When do we reduce anticoagulation (anti-clotting medication) dosage versus discontinuing it due to high fall risk in patients on anticoagulants like apixaban (apixaban) or warfarin (warfarin)?

Managing Anticoagulation in Patients with High Fall Risk

For patients with high fall risk, anticoagulation should generally be continued rather than discontinued, as the benefit of stroke prevention typically outweighs the bleeding risk, but dose reduction may be appropriate in specific circumstances with multiple risk factors. 1, 2

Assessment of Fall Risk vs. Thrombotic Risk

• Patients with atrial fibrillation and a history of falling have higher rates of major bleeding (including intracranial bleeding) and death, but similar rates of stroke or systemic embolism compared to those without fall history 1
• Despite fall risk, anticoagulation provides net clinical benefit in most patients, as the risk of thromboembolic events typically outweighs bleeding risk 2
• Modeling studies suggest an older adult would need to fall over 45 times per year (rivaroxaban) or 458 times per year (apixaban) for the quality-adjusted life-years to be lower than using aspirin alone 2

When to Consider Dose Reduction

Appropriate Dose Reduction Criteria:

• For apixaban: Reduce dose to 2.5 mg twice daily when patient has at least two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 3
• For rivaroxaban: Reduce dose to 15 mg daily when creatinine clearance is 15-50 mL/min 4
• For edoxaban: Reduce dose to 30 mg daily when creatinine clearance is 15-50 mL/min 4
• For dabigatran: Reduce dose to 75 mg twice daily when creatinine clearance is 15-30 mL/min 4

High-Risk Scenarios for Dose Reduction:

• Elderly patients (>75 years) with multiple fall risk factors and at least one dose reduction criterion 4
• Patients with history of intracranial bleeding and high fall risk 4
• Patients with concurrent use of medications that increase bleeding risk (e.g., antiplatelets, NSAIDs) 4
• Patients with fluctuating or decreased renal function 4

When to Consider Discontinuation

Temporary Discontinuation:

• After intracranial hemorrhage: Discontinue for 1-2 weeks, as this carries a relatively low probability of embolic events (2.6-4.8% at 30 days) even in high-risk patients 5
• Prior to surgical procedures: Discontinue apixaban 24-48 hours before procedures depending on bleeding risk 3

Permanent Discontinuation (Rare):

• Patients with suspected cerebral amyloid angiopathy 4
• Patients with lobar intracerebral hemorrhage 4
• Patients with >10 cerebral microbleeds on MRI 4
• Patients with disseminated cortical superficial siderosis on MRI 4
• Patients with untreated symptomatic vascular malformation or aneurysm 4

Practical Approach to Management

1. Assess stroke risk using CHA₂DS₂-VASc score 4

2. Evaluate bleeding risk factors including:

   • History of prior falls 4
   • Age >80 years 4
   • Renal function 4
   • Medication interactions 4
   • History of prior bleeding 4
   • Uncontrolled hypertension 4

3. Choose appropriate anticoagulant:

   • Direct oral anticoagulants (DOACs) are preferred over warfarin in patients with fall risk 1
   • Apixaban may have the most favorable safety profile in patients with fall risk (no subdural bleeding events observed in the ARISTOTLE trial among patients with history of falls) 1

4. Monitor and reassess regularly:

   • Evaluate renal function at least annually 4
   • Assess for new medication interactions 4
   • Re-evaluate fall risk and implement fall prevention strategies 4

Common Pitfalls to Avoid

• Discontinuing anticoagulation based solely on fall risk without considering stroke risk 6, 2
• Underdosing anticoagulants without meeting established dose reduction criteria 4
• Failing to restart anticoagulation after temporary discontinuation for procedures or bleeding events 4
• Continuing antiplatelet therapy alongside anticoagulation beyond recommended duration, which increases bleeding risk without additional benefit 4

Remember that provider decisions on anticoagulation are often guided more by concerns over bleeding complications than by patient's risk for stroke, which may lead to inappropriate discontinuation or underdosing 6. The evidence strongly suggests that for most patients with atrial fibrillation, the benefits of anticoagulation outweigh the risks, even in those with high fall risk 1, 2.