Selecting oral antithrombotic therapies in peripheral arterial disease: A guide for practitioners

The purpose of this review is to guide practitioners through the certainty, and uncertainty, that surrounds optimal management of antithrombotic therapies in patients with lower-extremity peripheral arterial disease. It also provides practitioners with a framework from which to apply these therapies safely and effectively to optimize patient outcomes.

Peripheral arterial disease is an underdiagnosed and undertreated disease entity. Chronic antithrombotic therapies play a pivotal role in the prevention of thrombotic events in patients with lower-extremity peripheral arterial disease. Whether antiplatelet therapy, oral anticoagulation, or a combination of antiplatelet and anticoagulant therapies is best suited to prevent major cardiovascular and limb events in this patient population has been a long-standing clinical question. There is a great deal of variability in real-world practice as to which agents and dose intensities are used chronically for this purpose. Recent major publications exploring the use of "dual-pathway inhibition" have helped clarify best antithrombotic practices in patients with symptomatic peripheral arterial disease, and these have had a major impact on recently updated guidelines in the US, Europe, and Canada.

Pharmacists play an important role in reevaluating antithrombotic regimens for all patients with peripheral arterial disease, recognizing that recent landmark publications have led to substantial changes to international guidelines. Dual-pathway inhibition with combined low-dose rivaroxaban and low-dose aspirin therapy should be considered in all patients with symptomatic peripheral arterial disease.