Aspirin deprescribing in patients on oral anticoagulation for atrial fibrillation or venous thromboembolism: A national survey of clinician practices

Introduction: Concomitant use of oral anticoagulation (OAC) and aspirin increases bleeding risk without decreasing thromboembolic events compared with OAC mono-therapy. Weak guideline recommendations and limited data exist for deprescribing aspirin for primary prevention or stable coronary artery disease in patients already on OAC for atrial fibrillation (AF) or venous thromboembolism (VTE). Objectives: The objective of this study was to identify aspirin deprescribing practices among clinicians for patients on OAC for AF or VTE and concomitant aspirin for non-compelling reasons. Methods: A cross-sectional, national survey was electronically distributed to pharmacists and non-pharmacists (physicians, nurse practitioners, physician assistants). Co-primary end points were composite aspirin discontinuation rates in patients on OAC for AF or VTE in primary prevention and stable coronary artery disease (CAD) cases. Key secondary end points were clinician comfort level with deprescribing aspirin and availability of institutional protocols. Results: Three hundred four responses were included: 212 (69.7%) pharmacists and 92 (30.3%) non-pharmacists. Mean age of respondents was 35.4 years, and 37.4% male. In the primary prevention cases, pharmacists were more likely to discontinue aspirin than non-pharmacists (76.7% vs. 54.6%, p < 0.001). In the stable CAD cases, composite rates of aspirin discontinuation by pharmacists and non-pharmacists were similar (41.7% vs. 40.1%, p = 0.140). More pharmacists than non-pharmacists stated that their aspirin deprescribing decisions were independent of the type of OAC that was used (60.4% vs. 35.9%, p < 0.001). Pharmacists were more likely to discontinue aspirin after discussing with patients compared with non-pharmacists (62.7% vs. 47.8%, p = 0.017). 27.3% of clinicians reported having a protocol to deprescribe aspirin at their institution/clinic. Conclusion: There are variations in aspirin deprescribing practices among clinicians in patients on OAC for AF or VTE and without compelling indications for aspirin.Further studies and stronger recommendations are warranted to guide clinicians regarding optimal antithrombotic therapy in these scenarios. Lack of institutional protocols for aspirin deprescribing creates opportunities for future quality improvement initiatives.