An Age-Old Question: Warfarin or a Direct Oral Anticoagulant in Frail Adults?

Authors:
Stephanie Schafer, PharmD
Komel Shahid, PharmD
Matthew Cantrell, PharmD, BCPS

Reviewers:
Tiffany M. Gardner, PharmD
Kristin Watson, PharmD, MS, BCCP

Citation:
Joosten LPT, van Doorn S, van de Ven PM, et al. Safety of Switching From a Vitamin K Antagonist to a Non-Vitamin K Antagonist Oral Anticoagulant in Frail Older Patients With Atrial Fibrillation: Results of the FRAIL-AF Randomized Controlled Trial. Circulation. 2024;149(4):279-289. 

The Problem

Direct oral anticoagulants (DOACs) have revolutionized anticoagulation management for atrial fibrillation (AF) in patients at elevated risk for thromboembolic events since their emergence in 2010. Several DOACs are associated with lower bleeding rates and with a reduction in thromboembolism risk, notably stroke, compared to vitamin K antagonists (VKAs), such as warfarin. It is now uncommon to see VKA therapy initiated when a DOAC is indicated. However, quality patient care is never a “one-size-fits-all” approach. New evidence from the FRAIL-AF trial suggests that some of our most vulnerable older adults should be maintained on VKA to reduce the risk of stroke. Let’s take a closer look.