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Direct Oral Anticoagulant Dosing in Patients With ...
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Article: Non–Vitamin K Antagonist Oral Anticoagulant Dosing in Patients With Atrial Fibrillation: An Asian Perspective
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The increasing prevalence of atrial fibrillation (AF) among the elderly Asian population poses significant challenges in the dosing of direct oral anticoagulants (DOACs) for stroke prevention, especially in patients considered to be in the "gray area" (e.g., very elderly, low body weight, high bleeding risk). This systematic review addresses the complexities faced in optimal DOAC dosing in Asia and highlights the clinical practice discrepancies.<br /><br />The review examines regional variations in DOAC dosing, the prevalence of nonrecommended dosing, and outcomes associated with such practices. Evidence from trials like the ELDERCARE-AF highlights that while low-dose DOACs can be effective and safer for high-risk elderly patients, clinicians often prescribe nonrecommended low doses out of fear of bleeding, overlooking the potential clinical benefits of higher on-label doses.<br /><br />The criteria for DOAC dose reduction are rigorously outlined, particularly for the elderly and those with low body weight or reduced renal function. The study emphasizes the need for clinicians to adhere to on-label dosing guidelines to achieve better clinical outcomes and reduce the risk of stroke and bleeding. <br /><br />Further, the review calls for enhanced therapeutic drug monitoring (TDM) in specific clinical settings (e.g., severe bleeding, VLBW, impaired kidney function) and suggests that more research is needed to refine DOAC dose reduction criteria to include additional high-risk patient characteristics.<br /><br />The consensus underscores the impact of demographic differences between Asian and non-Asian populations on DOAC treatment, accentuating that Asian patients tend to be older with a higher risk of bleeding. Moving forward, the review advocates for comprehensive patient assessments and shared decision-making to ensure optimal DOAC dosing in the complex landscape of AF management in Asia.<br /><br />In summary, while DOACs are effective and safer than warfarin, achieving optimal dosing in very elderly, frail, or low body weight patients remains a critical and complex issue that requires further targeted research and refined clinical guidelines.
Keywords
atrial fibrillation
elderly Asian population
direct oral anticoagulants
stroke prevention
DOAC dosing
clinical practice discrepancies
therapeutic drug monitoring
high-risk patients
on-label dosing
Asian demographics
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