use of anticoagulants in geriatrics: current evidence and ... · m sharma, vr cornelius, jg davies,...
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Better care, better population health and lower costs through improvement.
Use of Anticoagulants in Geriatrics: Current Evidence and Special Considerations
Aryn You, PharmDAssistant Professor, Pharmacy Practice
The Daniel K. Inouye College of Pharmacy
Aida Wen, MDAssociate Professor, Department of Geriatric Medicine
The John A Burns School of Medicine
Collaboration
JABSOM • – Geriatric Workforce Enhancement Program
Mountain• -Pacific Quality Health
The Daniel K. Inouye College of Pharmacy: •University of Hawaii at Hilo
1.0 AMA PRA Category 1 Credits™
Participation & Evaluation• Evaluation and requests for credit are sent via email
after the activity– Those requesting CPE are required to participate in
the entire activity– Physicians requesting CME should claim only the
credit commensurate with the extent of their participation in the activity.
If you have any questions regarding the CME / CPE credit email, follow up with [email protected]
Financial Disclosures• DKICP Disclosures: Dr. Wen has disclosed
that she holds stock with Pfizer. All other speakers have no relevant financial relationships to disclose. All planning committee members and Continuing Education staff from the University of Hawai`i Hilo College of Pharmacy have no relevant financial relationships to disclose.
Better care, better population health and lower costs through improvement.
Use of Anticoagulants in Geriatrics:Learning Objectives and Case Study
Aida Wen, MDAssociate Professor, Department of Geriatric Medicine
The John A Burns School of Medicine
Learning Objectives• Identify patient factors that may influence the
decision to use therapeutic anticoagulants• Discuss patient populations that may be at
increased risk of adverse effects associated with anticoagulants
• Highlight differences between individual anticoagulant agents
Patient Case: James 83 • year old male HPI: Presents with difficulty breathing on exertion and is •found to have new onset Atrial Fibrillation and CHFPast Medical History: •
HTN–GERD–Arthritis–Anemia–Chronic Kidney Disease (Stage – 3)
Patient Case: James• Vitals:
– BP: 160/90, P: 90 bpm (Irregular), O2 Sat: 92% RAWt : 62kg, Ht 72in, BMI: 18.3
• Exam: – Alert, NAD, Heart - irregularly irregular, Lungs - scattered
crackles and wheezing, Abdomen - soft, Extremities - trace pedal edema
– Gait - steady, but Timed Get up and Go test = 30 sec (INCREASED RISK FOR FALL)
• Studies: – Stool guaiac neg. Hb 10.5, Cr. 2.0, CXR- mild CHF, EKG
Afib.
Patient Case: James• Medications:
– Metoprolol Succinate 50 mg PO daily– Acetaminophen 1000 mg PO BID– Ranitidine (Zantac) 150 mg PO daily
• Social: – He is a married, retired lawyer. He helps care for his
two young grandchildren, picking them up from school every day and helping with homework. Enjoys social drinking and playing the ukulele.
• GOAL: Remain independent
Atrial Fibrillation• Prevalence increases with Age
– >60 years of age: 4%– >80 years of age: 10%
• 71% of strokes occur in patients >70 years of age
Incidence of Atrial Fibrillation
Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study. JAMA. 2001 May 9;285(18):2370-5.
WHAT IS JAMES’ RISK OF STROKE?
Better care, better population health and lower costs through improvement.
