Expert Discusses Navigating Anticoagulation in Older Adults | APhA 2025
Elizabeth Pogge, PharmD, professor in the College of Pharmacy at Midwestern University, discusses initiating anticoagulation for older adults as well as the risk-benefit balance of the therapy.
Elizabeth Pogge, PharmD, professor in the College of Pharmacy at Midwestern University, focuses on risk assessment and anticoagulation management for older adults with atrial fibrillation, emphasizing the critical role of comprehensive risk scoring systems. The CHADS2-VASc score is highlighted as a primary tool for evaluating stroke risk, with age being a particularly significant factor. Individuals over 65 receive one point, while those over 75 receive 2 points, underscoring the increased stroke vulnerability with advancing age.
When assessing bleeding risks, Pogge recommends using the HAS-BLED scoring system, which considers reversible factors like uncontrolled hypertension, peptic ulcer disease, alcohol consumption, and concurrent antiplatelet medications. For older adults, additional bleeding risk factors include falls, frailty, and potential complications from conditions like dementia. She emphasizes the importance of evaluating a patient's overall health status, life expectancy, and potential lag time to intervention benefit.
Recent guidelines from the American Geriatric Society and American College of Cardiology provide crucial recommendations for anticoagulation in older adults. The 2023 Beers Criteria advise caution with certain anticoagulants, specifically recommending against rivaroxaban and Warfarin due to higher bleeding risks. Instead, apixaban and dabigatran are preferred for treating atrial fibrillation and venous thromboembolism. Practical resources like the DOAC Playbook and European Heart Rhythm Society guidelines offer clinicians detailed guidance on managing direct oral anticoagulants. When initiating anticoagulation, key considerations include updating laboratory tests, calculating creatinine clearance, assessing renal function, and identifying reversible bleeding risk factors.
Pogge recommends regular monitoring through specialized anticoagulation clinics, conducting periodic lab tests to track CBC, renal and liver function, and potential drug-drug interactions. The ultimate goal is to balance stroke prevention with minimizing bleeding risks, particularly in vulnerable older adult populations.
"It's important to think about the patient in front of you and their bleed risk, and maybe drugs like apixaban or [doxazosin] might be more appropriate for an older adult, and so you need to think about what is the appropriate dose for them based on the package labeling," Pogge said.
