Do Ingredients Make the Difference?

Abstract

In clinical practice, the need to add 1 or 2 antiplatelet agents to an oral anticoagulant (OAC) often arises in patients with atrial fibrillation (AF). The indications can be diverse, from primary prevention in patients at high risk for an ischemic atherosclerotic event to secondary prevention after an acute coronary syndrome (ACS) to prevention of stent thrombosis.1,2 Unfortunately, adding antiplatelet agents to OACs increases bleeding risk, and although this risk is highest early after initiation of combination therapy, there appears to be no safe therapeutic window.1 The difficulty lies in balancing thromboembolic risk and bleeding risk in the individual patient. Because many new agents have come on the market recently, there is a wide variety of possible strategies with regard to not only the number and type of agents but also the intensity of anticoagulation and duration of the combination treatment. Article see p 634 Although ample guidance is available for preventing thromboembolic events and bleeding complications related to anticoagulant therapy on the one hand and for preventing ischemic events with antiplatelet agents on the other hand, there are few data from prospective studies on the combined use of antiplatelets with warfarin or one of the new OACs. Because the wide variety of clinical scenarios in which combination therapy is indicated can hardly be studied prospectively in dedicated clinical trials, we have to turn to post hoc analyses from trials such as the Randomized Evaluation of Long-term Anticoagulant Therapy (RE-LY) to obtain a better understanding of the benefits and risk of adding 1 or 2 antiplatelet agents to an OAC. In the RE-LY study, dabigatran at a dose of 110 mg twice daily reduced the risk of major bleeding and was noninferior to warfarin in preventing systemic emboli, whereas the 150-mg twice-daily dose reduced the risk …