‘Worrying’ number of patients prescribed risky anticoagulant drug combinations

Tens of thousands of patients are potentially being put at risk of a major bleed by being prescribed an antiplatelet without gastroprotection or a non-steroidal anti-inflammatory drug (NSAID) alongside an anticoagulant, NHS figures have shown.

The data show that, in the most recent period available for analysis (September 2018 to November 2018), there were more than 14,000 patients in England prescribed an NSAID with an anticoagulant and more than 30,000 patients prescribed an antiplatelet and anticoagulant without gastroprotection.

Both the National Institute for Health and Care Excellence and the Medicines and Healthcare products Regulatory Agency advise that special care should be taken when deciding to prescribe NSAIDs or antiplatelets with anticoagulants because of the increased risk of major bleeding.

In the same period there were 38 admissions to hospital for gastric bleeds for every 10,000 patients taking an NSAID and an anticoagulant, and 117 admissions for every 10,000 on an anticoagulant and antiplatelet without gastroprotection.

The figures — obtained by The Pharmaceutical Journal
from the Medication Safety Dashboard run by the NHS Business Services Authority — come as NHS England identified anticoagulation as one of six ‘headline issues’ to be addressed by its Medicines Safety Programme, details of which were published in July 2019
. 

Under the programme, pharmacists will be trained in shared decision making so that they can support patients with atrial fibrillation who are taking anticoagulants. Audits on anticoagulation will also form part of the Pharmacy Quality Scheme for 2020/2021, according to the community pharmacy contractual framework, which was also published in July 2019.

Eve Knights, chief executive of Anticoagulation UK described the figures as “worrying”. She said: “What is vitally missing is a patient care plan — every patient should have a care plan tailored to [them] so everyone can see they are on an [anticoagulant] — we really need to consider very carefully what we are giving them.”

Matthew Fay, a GP with a special interest in cardiology, said increasing pressure not to prescribe other analgesics, such as opioids and gabapentinoids, meant patients were being put on NSAIDs.

“GPs are feeling that there’s nowhere else to go with analgesics for patients and forget the basic rule that anticoagulants and NSAIDs are a no-go,” he said.

However, David Russell a pharmacist manager of a Well Pharmacy in Grenoside, Sheffield, who runs a warfarin-monitoring clinic, argues that it is not always simple when it comes to medicines that may potentially interact.

“[It’s about] weighing up risks and benefits. In training, you’re told you should never see aspirin and warfarin together but, in some situations, it’s less risky than someone getting a clot after a stent.

“It’s about having the background information and working out what’s appropriate for that patient — not one size fits all.”