Use of Anticoagulants in Geriatrics:Current Evidence and Special Considerations
Aryn You, PharmDAssistant Professor, Pharmacy Practice
The Daniel K. Inouye College of Pharmacy
CHA2DS2-VASc• CHF History (1 point)• Hypertension (1 point)• Age > 75 years old (2 points)• Diabetes Mellitus• Stroke or Prior TIA• Vascular Disease• Age: 64-74 years old• Sex• TOTAL: 4 points (High Risk):
– Stroke risk: 4.8% per year – 6.7% risk of stroke/ TIA/ systemic embolism
Antithrombotic Recommendations
• CHEST 9th Edition (2012)– Patients with CHA2DS2-VASc ≥2: Dabigatran
rather than Warfarin (2B)• ACC/AHA/HRS Guidelines 2014
– Warfarin (1A)– Dabigatran, Rivaroxaban, Apixaban (1B)
Antithrombotic Therapy• Antithrombotic therapy is associated with
– 67% reduction in stroke/systemic embolism– 65% reduction in ischemic stroke– 26% reduction in mortality
• Only 25-55% of eligible patients receive therapy
• 70% discontinue therapy within 12 months
Antithrombotic Therapy in Elderly
14% Reduction in Warfarin use with each decade of age
Brophy MT, Snyder KE, Fiore LD, et al. Anticoagulant Use for Atrial Fibrillation in Elderly. JAGS 2004(52): 1151-1156
Oral AnticoagulantsWarfarin ● (Coumadin®, Jantoven®)NOAC = DOAC●
Novel Oral Anticoagulants = Direct Oral AnticoagulantsDabigatran ○ (Pradaxa®)Rivaroxaban ○ (Xarelto®)Apixaban ○ (Eliquis®)Edoxaban ○ (Savaysa®)Betrixaban ○ (Bevyxxa®)
Mechanism of Action
Timeline of FDA-Approvals
Bleeding-Related Readmissions● Warfarin is one of the top medications to cause
hospital readmissions
● Trials that led to DOAC FDA-approval showed overall decreased bleeding rates compared to warfarin
● Does real-world data support this?○ Low-quality, retrospective reviews have been
conducted○ Scarce evidence focusing on the elderly
population
Bleeding-Related Readmissions
WHAT IS JAMES’ RISK OF
BLEEDING?
HAS-BLEDHypertension • (1 point)Renal Disease • (1 point)Liver Disease•Stroke History•Prior major bleeding or predisposition to bleeding • (1 point)Labeled INR•Age > • 65 years old (1 point)Medications that increase risk of bleed •Alcohol Use•TOTAL: • 4 points (HIGH):
8.9– % risk of bleed
Predicting Bleeds in Elderly
Poli D, Antonucci E, Palareti G, et al. Bleeding Risk in Very Old Patients on Vitamin K Antagonist Treatment: Results of a Prospective Collaborative Study on Elderly Patients Followed by Italian Centres for Anticoagulation. Circulation. 2011 (124): 824-829
Poli D, Antonucci E, Palareti G, et al. Bleeding Risk in Very Old Patients on Vitamin K Antagonist Treatment: Results of a Prospective Collaborative Study on Elderly Patients Followed by Italian Centres for Anticoagulation. Circulation. 2011 (124): 824-829
Predicting Bleeds in Elderly
Weak Correlation
with Conventional Risk Factors
Poli D, Antonucci E, Ageno W, et al. The Predictive ability of bleeding risk stratification models in very old patients on vitamin K antagonist treatment for venous thromboembolism: results of the prospective
collaborative EPICA study. J Thromb Haemost 2013; 11: 1053-8
Predicting Bleeds in Elderly
Poli D, Antonucci E, Ageno W, et al. The Predictive ability of bleeding risk stratification models in very old patients on vitamin K antagonist treatment for venous thromboembolism: results of the prospective collaborative EPICA study. J Thromb Haemost 2013; 11: 1053-8
Is the benefit associated with antithrombotic therapy greater than the risk?
Anticoagulant Therapy in Elderly
Patti G, Lucerna M, De Caterina R, et al. Thromboembolic Risk, Bleeding Outcomes and Effect of Different Antithrombotic Strategies in Very Elderly Patients with Atrial Fibrillation: A Sub- Analysis from the PREFER in AF. Heart Assoc. 2017, e005657. DOI: 10.1161/JAHA.117.005657
Anticoagulant Therapy in Elderly
Patti G, Lucerna M, De Caterina R, et al. Thromboembolic Risk, Bleeding Outcomes and Effect of Different Antithrombotic Strategies in Very Elderly Patients with Atrial Fibrillation: A Sub- Analysis from the PREFER in AF. Heart Assoc. 2017, e005657. DOI: 10.1161/JAHA.117.005657
Anticoagulant Therapy in Elderly
Patti G, Lucerna M, De Caterina R, et al. Thromboembolic Risk, Bleeding Outcomes and Effect of Different Antithrombotic Strategies in Very Elderly Patients with Atrial Fibrillation: A Sub- Analysis from the PREFER in AF. Heart Assoc. 2017, e005657. DOI: 10.1161/JAHA.117.005657
Birmingham Atrial Fibrillation Treatment of the Aged Study
(BAFTA)• Warfarin (n= 488) vs. Aspirin (n=485) in ≥75
years of age • Prospective Randomized open-label trial • Primary Aim:
– Fatal and non-fatal stroke– Intracranial hemorrhage– Other clinically significant arterial embolism
Mant J, Hobbs FD, Murray E. et al. Warfarin vs aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham atrial fibrillation treatment of the
aged study, BAFTA): a randomized controlled trial. Lancet 2007; 370: 493-503.
