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. 2014 Feb;21(2):231-43.
doi: 10.1177/2047487312451253. Epub 2012 Jun 8.

Adherence to guidelines for the prescribing of double and triple combinations of antithrombotic agents

Margaretha F Warlé-Van Herwaarden  1 , Monique Roukens, Gheorghe A M Pop, Evert J P Lamfers, Peter A G M De Smet, Cornelis Kramers
Affiliations

Adherence to guidelines for the prescribing of double and triple combinations of antithrombotic agents

Margaretha F Warlé-Van Herwaarden et al. Eur J Prev Cardiol. 2014 Feb.

Erratum in

  • Eur J Prev Cardiol. 2014 Mar;21(3):391
  • Corrigendum.
    [No authors listed] [No authors listed] Eur J Prev Cardiol. 2014 Mar;21(3):391. doi: 10.1177/2047487314525544. Eur J Prev Cardiol. 2014. PMID: 28071143 Free PMC article.

Abstract

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.

Keywords: Vitamin K antagonists; acetylsalicylic acid; anti-thrombotic drugs; bleeding risk; clopidogrel; combination therapy; gastric bleeding; guideline adherence.

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