Caution must be used when prescribing direct oral anticoagulants to older patients, especially those in a frail condition, according to an opinion piece by Anne-Laure Sennesael and her associates.

In the case study, an 86-year-old woman weighing 55 kg was admitted to an emergency department with persistent epistaxis. The patient was taking 20 mg of rivaroxaban and 80 mg of aspirin daily. There was a history of peripheral arterial disease, and the patient had received a bioprosthetic heart implant 4 years prior. Creatinine clearance was 21 mL/min, hemoglobin was 9.4 g/dL, and prothrombin time Quick value was 30%.

Rivaroxaban was discontinued, and the patient was switched to a new anticoagulant, acenocoumarol. Aspirin also was discontinued, and the patient was discharged, reported Ms. Sennesael, of the Université catholique de Louvain in Brussels.

Use of direct oral anticoagulants (DOACs) are increasing rapidly, the authors write, mostly because doctors and patients view them as more convenient to use. However, in some patients, vitamin K antagonists (VKAs) remain the best course of treatment. In this case, the patient was receiving too much rivaroxaban in light of her low creatinine level. In addition, aspirin plus a DOAC is not appropriate, as it increases the risk of major bleeding significantly.

“A conservative strategy may be more valuable,” Ms. Sennesael and her associates wrote. “This kind of ‘less is more’ approach includes avoiding prescribing DOACs rather than VKAs without clear, compelling, evidence-based reasons; regularly reassessing renal function; monitoring for adverse effects; and reappraising aspirin prescription.”

Read the full study at JAMA Internal Medicine (doi:10.1001/jamainternmed.2015.3589).