Warfarin vs. Aspirin
Mant J, Hobbs FD, Murray E. et al. Warfarin vs aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham atrial fibrillation treatment of the
aged study, BAFTA): a randomized controlled trial. Lancet 2007; 370: 493-503.
Warfarin vs. Aspirin
Mant J, Hobbs FD, Murray E. et al. Warfarin vs aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham atrial fibrillation treatment of the aged study, BAFTA): a randomized controlled trial. Lancet 2007; 370: 493-503.
WHICH ANTICOAGULANT
WOULD YOU CHOOSE?
Bleeding-Related Readmissions● Very little evidence in the elderly population● Overall major bleeding seems to be equal with
DOACs vs. warfarin
● DOACs are associated with lower readmissions due to ICH but increased readmissions due to GI bleed
DOAC: Concerns in Elderly• Lower body mass index (BMI 18.3)• Altered body composition• Higher frequency of renal
impairment (CKD3)
• (James also has anemia and increased Falls risk)
= inconsistent levels of anticoagulation?
Stroke and Systemic Embolism in Population
(< 75)
DOAC vs.
Warfarin
M Sharma, VR Cornelius, JG Davies, et al. Efficacy and harms of direct oral anticoagulants in elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: Systematic review and meta-analysis. Circulation. 2015; CIRCULATIONAHA.114.013267, originally published May 20,2015
Stroke and Systemic Embolism in Population
(≥ 75)
DOAC vs.
Warfarin
M Sharma, VR Cornelius, JG Davies, et al. Efficacy and harms of direct oral anticoagulants in elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: Systematic review and meta-analysis. Circulation. 2015; CIRCULATIONAHA.114.013267, originally published May 20,2015
Major Bleeding in Total Population
DOAC vs.
Warfarin
M Sharma, VR Cornelius, JG Davies, et al. Efficacy and harms of direct oral anticoagulants in elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: Systematic review and meta-analysis. Circulation. 2015; CIRCULATIONAHA.114.013267, originally published May 20,2015
Major Bleeding in Elderly (≥ 75)
DOAC vs.
Warfarin
M Sharma, VR Cornelius, JG Davies, et al. Efficacy and harms of direct oral anticoagulants in elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: Systematic review and meta-analysis. Circulation. 2015; CIRCULATIONAHA.114.013267, originally published May 20,2015
DOAC vs. Warfarin
All Cause Deathin Population
(<75)
M Sharma, VR Cornelius, JG Davies, et al. Efficacy and harms of direct oral anticoagulants in elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: Systematic review and meta-analysis. Circulation. 2015; CIRCULATIONAHA.114.013267, originally published May 20,2015
DOAC vs. Warfarin
All Cause Deathin Elderly
(≥ 75)
M Sharma, VR Cornelius, JG Davies, et al. Efficacy and harms of direct oral anticoagulants in elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: Systematic review and meta-analysis. Circulation. 2015; CIRCULATIONAHA.114.013267, originally published May 20,2015
Major Bleeding and Renal Function
Geldof V, Vadenbiele C, Vanassche T, et al. Venous thromoboembolism in the elderly: efficacy and safety of non-VKA oral anticoagulants. Thrombosis Journal 2014 (12): 21
NOW WHICH ANTICOAGULANT
WOULD YOU CHOOSE ?
Better care, better population health and lower costs through improvement.
Questions?
When deciding to use a DOAC in the elderly, which factor(s)
should be considered?
A. Renal impairmentB. Low body mass indexC. Fall riskD. All of the above
Apixaban may be favorable in the elderly due to less major
bleeding compared to the other oral anticoagulants.
A. True B. False
If deciding to start a DOAC in a patient with renal
insufficiency, rivaroxaban may be safer compared to the
other DOACs.A. True B. False