A PEER-REVIEWED JOURNAL OF RESEARCH AND CLINICAL MEDICINEISSN 1727-2378 (Print)         ISSN 2713-2994 (Online)
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An Elderly Patient with Atrial Fibrillation: Ways to Enhance Safety of Anticoagulant Therapy

DOI:10.31550/1727-2378-2019-165-10-16-22
For citation: Vorobyeva N.M., Tkacheva O.N. An Elderly Patient with Atrial Fibrillation: Ways to Enhance Safety of Anticoagulant Therapy. Doctor.Ru. 2019; 10(165): 16–22. (in Russian) DOI: 10.31550/1727-2378-2019-165-10-16-22
11 September 09:49

Purpose. To discuss the possibility of using an oral direct-acting anticoagulant, apixaban, to prevent stroke and/or systemic embolism in elderly patients with atrial fibrillation.

Key Points. In addition to the high risk of stroke and haemorrhage, elderly patients have some characteristics (e.g. multimorbidy and senile asthenia syndrome) which should be taken into account when prescribing anticoagulants. Apixaban efficiency and safety in elderly patients with atrial fibrillation were studied during ARISTOTLE trial subanalysis. The article describes the results of two recent retrospective observational studies which confirmed positive profile of apixaban efficiency and safety in elderly patients in clinical practice. The data from ARISTOTLE trial subanalysis regarding apixaban efficiency and safety in patients with only one out of three criteria for apixaban dose reduction or multimorbidy were discussed. Also, FORTA consensus document is discussed which specifies the individual approach to management of elderly patients on the basis of clinical characteristics. First Russian recommendations about senile asthenia are mentioned, including restricted prescription of anticoagulants to elderly patients with senile asthenia.

Conclusion. A full dose of apixaban (5 mg twice daily) is absolutely efficient and safe for patients with multimorbidy or only one criterion for apixaban dose reduction. According to FORTA experts, apixaban is a FORTA-A class drug and is the safest oral anticoagulant for elderly patients. Senile asthenia is not a contraindication for anticoagulant therapy and not a reason to reduce an anticoagulant dose.

Contribution: Vorobyeva, N.M. — concept, manuscript preparation, review of critically important material; Tkacheva, O.N. — concept, final approval of the manuscript for publication.

Conflict of interests: The article was prepared with the support from Pfizer, but it has in no way affected the author’s opinion.


N.M. Vorobyeva — Russian Clinical Research Center for Gerontology (a Standalone Unit of the N.I. Pirogov Russian National Research Medical University, a Federal Government-funded Educational Institution of Higher Education), Russian Ministry of Health; 16 Pervaya Leonova St., Moscow, Russian Federation 129226. E-mail: natalyavorobjeva@mail.ru

O.N. Tkacheva — Russian Clinical Research Center for Gerontology (a Standalone Unit of the N.I. Pirogov Russian National Research Medical University, a Federal Government-funded Educational Institution of Higher Education), Russian Ministry of Health; 16 Pervaya Leonova St., Moscow, Russian Federation 129226. E-mail: tkacheva@rgnkc.ru


