Prior to QMR

• Review the Quarterly Medication Review Deprescribing Focus – Optimizing Anticoagulation
• Determine the indication for OAC and the appropriate duration of treatment
• Assess the resident’s benefit and risk with receiving OAC
• For resident’s older than 65 years of age with atrial fibrillation, assess their risk of stroke by using the CHADS-65 score (see Figure 1 on page 2) and their risk of bleeding by calculating their HAS-BLED Score
• Reassess the dose of the anticoagulant based on resident-specific factors (e.g., renal function, indication) to ensure they are receiving the appropriate dose (see Table 2 on page 6)
• Assess for any issues with the resident taking the anticoagulant (e.g. warfarin—review recent INR levels; DOACs—taking as per manufacturer’s recommendations)
• Assess for any potential drug interactions or concomitant medications that may increase the risk of bleeding (e.g. antiplatelets, SSRIs, NSAIDs). Assess if the resident requires GI protection. 

During the QMR

• For nonvalvular atrial fibrillation with or without CAD, a DOAC is preferred over warfarin.³ For residents on warfarin with nonvalvular AF, consider switching to a DOAC.
• Reassess residents taking an antiplatelet for CAD and an OAC for AF. If CAD is stable, e.g. at least 12-months post-ACS, consider deprescribing the antiplatelet (see Figure 2 on page 3).
• Reassess residents taking an OAC for prevention of DVT or PE. Consider the duration since the DVT/PE occurred and the cause of the DVT/PE, if known, to identify residents who no longer require the OAC (see Table 1 on page 4).
• Inappropriate dosing of DOACs (either too high or too low) is common in elderly populations¹². Ensure residents are on the appropriate dose of their DOAC (see Table 2 on page 6). If CrCl less than 15 mL/min, discuss with nephrology.
• Apixaban was associated with superior safety, efficacy, effectiveness, and lower mortality than vitamin K antagonists (e.g. warfarin); superior safety than rivaroxaban and similar safety to dabigatran; and with similar effectiveness when compared with rivaroxaban or dabigatran¹¹. Compared to warfarin and rivaroxaban, apixaban is the anticoagulant with the highest benefit-risk ratio for older adults with atrial fibrillation²³.
• Apixaban is now available from generic companies, so it is the most cost-effective DOAC (see Table 3 on page 7).
• Apixaban is the preferred DOAC for PCH residents so consider switching residents from other DOACs to apixaban.
• Older adults with AF benefit from stroke prevention with anticoagulation even if they are at high risk of falls. Fall risk should not be a deciding factor for withholding anticoagulation in this population.²
• ASA alone is not sufficient for stroke prevention in older adults with atrial fibrillation. The stroke prevention benefit from apixaban was shown to be greater with no increased risk of hemorrhage (NNT=26 for 75 years and older and NNT=15 for 85 years and older).¹⁵