Compared with DOACs, warfarin in older adults with nonvalvular AF or VTE generally has which bleeding risk and effectiveness profile?

• A. Warfarin has higher major bleeding risk and similar or lower effectiveness
• B. Warfarin is safer than DOACs in all cases
• C. DOACs are rarely used due to bleeding risk
• D. Warfarin provides better net benefit in older adults

Answer: (A)

The main idea is that direct oral anticoagulants offer at least as good protection against stroke or VTE as warfarin in older adults, but with a safer bleeding profile overall. Warfarin has a narrow therapeutic window and is highly sensitive to drug and food interactions, plus it requires regular INR monitoring and dose adjustments. In older patients, this makes stable anticoagulation harder to achieve, increasing the chances of periods of over-anticoagulation and major bleeding. Direct oral anticoagulants, by contrast, have more predictable effects, fewer interactions, and fixed dosing, which generally leads to lower rates of major bleeding—especially intracranial hemorrhage—while not compromising, and often preserving or improving, effectiveness in preventing thromboembolism. There can be concern about GI bleeding with some DOACs, but the overall bleeding risk tends to be lower with DOACs, and the net clinical benefit in many older patients is greater.