Treatment of venous thromboembolism in elderly patients in the era of direct oral anticoagulants.

The incidence of venous thromboembolism (VTE) and VTE-related morbidity and mortality increase with advancing age. Over the past decade, substantial advances in treatment of VTE have been made, most notably the introduction of direct oral anticoagulants (DOACs) which offer simple treatment regimens across a broad spectrum of VTE patients and have become the first-choice anticoagulants in many VTE patients. Even though elderly patients are underrepresented in clinical trials, extrapolation of overall study results to the elderly subpopulation appears justified for acute VTE treatment and for the choice of anticoagulant agent. In the elderly, DOACs are not only associated with a lower risk of bleeding but they even appear to be more efficacious than vitamin K antagonists in preventing recurrent VTE during the acute treatment period. The most challenging aspect of VTE management in elderly patients is determination of optimal treatment duration. The risk of bleeding increases with advancing age but also several risk factors for recurrent VTE after stopping anticoagulation are more frequent in the elderly. Clinical decision rules estimating risk of recurrent VTE and bleeding have limited utility in elderly patients. Shared decision making considering patient preferences and values is therefore crucial to help determine individual treatment duration in elderly patients