Research Article: A prescription support-tool for chronic management of oral antithrombotic combinations in adults based on a systematic review of international guidelines

Date Published: February 14, 2019

Publisher: Public Library of Science

Author(s): Lorene Zerah, René-Sosata Bun, Sylvie Guillo, Jean-Philippe Collet, Dominique Bonnet-Zamponi, Florence Tubach, Christophe Leroyer.


Oral antithrombotic (AT) drugs, which include antiplatelet and anticoagulant therapies, are widely implicated in serious preventable bleeding events. Avoiding inappropriate oral AT combinations is a major concern. Numerous practical guidelines have been released; a document to enhance prescriptions of oral AT combinations for adults would be of great help.

To synthesize guidelines on the prescription of oral AT combinations in adults and to create a prescription support-tool for clinicians about chronic management (≥ one month) of oral AT combinations.

A systematic review of guidelines published between January 2012 and April 2017, in English or in French, from Trip database, Guideline International Network and PubMed, dealing with the prescription of oral ATs in adults was conducted. In-hospital management of ATs, bridging therapy and switches of ATs were not considered. Some specific topics requiring specialized follow-up (cancer, auto-immune disease, haemophilia, HIV, paediatrics and pregnancy) were excluded. Last update was made in November 2018.

A total of 885 guidelines were identified and 70 met the eligibility criteria. A prescription support-tool summarizing medical conditions requiring chronic management of oral AT combinations in adults with drug types, dosage and duration, on a double-sided page, was provided and tested by an external committee of physicians. The lack of specific guidelines for old people (age 75 years and older) is questioned considering the specific vulnerability of this age group to serious bleedings.

Recommendations on prescriptions about chronic management of oral AT combinations in adults were mainly consensual but dispersed in numerous guidelines according to the medical indication. We provide a prescription support-tool for clinicians. Further studies are needed to assess the impact of this tool on appropriate prescribing and the prevention of serious adverse drug events.

Partial Text

Combinations of oral antithrombotic (AT) drugs, which include antiplatelet (AP) and anticoagulant (AC) therapies, are increasingly being prescribed in relation to the increase in prevalence of cardiovascular diseases, multimorbidity (commonly defined as the presence of 2 or more chronic medical conditions in an individual) and medical progress.[1]

Our review was developed following the PRISMA statement for systematic reviews[10] (S1 Appendix). We did not declare a protocol for our systematic review of guidelines.

A total of 885 guidelines were found according to the algorithm search; 70 met the eligibility criteria (Fig 1) and covering the following topics: atrial fibrillation (n = 15), coronary artery disease (n = 15), peripheral artery disease (n = 12), stroke (n = 10), valvular heart disease (n = 3), venous thromboembolism (n = 9) and antithrombotics (n = 6).[11–80]

We propose a prescription support-tool, on a double-sided page, synthesizing all national and international guidelines about chronic management (at least one month) of oral AT combinations (drugs, dosages and duration) in adults (Fig 2). Synthesis figures were already released in some guidelines, but none encompassed all the clinical situations either isolated or associated requiring oral AT combinations. However, to gather all recommendations into one document may be the key to enhance accurate prescription of oral ATs for patients with multiple chronic conditions, more than half of whom have cardiovascular diseases.[84]

This is the first prescription support-tool synthesizing national and international guidelines on chronic management of oral AT combinations (drugs, dosages and duration) in adults. Further studies are needed to demonstrate the impact of this tool on AT inappropriate prescribing and on clinical outcomes. The review used to design this tool underlined also the lack of accurate guidelines regarding dual and triple AT therapies for the older people, although they are most at risk for severe bleeding events. Further research must focus on this population, especially the oldest-old individuals and those with frailty, to refine the recommendations.




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