Limit bleeding risk in patients on triple antithrombotic therapy

Some specialists are treating atrial fibrillation patients on triple therapy with a direct oral anticoagulant (DOAC) such as Eliquis or Xarelto.....

Overview

How to manage patients on an anticoagulant (warfarin, etc) who also need antiplatelet medications (aspirin, etc)? ㅡ Many patients end up on "triple antithrombotic therapy" such as warfarin for atrial fibrillation PLUS clopidogrel (Plavix) and aspirin after a stent. But bleeding risk is high. One in 50 patients will have a serious bleed in the first month of triple therapy and 1 in 8 in the first year. Consider these factors to minimize bleeding with triple therapy...

NPS-adv

Clinical practice

Anticoagulant choice

Warfarin (Marevan) has been the go-to anticoagulant for most triple therapy patients. But the thinking is starting to change.

Some specialists are treating atrial fibrillation patients on triple therapy with a direct oral anticoagulant (DOAC) such as Eliquis or Xarelto instead of warfarin (Marevan), especially if they were on one before needing antiplatelets.

And be aware, early evidence suggests using Xarelto 15 mg/day plus clopidogrel (Plavix) after a stent lowers bleeding risk versus triple therapy, but it's too soon to tell if efficacy is similar.

Antiplatelet choice

Use clopidogrel (Plavix) instead of the newer antiplatelet medications like prasugrel (Effient) or ticagrelor (Brilique). There's not much information yet on their safety when used with an anticoagulant. And limit aspirin to 75 to 81 mg/day.

Duration

Limit triple therapy to no more than 6 months for a post-MI patient with a drug-eluting stent and 3 months for a stent patient with STABLE heart disease. After that, go to just an anticoagulant plus clopidogrel for up to 12 months total. Then continue an anticoagulant plus one antiplatelet (usually aspirin) indefinitely in patients with atrial fibrillation and a stent.

NPS-adv

References

Gibson CM, Mehran R, Bode C, Halperin J, Verheugt FW, et al. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med. 2016 Dec 22;375(25):2423-2434.
Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation. 2016 Sep 6;134(10):e123-55.
Raval AN, Cigarroa JE, Chung MK, Diaz-Sandoval LJ, Diercks D, et al. Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association. Circulation. 2017 Mar 7;135(10):e604-e633.
Angiolillo DJ, Goodman SG, Bhatt DL, Eikelboom JW, Price MJ, Moliterno DJ, Cannon CP, et al. Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A North American Perspective-2016 Update. Circ Cardiovasc Interv. 2016 Nov;9(11):e004395.