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Gertrude Green is a 73 year old female presenting to the clinic with a request to change her anticoagulant regimen. She is currently taking warfarin 5mg daily for atrial fibrillation but does not like the frequent laboratory monitoring necessary to make sure the drug levels are therapeutic within her body. She also has moderate renal insufficiency. Mrs. Green is taking the warfarin, diltiazem 120mg twice a day, and Januvia 50mg daily.

The clinical practice guideline indicates that patients with a > 2% risk for thromboembolism should receive anticoagulation therapy. Mrs. Greenâ€™s atrial fibrillation qualifies her for this metric. The guidelines also outline that risks and benefits of anticoagulation should be regularly reassessed since risk of bleeding and/or hemorrhage can increase with age. They also state that DOACs are less likely to cause bleeding when compared to warfarin so a change in medication would be indicated. Choosing which specific DOAC should include consideration for renal function since Mrs. Green has a creatinine clearance of 24.8.

A DOAC such as apixaban would be a good pharmacological intervention for Mrs. Green. Apixaban (Eliquis) inhibits Factor Xa and does not need to be monitored frequently with lab work like warfarin. It also only has 27% renal excretion, which is significantly lower than the other DOACs (Joglar et al., 2024). Based on weight, age, and renal function, the ideal dosage would be 5mg twice daily (Joglar et al., 2024).

More information is needed prior to prescribing. The patientâ€™s liver function should be tested. A thorough history of any patient falls or potential gait instability should be reviewed and considered as well. Any history of bleeding, especially intracranial bleeding or subdural hematomas should be reviewed and included in the risk/benefit analysis of anticoagulation. Lastly, a discussion about price and financial barriers should be addressed. According too one study, the price of DOACs are significantly higher in the United States compared to other countries (Cynar et al., 2026). Mrs. Greenâ€™s current medication, Warfarin, is an old drug which means it may be cheaper than the newer apixaban.

References

Cynar, J., Cavaco, A. M., Nowakowska, E., Kus, K., Ratajczak, P., & Zaprutko, T. (2026). A new way to read the price: measuring global affordability of selected NOACs. Frontiers in Pharmacology, 17, 1767958. https://doi.org/10.3389/fphar.2026.1767958

Joglar, J.A., Chung, M.K., Armbruster, A.L., Benjamin, E.J., Chyou, J.Y., Cronin, E.M., Deswal, A., Eckhardt, L.L., Goldberger, Z.D., Gopinathannair, R., Gorenek, B., Hess, P.L., Hlatky, M., Hogan, G., Ibeh, C., Indik, J.H., Kido, K., Kusumoto, F., Link, M.S., Linta, K.T., Marcus, G.M., McCarthy, P.M., Patel, N., Patton, K.K., Perez, M.V., Piccini, J.P., Russo, A.M., Sanders, P., Streur, M.M., Thomas, K.L., Times, S., Tisdale, J.E., Valente, A.M., & Van Wagoner, D.R. (2024). 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation, 149, e1-e156. https://doi.org/10.1161/CIR.0000000000001193

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