Abstract
BackgroundOral antithrombotic (AT) drugs, which include antiplatelet and anticoagulant therapies, are widely implicated in serious preventable bleeding events. Avoiding inappropriate oral AT combinations is a major concern. Numerous practical guidelines have been released; a document to enhance prescriptions of oral AT combinations for adults would be of great help.ObjectiveTo synthesize guidelines on the prescription of oral AT combinations in adults and to create a prescription support-tool for clinicians about chronic management (≥ one month) of oral AT combinations.MethodsA systematic review of guidelines published between January 2012 and April 2017, in English or in French, from Trip database, Guideline International Network and PubMed, dealing with the prescription of oral ATs in adults was conducted. In-hospital management of ATs, bridging therapy and switches of ATs were not considered. Some specific topics requiring specialized follow-up (cancer, auto-immune disease, haemophilia, HIV, paediatrics and pregnancy) were excluded. Last update was made in November 2018.ResultsA total of 885 guidelines were identified and 70 met the eligibility criteria. A prescription support-tool summarizing medical conditions requiring chronic management of oral AT combinations in adults with drug types, dosage and duration, on a double-sided page, was provided and tested by an external committee of physicians. The lack of specific guidelines for old people (age 75 years and older) is questioned considering the specific vulnerability of this age group to serious bleedings.ConclusionsRecommendations on prescriptions about chronic management of oral AT combinations in adults were mainly consensual but dispersed in numerous guidelines according to the medical indication. We provide a prescription support-tool for clinicians. Further studies are needed to assess the impact of this tool on appropriate prescribing and the prevention of serious adverse drug events.
Highlights
Combinations of oral antithrombotic (AT) drugs, which include antiplatelet (AP) and anticoagulant (AC) therapies, are increasingly being prescribed in relation to the increase in prevalence of cardiovascular diseases, multimorbidity and medical progress.[1]Combinations of ATs have demonstrated their benefit in various medical neuro-cardiovascular conditions, but they increase widely the risk of severe bleeding.[2,3] For example, Hansen et al reported a 3.1-fold higher risk for fatal and non-fatal bleedings with dual warfarin and clopidogrel therapy and a 3.7-fold higher risk with triple therapy than warfarin monotherapy in patients with non-valvular atrial fibrillation (NV-AF).[3]
Recommendations on prescriptions about chronic management of oral AT combinations in adults were mainly consensual but dispersed in numerous guidelines according to the medical indication
Further studies are needed to assess the impact of this tool on appropriate prescribing and the prevention of serious adverse drug events
Summary
Oral antithrombotic (AT) drugs, which include antiplatelet and anticoagulant therapies, are widely implicated in serious preventable bleeding events. Avoiding inappropriate oral AT combinations is a major concern. Numerous practical guidelines have been released; a document to enhance prescriptions of oral AT combinations for adults would be of great help
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