ANAHEIM, Calif. — Some patients may be taking aspirin inappropriately, two single-center retrospective studies found.
In the first study, conducted at general medicine units at an academic medical center, 93 of 225 patients (41.3%) on dual antithrombotic therapy (a direct oral anticoagulant and aspirin) with coronary artery disease were eligible for aspirin deprescribing but only 19 (20.4%) actually were deprescribed 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 findings presented at the American Society of Health-System Pharmacists (ASHP) midyear meeting.
The 2023 American Heart Association Chronic Coronary Disease guidelines state that aspirin deprescribing 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 at if people were actually following these new guidelines, which is really tough, and we found that in our institution, they really 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] were actually deprescribed, we’re saying that this is really a good area for pharmacists to work on making more interventions.”
The second study found that 277 of 1,506 patients (18.4%) in a primary care clinic ages 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 U.S. 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 portion 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 — really looking at, could that be causing other issues?”
Guideline recommendations for aspirin use often are not implemented in routine care, observed Jordan Schaeffer, MD, of the University of Michigan in Ann Arbor, 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 a variety of other reasons,” Schaeffer told MedPage Today in an email.
“Pharmacist-led interventions seem to be an excellent way to improve guideline concordant aspirin use,” he added.
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 tumor, 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 ages 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 ages 76 to 77 years, mostly female, and more than half were white.
Both studies were limited by their single-center 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 years at a clinic that serves those primarily over age 65.
Chan, Rosebraugh, and Puryear reported no financial disclosures.
Schaeffer is involved with independent quality improvement projects to improve aspirin use. Some projects are supported by a 2022 mentored research award from the Hemostasis and Thrombosis Research Society which includes an educational grant from Takeda, and by an American Society of Hematology Scholar Award.
American Society of Health-System Pharmacists
Source Reference: Chan ET, et al “Aspirin de-escalation in patients with stable coronary artery disease and atrial fibrillation on a direct oral anticoagulant: a retrospective review” ASHP 2023; Abstract 3-339.
American Society of Health-System Pharmacists
Source Reference: Puryear MR, et al “Provider adherence to the 2022 USPSTF recommendation on aspirin for primary prevention of cardiovascular disease in older adults at an outpatient geriatric clinic” ASHP 2023; Abstract 07-268.