Reduced Dose Direct Oral Anticoagulants in Older Adults with Atrial Fibrillation

Purpose of ReviewDoses of direct oral anticoagulants (DOACs) are often reduced in older adults based on age, renal function, and bleeding risk. This review assesses recent evidence for safety and efficacy of reduced dose DOAC regimens in older adults.Recent FindingsDabigatran 110mg twice daily shows similar efficacy and similar or lower bleeding risk compared to 150mg twice daily in several studies. Dabigatran 110mg is approved outside the USA and can be considered in ages >75-80, or in patients with a propensity for higher dabigatran blood levels. Rivaroxaban 15mg, apixaban 2.5mg, and edoxaban 30mg are safe and effective when used appropriately in patients who qualify based on labeled dosing. Limited evidence suggests inappropriately dose-reduced DOACs may increase risk for thromboembolic events.SummaryBesides dabigatran, dose reduction of apixaban, rivaroxaban, and edoxaban should be limited to patients who qualify based on FDA-approved parameters. The risk of stroke and bleeding should be carefully considered and discussed with each patient when deciding whether to reduce a DOAC dose off-label.