Low adherence to national guidelines for proton-pump inhibitor prescription in patients receiving combination aspirin and anticoagulation

Sharma, Reetika; Roy, Abhik; Ramos, Christopher; Rosenberg, Richard; Garcia-Carrasquillo, Reuben J.; Lebwohl, Benjamin

doi:10.1177/1756283x17694807

Cited by 3 publications

(5 citation statements)

References 34 publications

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“…A retrospective cohort of 2422 patients 17 published in 2017 reported that 42.2% of patients on CAT with aspirin and anticoagulants received PPI at discharge. This is comparable to the rate of 40.9% PPI co‐therapy reported in our study cohort.…”

Section: Discussionmentioning

confidence: 99%

“…Recently a study of more than 1.6 million Medicare beneficiaries showed that PPI co‐therapy resulted in 34% overall reduction in the upper GIB across warfarin, apixaban, rivaroxaban, and dabigatran 16 . Despite the current guidance and available literature, a recent retrospective single‐center study showed that only 42.2% of patients discharged on aspirin with anticoagulant therapy received a prescription for a PPI 17 . Further research is warranted to identify patients at risk for GIB and guide use of PPI in those on combined antithrombotic therapy (CAT).…”

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confidence: 99%

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Proton Pump Inhibitor Utilization in Veteran Patients on Combined Antithrombotic Therapy and Validation of Simplified Bleeding Risk Score

et al. 2020

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BACKGROUND Concomitant use of anticoagulant and antiplatelet agents can increase the risk of gastrointestinal bleed (GIB). Use of proton pump inhibitors (PPIs) has been proposed to decrease the risk of GIB in patients on combined antithrombotic therapy (CAT). OBJECTIVE To describe the current utilization of PPIs in veteran patients on CAT and associated clinical predictors of GIB. METHODS This retrospective study included patients on CAT receiving PPIs, with at least one of the CAT agents initiated between January 1, 2018 and October 30, 2018. Data were extracted from the computerized patient record system. Primary end point included estimating proportion of patients on CAT receiving PPI co-therapy, describing patient characteristics, and identifying clinical predictors of GIB. Secondary outcomes included reporting GIB events and all-cause mortality. Additional outcome was to validate the five-factor risk score (FFRS) for GIB in patients on CAT and compare its overall predictive performance to HAS-BLED score. RESULTS This study reports an overall rate of PPI co-therapy in patients on CAT of 40.9% (484/1181), with only 22.3% of patients on CAT receiving PPI for GIB prophylaxis. There was no difference in the mean follow up duration of PPI users and PPI co-therapy (264.01 vs 271.92 days; p=0.3761). Current alcohol use (p=0.005), current smokers (p=0.022), chronic kidney disease (p=0.004), peptic ulcer disease (p<0.001), and non-steroidal anti-inflammatory drug use (p=0.048) were significant predictors of GIB in multivariate analyses of our study cohort. We further provide exploratory validation that use of a simplified FFRS to predict GIB showed a trend towards better overall predictive performance as compared to HAS-BLED score (C-statistic: 0.738; 95% CI 0.684-0.787 for FFRS vs C-statistic: 0.596; 95% CI 0.538-0.653 for HAS-BLED; p=0.0094). CONCLUSION This study reports lower rate of PPI co-therapy in veteran patients on CAT per currently available guidance. Further we explore utilization of simplified FFRS model to predict GIB in patients on CAT with long-term PPI co-therapy. KEY WORDS proton pump inhibitor, Antiplatelets, Anticoagulation, gastrointestinal bleed, antithrombotic, HAS-BLED, bleeding risk scores.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Proton Pump Inhibitor Utilization in Veteran Patients on Combined Antithrombotic Therapy and Validation of Simplified Bleeding Risk Score

et al. 2020

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“…In an American study Sharma et al (6) investigated the proportion of patients prescribed PPI when discharged from the hospital on aspirin and anticoagulation. The authors found that 42.2% were prescribed a PPI at discharge and predictors for PPI co-prescribing were older age and preadmission PPI use.…”

Section: Comparison With Existing Literaturementioning

confidence: 99%

“…Therefore, PPI therapy should be offered to patients with a true indication for antisecretory treatment. Nevertheless, it has been demonstrated that peptic ulcer prophylaxis often is lacking in patients at risk (6,7).…”

Section: Introductionmentioning

confidence: 99%

Proton pump inhibitor use among patients at risk of peptic ulcer bleeding: a nationwide register-based study

