Which direct oral anticoagulant (DOAC) should be used with caution in older adults due to an increased risk of GI bleeding compared with warfarin?

• A. Apixaban
• B. Dabigatran
• C. Rivaroxaban
• D. Warfarin

Answer: (B)

In older adults, GI bleeding risk is a key safety consideration when choosing an oral anticoagulant. Among the direct oral anticoagulants, dabigatran stands out because it is associated with a higher risk of GI bleeding compared with warfarin, especially at the higher 150 mg dose. This increased risk is tied to its pharmacology and how older patients process the drug: dabigatran is a direct thrombin inhibitor that is largely cleared by the kidneys, so reduced renal function often seen with aging leads to higher drug exposure and more bleeding risk. Clinical trial data comparing dabigatran to warfarin showed more major GI bleeding with the higher dose, which is why clinicians exercise particular caution when using it in the elderly or in patients with GI risk factors. Other DOACs may have neutral or even lower GI bleeding risk relative to warfarin, so the emphasis here is on dabigatran’s greater GI bleeding risk in this population.