Concomitant prehospital use of direct oral anticoagulants and antiplatelet agents in critically ill patients, prescribing practices and outcomes: a single academic center experience

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: To describe the current prescribing practices of concomitant Direct oral anticoagulants (DOACs) and antiplatelet use in critically ill patients, both medical and surgical. Secondly, to describe the relationships between concomitant use of DOACs and antiplatelet agents and associated clinical outcomes such as incidence of major bleeding episodes (primary outcome) and secondary outcomes of hospital and ICU length of stay (LOS), and mortality. METHODS: Observational study in a single large academic center including all ICU patients admitted to intensive care units from January 1st, 2012 through May 4th, 2018. Retrospective chart review examining the prescribing practices, morbidity, and clinical outcomes in patients with critical illness who were on DOAC therapy at the time of presentation to the hospital for the index hospitalization, from a single large academic center. Adult critically ill patients who had one of the DOACs including apixaban, rivaroxaban, dabigatran or Edoxaban as one of the active medications at the time of hospital admission. RESULTS: A total of 37,249 patients were screened for the study period, after excluding the patients that did not qualify; 558 unique encounters were included in the final analysis. Median age was 69 years (IQR 59-78), majority of the patients were male, white caucasians and had a median SOFA score of 4. Commonest comorbidity was cancer, diabetes mellitus and congestive heart failure. Commonest indications for DOAC prescription were history of DVT and pulmonary embolism, newly diagnosed DVT and pulmonary embolism. We did not find an increased risk of major bleeding when DOACs were prescribed concomitantly with antiplatelet agents as compared to without (13.7% vs 12.3%, p=0.6). Also, the combination of DOACs and antiplatelet agents did not increase the risk of hospital (12.6% vs 14.4%, p=0.6) and ICU mortality (6.3% vs 6.0%, p=0.9). Hospital (5.9 vs 5.7 days, p=0.7) and ICU (1.4 vs 1.6 days, p=0.8) LOS were similar in two groups CONCLUSIONS: Our single center retrospective study did not show an increased risk of major bleeding, or increased hospital and ICU mortality when DOACs are prescribed with antiplatelet agents in critically ill patients. CLINICAL IMPLICATIONS: Current literature about the safety of direct oral anticoagulants iin critically ill patients is limited. Over the past decade the use of DOACs has increased dramatically. Furthermore concomitant use of antiplatelet agents in this patient population remains understudied. Major bleeding events are the most concerning adverse effect of DOACs. Major bleeding is defined by the International Society on Thrombosis and Hemostasis as bleeding that is fatal, involves a critical organ (i.e., intraspinal, intracerebral, intraocular, retroperitoneal, intramuscular), causes at least a 2 g/dL drop in hemoglobin level, requires transfusion of ≥ 2 units of blood. Despite the retrospective nature, our study has several strengths. This is the first study specifically exploring the prescribing practices of DOACs (with and without concomitant antiplatelet use) in critically ill patients. In addition to assessing the bleeding risk with prehospital DOAC use in critically ill patients we have also explored the concomitant use of DOACs with antiplatelet agents which is a common real world practice and is very helpful to the intensivists for informed decision making and optimization of anticoagulation. DISCLOSURES: No relevant relationships by Sarah Chalmers, source=Web Response No relevant relationships by Amos Lal, source=Web Response No relevant relationships by Osama Mukhtar, source=Web Response No relevant relationships by John Park, source=Web Response No relevant relationships by Matthew Warner, source=Web Response No relevant relationships by Patrick Wieruszewski, source=Web Response