Haastrup

Hansen

Søndergaard

et al. 2020

Scandinavian Journal of Gastroenterology

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BackgroundProton pump inhibitors reduce the risk of peptic ulcer bleeding in patients at risk. The knowledge about the extent of gastroprotection in patients at increased risk and factors associated with prophylactic treatment is limited.Aims 1) to analyse the extent of gastroprotective undertreatment in patients using aspirin/non-steroidal anti-inflammatory drugs and 2) to analyse which patient characteristics are associated with proton pump inhibitor prophylaxis among those at increased ulcer bleeding risk. MethodsA Danish nationwide register-based study. Based on a risk stratification model we identified citizens at increased ulcer bleeding risk and analyzed the proportion concomitantly treated with proton pump inhibitors. Further, we analyzed associations between use of ulcer prophylaxis and comorbidity and socioeconomic characteristics. ResultsSome 44.4% of the high-risk patients were concomitantly treated with proton pump inhibitors. In the crude analyses cohabiting, having a high educational level and a high income were significantly associated with lower odds of being treated with proton pump inhibitors. When adjusting for medication use, age, sex and comorbidity the associations were insignificant. ConclusionsThere is room for improvement in the extent of ulcer prophylaxis but no clear social gradient in underprescribing of gastroprotection. With the substantial risk-reducing possibility concomitant proton pump inhibitor use could save numerous patients from ulcer bleeding each year. Our study calls for increased awareness of peptic ulcer bleeding risk and dissemination of knowledge to clinicians about risk factors for gastrointestinal hemorrhage and the risk reducing potential of coprescribing proton pump inhibitors to patients at risk.

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“…Specifically, in patients with atrial fibrillation (AF) who underwent recent percutaneous coronary intervention (PCI), clinical practice guidelines recommend (except in patients with a very high risk of bleeding and a low risk of ischemic events) triple antithrombotic therapy with DAPT and an anticoagulant agent. This regimen further increases the bleeding risk in this population [1,2,14]. Regarding dabigatran, a 15% decrease in drug exposure by PPI use was found in the Randomized Evaluation of Long-term Anticoagulant Therapy (RE-LY) trial, without an observable impact on efficacy or safety [15].…”

Section: Introductionmentioning

confidence: 99%

Dabigatran Dual Therapy vs Warfarin Triple Therapy Post-Percutaneous Coronary Intervention in Patients with Atrial Fibrillation With/Without a Proton Pump Inhibitor: A Pre-Specified Analysis of the RE-DUAL PCI Trial

Nicolau

Bhatt

Hohnloser

et al. 2020

Drugs

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Background and ObjectiveIn patients with atrial fibrillation following percutaneous coronary intervention, if a proton pump inhibitor is used, could that allow the use of warfarin triple therapy, or is there additional reduction in bleeding while using it with dual therapy? Methods The RE-DUAL PCI trial randomized 2725 patients with atrial fibrillation post-percutaneous coronary intervention to dabigatran dual therapy (110 or 150 mg twice daily, with clopidogrel or ticagrelor) or warfarin triple therapy (with clopidogrel or ticagrelor, and aspirin for 1-3 months). This prespecified subgroup analysis evaluated risks of a first major bleeding event or clinically relevant non-major bleeding event, all gastrointestinal bleeding, and a composite efficacy endpoint of allcause mortality/thromboembolic event or unplanned revascularization according to baseline use of a proton pump inhibitor. Results Of 2678 analyzed patients, 1641 (61.3%) were receiving a proton pump inhibitor at baseline. Dabigatran 110 and 150 mg dual therapy reduced the risk of major bleeding events or clinically relevant non-major bleeding events vs warfarin triple therapy regardless of proton pump inhibitor use, with comparable risk of the composite efficacy endpoint (all interaction p values > 0.05). For gastrointestinal bleeding, no interaction was observed between study treatment and proton pump inhibitor use (interaction p values 0.84 and 0.62 for dabigatran 110 and 150 mg dual therapy, respectively, vs warfarin triple therapy). Conclusions Dabigatran 110 and 150 mg dual therapy reduced the risk of major bleeding events or clinically relevant nonmajor bleeding events vs warfarin triple therapy, regardless of proton pump inhibitor use at baseline, in patients with atrial fibrillation who underwent percutaneous coronary intervention. Risk of the composite efficacy endpoint appeared to be similar for dabigatran dual therapy vs warfarin triple therapy in patients receiving/not receiving a proton pump inhibitor. ClinicalTrials.gov unique identifier NCT02164864.

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Low adherence to national guidelines for proton-pump inhibitor prescription in patients receiving combination aspirin and anticoagulation

Cited by 3 publications

References 34 publications

Proton Pump Inhibitor Utilization in Veteran Patients on Combined Antithrombotic Therapy and Validation of Simplified Bleeding Risk Score

Proton Pump Inhibitor Utilization in Veteran Patients on Combined Antithrombotic Therapy and Validation of Simplified Bleeding Risk Score

Proton pump inhibitor use among patients at risk of peptic ulcer bleeding: a nationwide register-based study

Dabigatran Dual Therapy vs Warfarin Triple Therapy Post-Percutaneous Coronary Intervention in Patients with Atrial Fibrillation With/Without a Proton Pump Inhibitor: A Pre-Specified Analysis of the RE-DUAL PCI Trial

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