban is unique among the currently approved NOACs in that it comes as a single daily dose. Although overall bleeding rates were higher for older patients than for younger patients in the ROCKET-AF trial, they were not significantly higher for rivaroxaban compared with warfarin in the older population.[6,7]
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