What would be the best treatment option for a patient who suffers a major bleeding event while on anticoagulation therapy to treat atrial fibrillation?
a. stop anticoagulation therapy
b. resume anticoagulation therapy with dabigatran
c. resume anticoagulation therapy with warfarin
d. resume anticoagulation therapy with either dabigatran or warfarin
Providers caring for atrial fibrillation (AF) patients who suffer a major bleeding event are faced with a common dilemma, according to Dr Inmaculada Hernandez, an assistant professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy.
Do they discontinue anticoagulation therapy in order to avoid future bleeding events, but place patients at increased risk of recurrent stroke? Or do they resume anticoagulation in order to lower risk of stroke but increase the likelihood of another bleeding event occurring?
Her recent study, which involved analyzing the records of 90,000 Medicare beneficiaries who took warfarin and dabigatran to treat AF, attempted to provide some guidance. More than 1500 of the patients suffered a major bleeding event while on warfarin or dabigatran, and approximately half resumed one of the therapies a couple months after the event (Stroke. 201748:159-166).
Patients who took dabigatran were nearly 50% less likely than patients on warfarin to suffer another bleeding event within a year. In addition, the risk of all-cause mortality or stroke was as much as 34% higher in patients who discontinued anticoagulation therapy altogether.
The findings highlight the importance of resuming anticoagulation therapy after a major bleeding event in patients with AF and showed that dabigatran was associated with more benefit than risk when compared with warfarin, according to Dr Hernandez.
She acknowledged that clinicians are often hesitant to restart anticoagulants in patients who are hospitalized after suffering a major bleeding event but added that pharmacists could use the study’s results to help educate prescribers about the importance of resuming the therapy and should confirm that patients do in fact receive the needed treatment.—Dan Cook