Can I Stop the Warfarin? A Review of the Risks and Benefits of Discontinuing Anticoagulation

Abstract

Long-term anticoagulant therapy with warfarin is part of standard therapy for several disorders commonly present in patients seen in hospice and palliative care programs. Yet warfarin is also the drug most implicated in adverse drug reactions and its risks rise with increasing age and comorbidity. Clinicians caring for patients with multiple comorbidities or a limited life expectancy often are faced with the decision as to whether anticoagulation should be continued. Published guidelines for the use of warfarin in venous thromboembolism and nonvalvular atrial fibrillation are based on studies in which such patients were underrepresented or excluded. Our review of the randomized trials on which these guidelines are based shows that the annual risk of recurrent venous thromboembolism after stopping warfarin is 2%-10%. No similar evidence is available for patients with atrial fibrillation, but the published CHADS(2) index uses multiple factors to estimate stroke risk. The risk of bleeding complications with warfarin is most closely linked to degree of anticoagulation. Nutritional compromise and changes in drug therapy increase this risk and require that any patient remaining on warfarin must undergo frequent monitoring of anticoagulant effect.

Predictors of anticoagulation in hospice patients with lung cancer

“…The annual thromboembolic recurrence rate after discontinuing warfarin after at least 3 months of therapy is between 3.2% and 10.9%. 21 However, many of the trials that evaluated the effects of discontinuing warfarin have excluded patients with limited mobility or with limited life expectancy. A secondary consideration would be to extend life to afford patients and families more time for resolution and closure at the end of life.…”

“…Although dose reduction strategies to reduce bleeding risk have been advocated for LMWH, 18 there is no rationale for using low-intensity warfarin, because it conveys a higher thromboembolic recurrence rate with a similar risk of bleeding. 21 The risk of bleeding from anticoagulation may be higher in hospice patients because of alterations in renal function, malnutrition, and multiple drug-drug and drug-disease interactions that require more intense monitoring. Drug interactions are a concern, because many hospice patients have medications added to their regimens at the end of life.…”

“…A possible strategy to reduce the risk of warfarin could be to estimate bleeding risk and discontinue warfarin in those at high risk. 21 However, a risk-prediction tool has not been shown to strongly predict bleeding or patient outcomes. 25 One outpatient bleeding risk index includes risks of age ≥65 years, history of stroke, history of gastrointestinal bleeding, and ≥1 comorbid conditions, including recent myocardial infarction, anemia, renal impairment, or diabetes mellitus.…”

Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians

“…Factors to consider include the likelihood of benefit in terms of altering the person's baseline risk for the particular outcome, the risk of harm, and a comparison of the time horizon to benefit and the patient's likely remaining life expectancy (prognosis). For older adults with advanced disease or limited remaining life expectancy, achievable benefits are unlikely to offset the risks and burdens of clinical management . For example, secondary prevention interventions in diabetes mellitus to reduce risk of long‐term complications are unlikely to provide meaningful benefit in this context.…”

“…For older adults with advanced disease or limited remaining life expectancy, achievable benefits are unlikely to offset the risks and burdens of clinical management. [147][148][149][150][151][152][153] For example, secondary prevention interventions in diabetes mellitus to reduce risk of long-term complications are unlikely to provide meaningful benefit in this context. In older adults with multimorbidity, clinicians would be advised to avoid starting this type of clinical management or to stop the intervention if it has already been initiated.…”