Доктор.ру
11 September 09:49
LITERATURE
  1. Schnabel R. B., Yin X., Gona P., Larson M. G., Beiser A. S., McManus D. D. et al. 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study. Lancet. 2015; 386(9989): 154–162. DOI: 10.1016/S0140-6736(14)61774-8
  2. Wehling M. Drug therapy in the elderly: too much or too little, what to do? A new assessment system: fit for the aged (FORTA) [in German]. Dtsch Med Wochenschr. 2008; 133: 2289–2291. DOI: 10.1055/s-0028-1091275
  3. Wehling M. Multimorbidity and polypharmacy: how to reduce the harmful drug load and yet add needed drugs in the elderly? Proposal of a new drug classification: fit for the aged. J Am Geriatr Soc. 2009; 57: 560–561. DOI: 10.1111/j.1532-5415.2009.02131.x
  4. Michalek C., Wehling M., Schlitzer J., Frohnhofen H. Effects of «Fit fOR The Aged» (FORTA) on pharmacotherapy and clinical endpoints — a pilot randomized controlled study. Eur J Clin Pharmacol. 2014; 70: 1261–1267. DOI: 10.1007/s00228-014-1731-9
  5. Wehling M., Burkhardt H., Kuhn-Thiel A. M., Pazan F., Throm C., Weiss C. et al. VALFORTA – a randomized trial to validate the FORTA («Fit fOR The Aged») classification. Age Ageing. 2016; 45: 262–267. DOI: 10.1093/ageing/afv200
  6. Pazan F., Burkhardt H., Frohnhofen H., Weiss C., Throm C., Kuhn-Thiel A. et al. Changes in prescription patterns in older hospitalized patients: the impact of FORTA on disease-related over- and under-treatments. Eur J Clin Pharmacol. 2018; 74: 339–347. DOI: 10.1007/s00228-017-2383-3
  7. Kuhn-Thiel A. M., Weiss C., Wehling M.; FORTA Authors/Expert Panel Members. Consensus validation of the FORTA (Fit fOR The Aged) list: a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly. Drugs Aging. 2014; 31: 131–140. DOI: 10.1007/s40266-013-0146-0
  8. Pazan F., Weiss C., Wehling M. FORTA. The FORTA (Fit fOR The Aged) List 2015: update of a validated clinical tool for improved pharmacotherapy in the elderly. Drugs Aging. 2016; 33: 447–449. DOI: 10.1007/s40266-016-0371-4
  9. Wehling M., Collins R., Gil V. M., Hanon O., Hardt R., Hoffmeister M. et al. Appropriateness of oral anticoagulants for the long-term treatment of atrial fibrillation in older people. Results of an Evidence-Based Review and International Consensus Validation Process (OAC-FORTA 2016). Drugs Aging. 2017; 34 (7): 499–507. DOI: 10.1007/s40266-017-0466-6
  10. Pazan F., Weiss C., Wehling M.; FORTA. The FORTA (Fit fOR The Aged) List 2018: Third Version of a Validated Clinical Tool for Improved Drug Treatment in Older People. Drugs Aging. 2019; 36(5): 481–484. DOI: 10.1007/s40266-019-00669-6
  11. Granger C. B., Alexander J. H., McMurray J. J., Lopes R. D., Hylek E. M., Hanna M. et al.; ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011; 365(11): 981–992. DOI: 10.1056/NEJMoa1107039
  12. Halvorsen S., Atar D., Yang H., De Caterina R., Erol C., Garcia D. et al. Efficacy and safety of apixaban compared with warfarin according to age for stroke prevention in atrial fibrillation: observations from the ARISTOTLE trial. Eur Heart J. 2014; 35(28): 1864–1872. DOI: 10.1093/eurheartj/ehu046
  13. Deitelzweig S., Luo X., Gupta K., Trocio J., Mardekian J., Curtice T. et al. Comparison of effectiveness and safety of treatment with apixaban vs. other oral anticoagulants among elderly nonvalvular atrial fibrillation patients. Current Medical Research and Opinion 2017; 33 (10): 1745–1754. DOI: 10.1080/03007995.2017.1334638
  14. Graham D. J., Baro E., Zhang R., Liao J., Wernecke M., Reichman M. E. et al. Comparative Stroke, Bleeding, and Mortality Risks in Older Medicare Patients Treated with Oral Anticoagulants for Nonvalvular Atrial Fibrillation. Am J Med. 2019; 132(5): 596–604.e11. DOI: 10.1016/j.amjmed.2018.12.023
  15. Yao X., Shah N. D., Sangaralingham L. R., Gersh B. J., Noseworthy P. A. Non-Vitamin K Antagonist Oral Anticoagulant Dosing in Patients With Atrial Fibrillation and Renal Dysfunction. J Am Coll Cardiol. 2017; 69(23): 2779–2790. DOI: 10.1016/j.jacc.2017.03.600.
  16. Alexander J. H., Andersson U., Lopes R. D., Hijazi Z., Hohnloser S. H., Ezekowitz J. A. et al.; for the ARISTOTLE Investigators. Apixaban 5 mg Twice Daily and Clinical Outcomes in Patients With Atrial Fibrillation and Advanced Age, Low Body Weight, or High Creatinine A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol. 2016; 1(6): 673–681. DOI:10.1001/jamacardio.2016.1829
  17. Alexander K. P., Brouwer M. A., Mulder H., Vinereanu D., Lopes R. D., Proietti M. et al.; ARISTOTLE Investigators. Outcomes of apixaban versus warfarin in patients with atrial fibrillation and multi-morbidity: Insights from the ARISTOTLE trial. Am Heart J. 2019; 208: 123–131. DOI: 10.1016/j.ahj.2018.09.017
  18. Старческая астения. Клинические рекомендации. 2018; http://rgnkc.ru/images/pdf_documets/Asteniya_final_2018.pdf
  19. Walston J., McBurnie M.A., Newman A., Tracy R. P., Kop W. J., Hirsch C. H. et al.; Cardiovascular Health Study. Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the Cardiovascular Health Study. Arch Intern Med. 2002; 162: 2333–2341.
  20. Kim S., Yoon S., Choi J., Kang M. G., Cho Y., Oh I. Y. et al. Clinical implication of frailty assessment in older patients with atrial fibrillation. Arch Gerontol Geriatr. 2017; 70: 1–7. DOI: 10.1016/j.archger.2016.12.001
  21. Perera V., Bajorek B. V., Matthews S., Hilmer S. N. The impact of frailty on the utilisation of antithrombotic therapy in older patients with atrial fibrillation. Age Ageing. 2009; 38: 156–162. DOI: 10.1093/ageing/afn293
  22. Marzona I., O’Donnell M., Teo K., Gao P., Anderson C., Bosch J. et al. Increased risk of cognitive and functional decline in patients with atrial fibrillation: results of the ONTARGET and TRANSCEND studies. CMAJ. 2012; 184 (6): E329–E336. DOI: 10.1503/cmaj.111173.

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