DOACs and warfarin beneficial for older AF patients according to FORTA classification
Appropriateness of Oral Anticoagulants for the Long-Term Treatment of Atrial Fibrillation in Older People: Results of an Evidence-Based Review and International Consensus Validation Process (OAC-FORTA 2016)Wehling M, Collins R, Gil VM, et al. - Drugs Aging. 2017; published online ahead of print
The prevalence of atrial fibrillation (AF) rises with age and anticoagulants are most often used in older AF patients . However, it is not clear whether long-term anticoagulation treatment for AF patients at older ages is appropriate [2,3].
The Fit-fOR-The-Aged (FORTA) classification is based on benefit, risk and appropriateness of drugs for older patients in everyday clinical settings [4,5]. In the randomized controlled trial VALFORTA, FORTA significantly improved medication quality, as measured by FORTA score that adds over- and undertreatment errors, and it reduced adverse drug effects at a number needed to treat of only five . Categories include: Forta-A - highly beneficial, FORTA-B - beneficial, FORTA-C - questionable and FORTA-D - don’t.
In this analysis, the FORTA classification was used to classify eight anticoagulants (vitamin K antagonists [VKA] acenocoumarol, fluindione, phenprocoumon, warfarin and DOACs apixaban, dabigatran, edoxaban and rivaroxaban) as appropriate or inappropriate drugs to prevent stroke in older AF patients, based on efficacy, safety and tolerability. This was based on a structured comprehensive literature review and a subsequent two-step assessment approach.
- No item was assigned the FORTA-D label.
- Three VKAs (phenprocoumon, acenocoumarol and fluindione) were labelled FORTA-C, mainly reflecting the lack of study data in older AF patients. This category indicates that the given therapeutic approach requires even more intense monitoring compared with well-studied therapies for a given indication.
- Warfarin, dabigatran, edoxaban and rivaroxaban were labelled B, which means that older AF patients can be safely and effectively treated with these medications. Medications in this category are standard treatments for the given indication.
- Apixaban was labelled A, meaning it was seen as the drug with the most beneficial risk–benefit ratio in this group. This differentiation was mainly based on the fact that endpoint superiority was most prominent for apixaban.
All DOACs and warfarin were classified as beneficial or very beneficial in older AF patients (FORTA-A or -B), underlining the overall positive assessment of the risk-benefit ratio for these drugs based on available evidence. For other VKAs (FORTA-C) regionally used in Europe, the lack of evidence should challenge current practice.