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)

Literature - 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 [1]. 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 [6]. 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.

Main results

  • 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.


1. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke.1991;22:983–8.

2. Wehling M. Drug therapy in the elderly: too much or too little, what to do? A new assessment system: fit for the aged (FORTA) [in German]. Dtsch Med Wochenschr. 2008;133:2289–91.

3. Wehling M. Multimorbidity and polypharmacy: how to reduce the harmful drug load and yet add needed drugs in the elderly? Proposal of a new drug classification: fit for the aged. J Am Geriatr Soc. 2009;57:560–1.

4. Kuhn-Thiel A, Weiss C. Wehling M; FORTA authors/expert panel members. Consensus validation of the FORTA (Fit fOR The Aged) list: a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly. Drugs Aging. 2014;31:131–40.

5. Pazan F, Weiss C, Wehling M. The FORTA (Fit fOR The Aged) list 2015: update of a validated clinical tool for improved pharmacotherapy in the elderly. Drugs Aging. 2016;33:447–9.

6. Wehling M, Burkhardt H, Kuhn-Thiel A, et al. VALFORTA: a randomized trial to validate the FORTA (Fit fOR The Aged) classification. Age Ageing. 2016;45:262–7.

Find this article online at Drugs & Aging

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