Some patients may still be taking aspirin inappropriately, according to the findings of two single-centre retrospective studies, presented at the recent American Society of Health-System Pharmacists (ASHP) mid-year meeting.
In the first study, conducted at general medicine units at an academic medical centre, 93 of 225 patients (41.3%) on dual antithrombotic therapy (a direct oral anticoagulant and aspirin) with coronary artery disease were eligible for aspirin de-prescribing but only 19 (20.4%) actually were de-prescribed at discharge, reported Elise Chan, a pharmacy student at Northeastern University in Boston, and colleagues.
Coronary artery disease without intervention was the most common indication for aspirin, according to the findings.
The 2023 American Heart Association Chronic Coronary Disease guidelines state that aspirin de-prescribing may benefit patients on a direct oral anticoagulant (DOAC) with coronary artery disease and no acute indication for aspirin because of bleeding risk.
“We were looking see if people were following these new guidelines… and found that in our institution, they weren’t,” co-author Samantha Rosebraugh, also a pharmacy student at Northeastern University, told MedPage Today.
Rosebraugh noted that the guideline was fairly new and prescribers may have needed more time to adopt it. “Because only one in five (of eligible patients) was actually de-prescribed, we're saying that this is a good area for pharmacists to work on more interventions.”
The second study found that 277 of 1 506 patients (18.4%) in a primary care clinic aged 60 and older used aspirin for primary prevention of cardiovascular disease before a 2022 recommendation to not initiate aspirin in this age group was issued from the US Preventive Services Task Force (USPSTF).
The recommendation came from findings that risks for bleeding with aspirin outweighed the benefits in older adults.
After the recommendation, 312 of 1 759 patients (17.7%) used aspirin for primary prevention, reported Madison Puryear, a PharmD candidate at Virginia Commonwealth University (VCU) in Richmond, and colleagues.
The proportion of people taking aspirin for primary prevention – who also had type 2 diabetes – grew post-recommendation, as did the portion of patients taking aspirin with anticoagulants and other anti-platelets.
“Our recommendation is to be more thoughtful about the medication that you’re prescribing,” Puryear told MedPage Today. “Something that you may think is harmless, like a Tylenol (acetaminophen), or in this case an aspirin, or multivitamin: could that be causing other issues?”
Guideline recommendations for aspirin often are not implemented in routine care, observed Dr Jordan Schaeffer of the University of Michigan, who wasn’t involved with either study.
“This could be due to a lack of knowledge of the various guidelines, patient specific factors or preferences, time constraints, ‘medication inertia’, a lack of resources, uncertainty about who is responsible for addressing aspirin when a patient is followed by several doctors, among other reasons," Schaeffer said.
“Pharmacist-led interventions seem to be an excellent way to improve guideline concordant aspirin use.”
For the DOAC de-escalation study, researchers included adult patients admitted to general medicine units from September to November 2022 who were prescribed aspirin and a DOAC.
Patients with co-existing active tumour, a history of stent thrombosis, poorly controlled hypertension, and alternative aspirin indications, were excluded. Patients were around age 75, mostly male, and mostly white.
For the primary prevention study in older adults, researchers identified patients at VCU aged 60 or older with no evidence of cardiovascular disease who were seen in periods before and after the USPSTF recommendation (January-April 2022 and May-August 2023). Patients were 76 to 77, mostly female, and more than half were white.
Both studies were limited by their single-centre design and short time frames.
Chan and colleagues acknowledged the limitations of potentially incorrect information from their manual chart review or possible exclusion of patients who could benefit from aspirin de-escalation.
Puryear and colleagues said their study was limited by an unspecified dosage strength of aspirin, potentially missed diagnosis codes that qualified patients for secondary prevention, and a data gap for patients ages 60-65 at a clinic that serves those primarily over 65.
No abstracts available
virani-et-al-2023-2023-aha-acc-accp-aspc-nla-pcna-guideline-for-the-management-of-patients-with-chronic-coronary
MedPage Today article – Inappropriate Aspirin Use Continues, Research Suggests (Open access)
See more from MedicalBrief archives:
Brain bleed risk upped by daily aspirin – second ASPREE trial analysis
Regular aspirin increases anaemia risk in seniors – ASPREE study
Daily aspirin increases risk of falls in the elderly – ASPREE trial
How and when to de-prescribe meds