What is the recommended management for a patient on long-term Dual Antiplatelet Therapy (DAPT) and blood thinners?

Management of Patients on Long-term Dual Antiplatelet Therapy and Blood Thinners

For patients requiring both dual antiplatelet therapy (DAPT) and oral anticoagulation, triple therapy should be limited to a maximum of 6 months or omitted after hospital discharge, with careful consideration of both ischemic and bleeding risks. 1

Risk Assessment and General Approach

When managing patients on both DAPT and anticoagulation, the following algorithm should be followed:

1. Reassess the indication for oral anticoagulation (OAC) - Continue only if a compelling indication exists, as triple therapy increases bleeding risk 2-3 fold compared to OAC alone 1

2. Choose appropriate antiplatelet agents:

   • Use clopidogrel as the P2Y12 inhibitor (not prasugrel or ticagrelor) 1
   • Maintain low-dose aspirin (75-100 mg daily) 1

3. Minimize bleeding risk:

   • Use radial over femoral access for any coronary procedures 1
   • Consider proton pump inhibitor for gastrointestinal protection 1
   • Maintain INR in the lower therapeutic range if using warfarin

Duration of Triple Therapy

The duration of triple therapy depends on the clinical scenario:

For ACS patients with coronary stents:

• High bleeding risk: Consider triple therapy for 1 month, then dual therapy (OAC + clopidogrel) for up to 12 months 1
• Moderate-to-low bleeding risk: Triple therapy for up to 6 months, then dual therapy (OAC + clopidogrel) to complete 12 months 1

For stable CAD patients with coronary stents:

• High bleeding risk: Consider triple therapy for 1 month, then dual therapy (OAC + clopidogrel) 1
• Moderate-to-low bleeding risk: Triple therapy for 1-3 months, then dual therapy (OAC + clopidogrel) 1

Management of Bleeding Complications

If bleeding occurs while on triple therapy:

1. For minor bleeding: Consider reducing triple therapy to dual therapy (OAC + clopidogrel)

2. For major bleeding:

   • Withhold antiplatelet agents temporarily if necessary 1
   • For life-threatening bleeding, consider reversal agents appropriate to the anticoagulant 1
   • Resume therapy after adequate hemostasis is achieved 1
   • If both antiplatelet agents must be discontinued, this should only be done if bleeding is life-threatening and the source cannot be treated 1

Special Considerations

Perioperative Management

• For elective surgery, a multidisciplinary approach is recommended 1
• Consider discontinuing P2Y12 inhibitor if surgery is performed after at least 1 month of therapy, while maintaining aspirin if possible 1
• For urgent surgery within 1 month of stent placement, consider bridging strategies with intravenous antiplatelet agents if oral agents must be discontinued 1

Dosing Considerations

• For patients <60 kg on prasugrel, consider reducing maintenance dose to 5 mg daily due to increased bleeding risk 2
• Prasugrel is contraindicated in patients with prior stroke or TIA 2
• Avoid prasugrel in patients ≥75 years unless they have diabetes or prior MI 2

Common Pitfalls to Avoid

1. Using prasugrel or ticagrelor with anticoagulation - These more potent P2Y12 inhibitors are not recommended in triple therapy due to excessive bleeding risk 1

2. Prolonging triple therapy unnecessarily - Extended triple therapy significantly increases bleeding without proportional reduction in ischemic events 1

3. Discontinuing all antiplatelet therapy abruptly - This increases risk of stent thrombosis and should only be done in life-threatening bleeding situations 1

4. Failing to reassess therapy regularly - Periodic evaluation of the need for continued triple therapy is essential to minimize bleeding risk while maintaining protection against thrombotic events

By following this approach, clinicians can balance the competing risks of thrombosis and bleeding in this challenging patient population.