Limit bleeding risk in patients on triple antithrombotic therapy

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...

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.

References

• Gibson CM, Mehran R, Bode C, Halperin J, Verheugt FW, Wildgoose P, Birmingham M, Ianus J, Burton P, van Eickels M, Korjian S, Daaboul Y, Lip GY, Cohen M, Husted S, Peterson ED, Fox KA. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med. 2016 Dec 22;375(25):2423-2434. Available at: https://www.nejm.org/doi/full/10.1056/nejmoa1611594

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