American Society of Consultant Pharmacists
View all recommendations from this societyReleased May 17, 2021
Don’t use two or more medications that are known to increase the risk of bleeding without evaluating the potential risks and benefits. These medications include direct oral anticoagulants (DOACs), warfarin, aspirin, selective serotonin reuptake inhibitors (SSRIs), antiplatelet agents, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids.
Prescribing more than one of these medications concurrently may result in an enhanced risk of bleeding. This heightened bleeding risk may be mediated
through complex pharmacokinetic and/or pharmacodynamic mechanisms. It is well established that the combination of anticoagulants and NSAIDs
increase bleeding risk. A combination of warfarin with either single or dual antiplatelet therapy significantly increases the risk of major bleeding by
2- to 4-fold, respectively. The most commonly prescribed antidepressant therapeutic class (SSRIs), may decrease platelet serotonin uptake, leading
to impaired platelet aggregation, and thereby increased bleeding risk. Specific to gastrointestinal bleeding, SSRIs may also increase gastric acid
secretion. Bleeding has been observed in association with other antidepressants in some observational studies, however recent systematic reviews
give weight to SSRIs in combination with NSAIDs for increased vigilance for risk of upper gastrointestinal bleeding. In patients where benefits outweigh
the risks of the combination, appropriate education of patient and caregivers and appropriate follow-up monitoring for early detection of any signs and
symptoms of bleeding is highly recommended.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
How The List Was Created
(1–5)
A deprescribing task force led by chair (Manju T. Beier, Pharm D, BCGP, FASCP) was created by ASCP in November 2018. Members comprised of pharmacists practicing in academia, community and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and literature base. The collective experience and knowledge represent a focus on medication management, medication selection and reconciliation, and monitoring for drug-drug interactions (DDIs). The emphasis is on older adults no matter where they reside in step with ASCP’s mission.
Definition wise, deprescribing is a stepwise reduction of unnecessary or potentially inappropriate medications in concert with patient and family goals and wishes. We recognize that even with the best of intentions, many older adults are left on unnecessary and potentially dangerous or duplicative medications that might precipitate adverse events and other negative outcomes.
The task force prioritized formulation of the Choosing Wisely (CW) List, since the goals of CW intersect and overlap with deprescribing initiatives. The list was created to address general medication regimen review statements, and more importantly to address the paucity of statements that address DDIs with several incriminating medication therapeutic classes prescribed for older adults. After a review of published CW statements on www.choosingwisely.org and also a review of CW statements published by international countries, it was decided by consensus to have a strong emphasis on DDIs.
After several virtual meetings, the CW workgroup was divided into subgroups to formulate DDIs that have a strong evidence base in the literature and those that focus on CNS therapeutic classes, anticholinergic burden, heightened bleeding risk, and other pivotal pharmacokinetic and pharmacodynamic DDIs. For each statement the group formulated a rationale that was evidence-based accompanied with several recent, pertinent references. The compiled list (after several virtual meetings and email discussion) was further reduced to top ten statements with the strongest evidence base and practice trends on medication management in older adults.
The top five list was selected by consensus for initial submission.
Attached is a recently published guest editorial in ASCP’s journal that highlights the emphasis on DDIs.
Beier MT. Vigilance of Drug-Drug Interactions to Mitigate ADRs: Front and Center for Pharmacists (Guest Editorial). Sr Care Pharm 2020; 35:336-7.
(6–10)
A deprescribing task force led by chair (Manju T. Beier, Pharm D, BCGP, FASCP) was created by ASCP in November 2018. Members comprised of pharmacists practicing in academia, community and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and literature base. The collective experience and knowledge represent a focus on medication management, medication selection and reconciliation, and monitoring for drug-drug interactions (DDIs). The emphasis for all our statements is on older adults no matter where they reside in step with ASCP’s mission. Our first 5 CW statements were published in May 2021.
As previously addressed, the rationale for the new 2022 list (statements 6–10) includes one medication review statement in older adults with limited life expectancy, and three statements emphasizing the adverse combination of CNS medications that have a strong evidence base in the literature including tramadol’s potential for greater harm than benefit for pain relief, especially in older adults. We had previously highlighted pharmacodynamic DDIs for heightened bleeding risk, and this time our statement addresses the complexity of pharmacokinetic DDIs with Direct Oral Anticoagulants (DOACs).
Sources
Juurlink DN. Antidepressants, antiplatelets and bleeding: one more thing to worry about? CMAJ 2011;183(16):1819-1820.
Chang S-H, Chou I-J, Yeh Y-H, Chiou M-J, Wen M-S, Kuo C-T, et al. Association Between Use Of Non-Vitamin K Oral Anticoagulants With And Without Concurrent Medications And Risk Of Major Bleeding In Nonvalvular Atrial Fibrillation. JAMA 2017;318(13):1250-1259.
Spina E, Barbieri MA, Cicala G, Bruno A, de Leon J. Clinically relevant drug interactions between newer antidepressants and oral anticoagulants. Expert Opin Drug Metab Toxicol 2020;16(1):31-44.
Vazquez SR. Drug-drug interactions in an era of multiple anticoagulants: a focus on clinically relevant drug interactions. Hematology Am Soc Hematol Educ Program 2018(1):339-347.
Liu L, Huang J, Zhang X, Tang X. Efficacy and safety of triple therapy versus dual antiplatelet therapy in patients with atrial fibrillation undergoing coronary stenting: A meta-analysis. PLoS ONE 2018;13(6):e0199232.
Kumar S, Danik SB, Altman RK, Barrett CD, Lip GY, Chatterjee S, et al. Non-Vitamin K Antagonist Oral Anticoagulants and Antiplatelet Therapy for Stroke Prevention in Patients With Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials. Cardiology in Review 2016;24(5):218-223.
Lin C-C, Hu H-Y, Luo J-C, Peng Y-L, Hou M-C, Lin H-C, et al. Risk factors of gastrointestinal bleeding in clopidogrel users: a nationwide population-based study. Aliment Pharmacol Ther 2013;38(9):1119-1128.
Labos C, Dasgupta K, Nedjar H, Turecki G, Rahme E. Risk of bleeding associated with combined use of selective serotonin reuptake inhibitors and antiplatelet therapy following acute myocardial infarction. CMA 2011;183(16):1835-1843.
Hansen ML, Sørensen R, Clausen MT, Fog-Petersen ML, Raunsø J, Gadsbøll N, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010;170(16):1433-1441.
Anglin R, Yuan Y, Moayyedi P, Tse F, Armstrong D, Leontiadis GI. Risk of upper gastrointestinal bleeding with selective serotonin reuptake inhibitors with or without concurrent nonsteroidal anti-inflammatory use: a systematic review and meta-analysis. Am J Gastroenterol. 2014 Jun;109(6):811-9.
