Well then come up with a diagnostic test that will identify those patients with a bleeding risk from aspirin. Otherwise you are just shooting in the dark and your patients are not very well served.
Aspirin frequently used by patients on direct oral anticoagulants, tied to bleeding risk
Nearly one-third of patients with atrial fibrillation and/or venous thromboembolism treated with a direct oral anticoagulant, or DOAC, were also using aspirin without clear indications, researchers reported.
In the cohort, those who used aspirin had elevated risk for bleeding and hospitalization but similar risk for thrombosis compared with those who did not.
“Compared with dual therapy with acetylsalicylic acid and warfarin, one could hypothesize a lower rate of bleeding in patients taking acetylsalicylic acid plus DOAC given the overall safer profile of DOAC medications as compared with warfarin,” Jordan K. Schaefer, MD, clinical assistant professor in the division of hematology/oncology in the department of internal medicine at the University of Michigan, Ann Arbor, and colleagues wrote in JAMA Internal Medicine. “When combining treatment doses of DOACs with acetylsalicylic acid, it is plausible that overall bleeding rates could be elevated beyond those seen with combination acetylsalicylic acid and warfarin.”
The registry-based cohort study included 3,280 adults (mean age, 68 years; 51% men) undergoing DOAC treatment for AF or VTE at four anticoagulation clinics in Michigan from 2015 to 2019. Patients did not have a recent MI or heart valve replacement and had at least 3 months of follow-up.
The primary outcomes were rates of bleeding, thrombosis, ED visits, hospitalization and death.
Researchers observed that 33.8% of patients treated with DOACs were using aspirin without a clear indication for it. The researchers compared matched cohorts of 1,047 patients each, one of patients using a DOAC and aspirin and one using a DOAC only. Mean follow-up was 20.9 months.
Compared with patients treated with a DOAC only, patients treated with a DOAC plus aspirin experienced more bleeding events (26 vs. 31.6 bleeds per 100 patient-years; P = .01). Patients treated with a DOAC plus aspirin demonstrated higher rates of nonmajor bleeding with 26.1 bleeds per 100 patient-years compared with 21.7 bleeds per 100 patient-years among patients treated with a DOAC only (P = .02).
Rates of major bleeding were not statistically different between both cohorts. There were also similar rates of thrombotic events per 100 patient-years between patients treated with a DOAC only and patients treated with DOAC plus aspirin (2.5 and 2.3, respectively; P = .8).
Patients treated with a DOAC plus aspirin were more likely to be hospitalized during their combination therapy compared with patients treated with a DOAC only (9.1 vs. 6.5 admissions per 100 patient-years; P = .02).
“Further research is needed to determine if select high-risk patient subgroups derive a net benefit from combination therapy,” the researchers wrote. “Efforts should be made to help clinicians identify and deprescribe acetylsalicylic acid for patients taking a DOAC without an indication for acetylsalicylic acid.”
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