Older adults who develop a dangerous blood clot often need months or years of treatment to prevent another clot from forming.
New research suggests that the choice of blood-thinning medicine may affect not only the risk of serious complications, but also how much time patients are able to spend at home.
The study was led by researchers at the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife. It was published in the American Journal of Hematology and examined more than 18,000 older adults covered by Medicare.
The researchers focused on venous thromboembolism, often shortened to VTE. This term includes deep vein thrombosis, in which a clot usually develops in a deep vein in the leg, and pulmonary embolism, which occurs when a clot travels to the lungs.
A pulmonary embolism can block blood flow through the lungs and can become life-threatening. Even after treatment of the first clot, patients can remain at risk of another event, so doctors often prescribe medicines called anticoagulants to reduce the blood’s ability to form harmful clots.
Three commonly used oral anticoagulants were compared in the study: apixaban, sold under the brand name Eliquis; rivaroxaban; and warfarin, an older drug sold under names including Coumadin and Jantoven. Each medicine can prevent clots, but they differ in how they are taken, monitored and processed by the body.
Warfarin has been used for decades and can be highly effective, but patients usually need regular blood tests and careful dose adjustments. It can also interact with certain foods and medicines, which may make treatment more complicated.
Newer drugs such as apixaban and rivaroxaban generally require less routine monitoring. However, choosing the best drug can be especially challenging for older people, who may have several medical conditions, take many medicines or be more vulnerable to bleeding.
The researchers used Medicare claims from 2015 through 2019 to compare outcomes after an acute blood clot. They looked at recurrent clots, death, major bleeding and a patient-centered measure called home time.
Home time measures how many days a person is able to remain outside hospitals, emergency departments and skilled nursing facilities. It also accounts for time lost because of death, making it a useful way to describe the broader impact of illness on an older person’s independence.
Compared with warfarin, apixaban was associated with a lower combined risk of another blood clot or death during the following year. It was also linked with fewer episodes of major bleeding, one of the most important risks of anticoagulant treatment.
People taking apixaban also lost fewer days at home. In practical terms, this suggests that they spent less time in hospitals or nursing facilities, an outcome that may matter as much to some older adults as traditional medical measures.
Rivaroxaban did not show the same clear advantage over warfarin for preventing major complications. It was also associated with more home-time loss than apixaban, although comparisons from an observational study must be interpreted cautiously.
A major strength of the research was its attention to frailty. Frailty describes reduced physical reserve and resilience, meaning that an illness, fall or other stress can have a much greater effect on a frail person than on a healthier adult of the same age.
Frail adults are frequently left out of clinical trials, even though they are among the people most likely to need treatment for blood clots. The researchers therefore examined frail and non-frail patients separately.
Apixaban’s favorable results compared with warfarin were seen in both groups, although the clearest benefits appeared among adults who were not frail. This gives doctors useful real-world information when discussing treatment with patients whose health and physical abilities vary widely.
The study does not prove that apixaban itself caused the better outcomes. Researchers analyzed existing Medicare records rather than randomly assigning patients to different medicines, so differences between the groups could have influenced the results even after statistical adjustments.
Claims data also provide less detailed clinical information than a carefully controlled trial. Factors such as why a particular doctor selected one drug, how consistently patients took it and some differences in overall health may be difficult to capture completely.
Still, the study has important strengths, including its large number of older patients and its focus on outcomes that matter in everyday life. Looking at days spent at home gives a fuller picture than simply counting clots or bleeding events.
Overall, the findings suggest that apixaban may offer a favorable combination of effectiveness, bleeding safety and independence for many older adults being treated for VTE. Treatment must still be individualized because kidney function, other medicines, bleeding risk, cost and personal preferences can all affect which anticoagulant is most appropriate.
The study therefore supports a conversation rather than a one-size-fits-all answer. For older adults and their families, the best blood thinner may be the one that not only prevents another dangerous clot but also helps preserve the person’s ability to recover and live at home.
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Source: Hebrew SeniorLife.
