Anticoagulation is significantly underused in older adults, especially those who are frail and thus at risk for falls. Closing that treatment gap should be a focus for pharmacists who help manage these vulnerable patients, an expert said during APhA25, in Nashville, Tenn.
The reluctance to use anticoagulants is particularly acute for older adults who are newly diagnosed with atrial fibrillation (AFib): Less than half (48.7%) are prescribed oral anticoagulants (J Interv Card Electrophysiol 2023;66[3]:771-782).
This reluctance “oftentimes is related to a fear of adverse effects such as bleeding,” Elizabeth Pogge, PharmD, MPH, BCPS, BCGP, FASCP, a professor of pharmacy practice at Midwestern University College of Pharmacy, in Glendale, Ariz., told Pharmacy Practice News in an interview after the APhA25 meeting. Pharmacists can help lessen the chances that a bleed may occur “by reducing risk factors, making sure dosing is appropriate and checking for drug–drug interactions,” she said.
As an example, AFib is common in older adults, and anticoagulation—when appropriately used—is very effective for reducing the risk for stroke, Dr. Pogge said. Direct oral anticoagulants (DOACs) are recommended over warfarin for this population (Circulation 2023;149[1]:e1-e156). The 2023 American Geriatrics Society Beers Criteria provides guidance on which anticoagulants are best for older adults. They recommend avoiding rivaroxaban and warfarin if possible, and using caution when prescribing dabigatran, mostly related to an increased risk for major bleeding seen with these agents compared with apixaban (Eliquis, Bristol Myers Squibb) or edoxaban (Savaysa, Daiichi Sankyo).
The GARFIELD-AF registry followed more than 52,000 newly diagnosed patients with AFib, and found that older adults “can benefit from anticoagulation therapy when they have AFib because it reduces the risk of all-cause mortality, as well as the risk for nonhemorrhagic stroke,” Dr. Pogge said (Am J Med 2024;137[2]:128-136). However, anticoagulation also increases the risk for major bleeding in older adults. Because of this, the risk versus benefit should be considered when prescribing anticoagulants for older adults, she noted.
Scoring Tools
Pharmacists can use scoring tools such as the HAS-BLED, HEMORR2HAGES and ATRIA to identify a patient’s modifiable risk factors for bleeding, which include the use of alcohol and long-term nonsteroidal anti-inflammatory drugs (NSAIDs), or the presence of uncontrolled diabetes, Dr. Pogge noted. With the results, they can work with patients to try to reduce those risks, she said.
Aspirin is not a good alternative to anticoagulation for patients with a high risk for bleeding, she stressed. The AVERROES trial (Age Ageing 2016;45[1]:77-83) found that older adults had just as much bleeding with aspirin therapy as they did with apixaban, and with much less efficacy.
In addition, pharmacists should make sure patients are not taking extra antithrombotic therapy they don’t need, such as aspirin or clopidogrel. Generally, triple therapy (anticoagulation, aspirin and a P2Y12 inhibitor) should be limited to four weeks, and dual therapy (anticoagulation plus a P2Y12 inhibitor) should be limited to one year, Dr. Pogge said.
When a bleeding episode happens, there are several strategies to pursue, Dr. Pogge said. For minor bleeding not requiring hospitalization, observe the patient and consider interrupting the anticoagulant. Major bleeding requiring hospitalization, which can occur in patients on blood thinners, may be treated with idarucizumab (Praxbind, Boehringer Ingelheim) for bleeding caused by dabigatran, or andexanet alfa (Andexxa, AstraZeneca) for bleeding caused by factor Xa inhibitor, prothrombin complex concentrate (PCC) or activated PCC (J Am Coll Cardiol 2020;76:594-622).
Once the bleeding has been managed, assess the risk versus benefit of restarting anticoagulation, she said. Most patients’ therapy can be restarted once hemostasis has been achieved. After an intracranial hemorrhage, however, delay resumption for at least four weeks.
Pharmacists also can play a vital role in assessing patients for drug–drug interactions that may increase the risk for bleeding, Dr. Pogge said, such as antiplatelet drugs, NSAIDs, systemic steroid therapy and other anticoagulants. Some examples of commonly used medications that increase anticoagulation levels include amiodarone, diltiazem/verapamil, dronedarone, cyclosporine/tacrolimus, azole antifungals, HIV protease inhibitors and anticancer agents. Some medications, such as carbamazepine, levetiracetam, phenytoin/phenobarbital, rifampin and the herb St. John’s wort can reduce anticoagulation levels (Eurospace 2021;23[10]:1612-1676).
Although older adults have a tendency to fall, with a mean of 1.81 falls per year, falling does not always equal bleeding, Dr. Pogge said. Studies have indicated that a person would have to fall hundreds of times a year for the risk for a subdural hematoma to outweigh the benefits of anticoagulation (J Am Coll Cardiol 2022;72[2]:166-179). For patients with chronic kidney disease, apixaban is the drug of choice because it has the lowest renal excretion, she said.
Health Literacy and Other Factors
Additional considerations in working with this patient population include health literacy, polypharmacy and medication adherence, said Megan Lang, PharmD, BCACP, the manager of the anticoagulation clinic at the University of California, San Diego. Medication cost, access to care, and other social determinants of health such as transportation also should be part of treatment planning, she told PPN. “You want to be as cautious as possible for fall and bleeding risks,” said Dr. Lang, noting that her team also collects a hemoglobin count at every clinic visit as an additional step to monitor for bleeding.
Despite the known risk for bleeding associated with warfarin or other anticoagulants, patients still prefer to use these medications, Dr. Lang said. “I’ve even seen some patients who have been placed on hospice [care] continue to take warfarin because the patient or their family are afraid of a stroke.”
Drs. Lang and Pogge reported no relevant financial disclosures.
This article is from the July 2025 print issue.