Antithrombosis stewardship efforts to de-escalate inappropriate combined therapy in outpatient clinics.

Antithrombotic therapies include anticoagulants and antiplatelet agents. It is increasingly recognized that combined dual antithrombotic (DAT, which consists of an oral anticoagulant and a single antiplatelet) and triple antithrombotic therapies (TAT, which consists of an oral anticoagulant and two antiplatelets) increase bleeding risk. Additionally, the benefit of aspirin for primary prevention has been called into question by a number of randomized controlled trials over the last few years. As such, several recent clinical trials have explored de-escalated antithrombotic regimens that have resulted in less bleeding with similar efficacy. Our study was a retrospective, observational investigation assessing the effect of a systematic antithrombosis stewardship intervention implemented in outpatient, pharmacy-driven antithrombosis clinics on the number of patients receiving potentially inappropriate combined antithrombotic therapy. Pharmacists identified anticoagulation patients on concomitant antiplatelet therapy, assessed for appropriateness, and performed interventions if needed. Of the 875 patients included, 261 (29.8%) were on combined antithrombotic therapy, 48 (18.4%) of which were deemed inappropriate at baseline. By the end of the intervention period, 45 (93%) of these patients had a de-escalation in combined therapy (p < 0.001). We found that a systematic de-escalation protocol led to a significant reduction in patients on inappropriate combined antithrombotic therapy.