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Clinical Articles, Lead Article

NOACs carry different bleeding risks for elderly

Non-vitamin K antagonist oral anticoagulants (NOACs) have equal efficacy to older treatments, but carry different risk of bleeding complications in the elderly, finds a study published recently in Circulation.1

The meta-analysis, led by researchers from King’s College London, is the first to assess all available evidence for efficacy and bleeding outcomes of direct anticoagulants in elderly patients treated for stroke prevention. The authors analysed 11 trials which reported on elderly participants aged 75 years or older and found that all the direct anticoagulant drugs were equal to or better than the older vitamin K antagonists in managing stroke risks.

Dabigatran 150 mg, one of the direct anticoagulants, was associated with a 78% higher risk of gastrointestinal bleeding than older vitamin K antagonist anticoagulants such as warfarin. However, the study also found 150 mg dabigatran had a 57% lower risk of intracranial bleeding than vitamin K antagonists in the elderly.

The other direct anticoagulants, apixaban and edoxaban, had a lower major bleeding risk compared to vitamin K antagonists, while rivaroxaban showed similar risk. The authors noted that insufficient published data for apixaban, edoxaban and rivaroxaban meant that all bleeding risks, particularly gastrointestinal risks could not be fully explored in the elderly.

Dr Manuj Sharma (Guy’s and St Thomas’ Hospital NHS Foundation Trust)

Dr Manuj Sharma (Guy’s and St Thomas’ Hospital NHS Foundation Trust)

Senior author Dr Mariam Molokhia (Department of Primary Care and Public Health, King’s College London) said: “Our study suggests that caution is required in prescribing where there may be additional risk factors for gastrointestinal bleeding in the elderly, particularly with the anticoagulant dabigatran”.

“To determine bleeding risks further for these drugs, better availability of existing unpublished trial data is needed, in addition to more research,” Dr Molokhia added.

Lead author Dr Manuj Sharma (Guy’s and St Thomas’ Hospital NHS Foundation Trust) said: “Though intracranial bleeds are more often life threatening when they occur, gastrointestinal bleeds are more common and can also have devastating effects. Hence it is important the anticoagulant chosen for a particular patient balances the benefit and risks of the particular drug against the history and risk profile for the patient being treated.”


1. Sharma M, Cornelius VR, Patel JP, Davies JG, Molokhia M. Efficacy and harms of direct oral anticoagulants in the elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism. Circulation 2015;132:194–204.

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Published on: July 30, 2015

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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