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Adherence to guidelines for the prescribing of double and triple combinations of antithrombotic agents
Margaretha F Warlé-Van Herwaarden1, Monique Roukens, Gheorghe A M Pop
1IQ Healthcare, Nijmegen, The Netherlands.
Insights
Prescribing high-risk antithrombotic combinations like VKA, clopidogrel, and ASA requires strict guideline adherence. Many patients lack indications and adequate gastric protection, increasing bleeding risks.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Pharmacy
Background:
- Cardiovascular disease often necessitates antithrombotic therapies, including vitamin K antagonists (VKA), clopidogrel, and acetylsalicylic acid (ASA).
- Combining these agents (double or triple therapy) increases efficacy but significantly elevates the risk of serious bleeding events.
- Strict adherence to clinical guidelines is crucial for safe and effective prescription of these high-risk antithrombotic combinations.
Purpose of the Study:
- To evaluate adherence to guideline-based prescribing for VKA, clopidogrel, and ASA combination therapies.
- To assess the incidence of inadequate gastric protection in patients receiving these high-risk antithrombotic regimens.
- To understand cardiologists' perspectives on prescribing antithrombotic combinations and guideline adherence.
Main Methods:
- A retrospective cohort study analyzed 238 patient cases from community pharmacies (2006-2009).
- Data collection involved hospital and pharmacy records to identify indications, therapy duration, co-medications, and comorbidities.
- Cardiologists' attitudes and self-reported guideline adherence were assessed via questionnaire.
Main Results:
- No guideline-based indication was found for 14% of ASA plus clopidogrel and 23% of VKA plus ASA combinations.
- 32% of patients on combination therapy faced increased gastrointestinal risk, with 56% lacking adequate gastric protection.
- A majority of responding cardiologists (90% and 68%) emphasized the importance of strict indications for ASA/clopidogrel and ASA/VKA therapies, respectively.
Conclusions:
- There is a need to improve adherence to guideline-based prescribing for antithrombotic combination therapies.
- Enhanced prescription of gastric protection is necessary for patients receiving high-risk antithrombotic combinations.
- Optimizing prescribing practices can mitigate bleeding risks associated with dual and triple antithrombotic therapy.
Background:
To prevent cardiovascular complications, sometimes double and triple therapy with a vitamin K antagonist (VKA), clopidogrel and/or acetylsalicylic acid (ASA) are indicated. These combinations increase the patient's risk of serious bleeding events. Therefore, adherence to clinical guidelines is of the utmost importance when these high-risk therapies are prescribed.
Methods:
We performed a retrospective cohort study of 238 cases in a community pharmacy that were treated with a combination of VKA, clopidogrel and/or ASA between January 2006 and December 2009. Hospital records and community pharmacy records were used to obtain the indication(s), the duration of combination therapy, the presence of risk-increasing and risk-decreasing co-medications and any relevant co-morbidities. The cardiologists' attitudes towards the prescribing of antithrombotic combinations and their self-reported adherence to guidelines were assessed by a brief questionnaire.
Results:
We found there was no guideline-based indication for 22 of the 146 cases (14%) on ASA plus clopidogrel and 19 of the 82 cases (23%) on VKA plus ASA. Of the 238 cases given antithrombotic combination therapies, 77 (32%) were placed at an additional increased risk of serious gastrointestinal events, yet 43 (56%) of these did not receive adequate gastric protection. Out of the 19 of 60 cardiologists (32%) who responded to our questionnaire; 17 (90%) and 13 (68%) stated that a strict indication is very important when initiating therapy with ASA plus clopidogrel or ASA plus VKA, respectively.
Conclusions:
There is room to further develop adherence to guideline-based prescribing of antithrombotic combination therapies and to improve prescription of gastric protection for patients receiving these high-risk combinations.
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