What is the optimal anticoagulation and antiplatelet therapy regimen for a patient with A-fib, CAD, HTN, HLD, DM 2, CVA, PAD, CKD stage III, and history of GI bleed?

Optimal Anticoagulation and Antiplatelet Therapy for a Patient with Multiple Comorbidities and Recent GI Bleed

Switching from Xarelto to Eliquis 5 mg twice daily plus Plavix 75 mg daily (without aspirin) is the optimal antithrombotic regimen for this patient with recent GI bleeding, while continuing pantoprazole 40 mg twice daily for GI protection. 1

Assessment of Patient's Thrombotic and Bleeding Risks

This 74-year-old nursing home resident has multiple high-risk conditions requiring consideration:

• Thrombotic risk factors:

  • Atrial fibrillation (requiring anticoagulation)
  • CAD with severe multivessel disease (recent cardiac catheterization)
  • Prior CVA x2
  • PAD status post femoral-popliteal bypass

• Bleeding risk factors:

  • Recent GI bleed requiring 4 units PRBC transfusion
  • Duodenal ulcers with non-bleeding vessels requiring clip placement
  • CKD stage III
  • Advanced age (74)
  • Polypharmacy

Recommended Antithrombotic Regimen

1. Anticoagulation Strategy

• Switch from Xarelto to Eliquis 5 mg twice daily 1
  • Apixaban (Eliquis) has demonstrated a lower risk of GI bleeding compared to rivaroxaban (Xarelto) in patients with atrial fibrillation
  • The patient's CKD stage III does not require dose reduction as long as he doesn't meet two of the following criteria: serum creatinine ≥1.5 mg/dL, age ≥80 years, or body weight ≤60 kg 2

2. Antiplatelet Strategy

• Continue Plavix (clopidogrel) 75 mg daily 2
  • Single antiplatelet therapy with clopidogrel is recommended for PAD to reduce MACE risk
  • Discontinue aspirin to reduce bleeding risk

3. GI Protection

• Continue pantoprazole 40 mg twice daily 2
  • Proton pump inhibitor therapy is essential with antithrombotic therapy, especially after recent GI bleed

Rationale for Recommended Regimen

1. Need for anticoagulation: The patient has atrial fibrillation with multiple risk factors (age, hypertension, diabetes, prior stroke), giving him a high CHA₂DS₂-VASc score requiring oral anticoagulation 2

2. Choice of anticoagulant: Apixaban is preferred over rivaroxaban in this case because:

   • Lower risk of GI bleeding compared to rivaroxaban
   • Appropriate for patients with moderate renal impairment (CKD stage III) 2

3. Antiplatelet therapy: Single antiplatelet therapy with clopidogrel is recommended for:

   • Symptomatic PAD (status post femoral-popliteal bypass) 2
   • Recent multivessel CAD being treated medically 2

4. Avoiding triple therapy: Triple therapy (anticoagulant plus dual antiplatelet therapy) significantly increases bleeding risk by 2-3 fold compared to anticoagulation alone or with single antiplatelet therapy 2, 1

Important Considerations and Monitoring

1. Regular monitoring:

   • Assess renal function regularly (at least annually) due to CKD stage III 2
   • Monitor for signs of GI bleeding (melena, hematemesis, fatigue, dizziness)
   • Check hemoglobin/hematocrit periodically

2. Duration of therapy:

   • Anticoagulation for atrial fibrillation should be lifelong 2
   • Reassess the need for continued antiplatelet therapy periodically, with potential to discontinue clopidogrel if bleeding risk becomes excessive 2

3. Medication interactions:

   • Ensure no significant drug interactions with current medications
   • Avoid NSAIDs due to increased bleeding risk 2

Common Pitfalls to Avoid

1. Continuing triple therapy unnecessarily: Triple therapy significantly increases bleeding risk without providing additional ischemic protection in most patients 1

2. Inadequate GI protection: Failure to continue PPI therapy after GI bleeding while on antithrombotics increases rebleeding risk 2

3. Inappropriate NOAC dosing: Using full-dose NOACs in patients with significant renal impairment can lead to increased bleeding risk 2

4. Discontinuing all antithrombotic therapy: Despite recent bleeding, the patient's high thrombotic risk requires continued antithrombotic therapy with appropriate adjustments 2

By implementing this regimen of Eliquis 5 mg twice daily plus Plavix 75 mg daily with continued pantoprazole 40 mg twice daily, the patient will receive optimal protection against thrombotic events while minimizing the risk of recurrent GI bleeding.