When doctors treat an older person for a serious blood clot, preventing another clot is only one part of the goal.
Avoiding dangerous bleeding, reducing hospital stays and helping the person remain independent can be just as important, and a new study suggests one commonly prescribed medicine may perform particularly well across these areas.
Researchers from the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife and collaborating institutions studied more than 18,000 Medicare beneficiaries. Their findings were published in the American Journal of Hematology.
The patients had been treated for venous thromboembolism, a condition in which a blood clot forms in a vein. It can appear as deep vein thrombosis in the leg or as a pulmonary embolism when part of a clot reaches the lungs.
Blood clots become more common with age and can cause severe illness or death. After someone experiences one clot, the chance of another can remain high, which is why long-term blood-thinning treatment is often needed.
Blood thinners do not literally make blood watery. Instead, anticoagulant medicines interfere with the body’s clotting process so that dangerous clots are less likely to form or grow.
The challenge is finding a balance. Too little anticoagulant protection can allow another clot to develop, while too much can increase the chance of serious bleeding in the brain, digestive system or elsewhere.
This balance can be particularly difficult in older adults. Kidney function may decline with age, people may take several medicines at once, and falls or other health problems can increase the consequences of bleeding.
The researchers compared three widely prescribed medicines: apixaban, rivaroxaban and warfarin. They analyzed Medicare information collected from 2015 to 2019 and followed outcomes for up to one year after treatment for an acute clot.
Warfarin has been a standard anticoagulant for many years, but using it often requires repeated blood tests to make sure the dose is neither too weak nor too strong. Newer anticoagulants such as apixaban and rivaroxaban are easier to use in some respects because routine blood-level monitoring is generally not required.
The study found that apixaban was associated with better outcomes than warfarin on several important measures. Patients taking apixaban had a lower combined risk of suffering another venous blood clot or dying during the year after treatment.
They also experienced less major bleeding. That finding is important because bleeding is one of the main concerns when doctors prescribe long-term anticoagulants to older patients.
But the researchers went beyond standard medical outcomes. They also measured ‘home time,’ which reflects how much of the year a patient spends at home instead of in a hospital, emergency department or skilled nursing facility.
Days lost because of death were included as well. This measure is increasingly useful in studies of older adults because it reflects something many patients strongly value: being alive, independent and outside an institution.
Patients treated with apixaban lost fewer days of home time than those treated with warfarin. Apixaban also compared favorably with rivaroxaban, which was associated with greater loss of time at home.
Rivaroxaban showed no clear advantage over warfarin for the main complications studied. This does not mean rivaroxaban is unsuitable for every older patient, because individual circumstances can make one anticoagulant more appropriate than another.
Another important feature of the study was the researchers’ examination of frailty. Frailty is not simply old age; it describes a state in which the body has less ability to recover from illness, injury or other physical stress.
Frail patients can respond differently to medicines and may face greater risks from both blood clots and bleeding. Yet they are often underrepresented in clinical trials, leaving doctors with less evidence to guide treatment decisions.
In this real-world Medicare population, apixaban’s advantages over warfarin were observed among both frail and non-frail adults. The differences were strongest among non-frail patients, suggesting that frailty may still influence the size of the benefit.
The large sample and focus on older adults are important strengths of the study. Including home time also makes the research more relevant to patients and families who care about quality of life and independence, not just laboratory numbers or diagnoses.
However, this was not a randomized clinical trial. Doctors had already chosen each patient’s medication, so people receiving apixaban, rivaroxaban or warfarin may have differed in ways that influenced their outcomes.
Researchers can use statistical methods to account for many differences, but they cannot remove every possible source of bias from Medicare records. The results therefore show strong associations rather than proving that one medicine directly caused patients to live longer or spend more time at home.
Even so, the findings add useful evidence for treatment decisions in a population that is often medically complex. They suggest that apixaban may provide a strong balance between preventing recurrent clots, limiting major bleeding and preserving time outside hospitals and nursing facilities.
For an individual patient, the final choice still depends on factors such as kidney health, other medications, previous bleeding, cost and personal treatment goals. The study’s broader message is that when treating blood clots in older adults, success should include not only preventing another clot but also helping people remain safely at home for as much of their lives as possible.
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Source: Hebrew SeniorLife.
