Purpose: Patients on dual and triple antithrombotic therapy present the therapeutic dilemma of mitigating bleed risk while sustaining antithrombotic efficacy. Lack of literature and variability in existing published guidance potentiates inconsistent management of these patients. Furthermore, suboptimal dosing of direct oral anticoagulants is relatively common. One study reported as high as 43% of patients receive higher and 13% receive lower than clinically indicated doses. These findings were associated with a significantly increased risk of major bleeding and incidence of stroke, thus highlighting the importance of selecting an ideal regimen. The purpose of this project is to highlight pharmacists’ role in the optimization of antithrombotic therapy in patients with concurrent indications for antiplatelet and anticoagulant agents.

Methods: This was a single center, quality improvement project including adult patients concomitantly receiving at least one antiplatelet agent and a therapeutic-dose anticoagulant between January and March 2021 at Baptist Hospital. Eligible patients were assessed and evaluated on a daily basis. Data collection included indications for prescribed antithrombotic agents and rationale for clinical recommendations. Potential therapeutic de-escalations and/or dose adjustments were communicated with the provider as necessary. The primary outcome of this study was appropriateness of anticoagulant and antiplatelet therapy based on their specific indications. Secondary outcomes included the types of pharmacy interventions made and accepted.

Results: A total of 239 patients receiving dual or triple antithrombotic therapy were prospectively reviewed over the 10-week study period. The average age was 74 years, and 56% of patients were male. The majority of regimens reviewed (95.4%) were dual antithrombotic therapy. Overall, 82% of all reviewed regimens were considered appropriate at time of pharmacist review (85% of dual therapy regimens and 27% of triple therapy regimens were appropriate). After pharmacist intervention, regimen appropriateness increased to 97% overall, with dual therapy regimens adjusted to 96.5% appropriate (78% acceptance rate) and triple therapy regimens adjusted to 100% appropriate (100% acceptance rate). The most common intervention was antiplatelet discontinuation (46%), however the most clinically significant intervention was discontinuation of oral anticoagulation (7.8%).

Conclusion: Pharmacist intervention resulted in optimization of dual and triple antithrombotic therapies by 15% with an intervention acceptance rate of 83%. Triple antithrombotic regimens had the greatest room for optimization, as was demonstrated by a 73% increase in regimen appropriateness as a result of pharmacist review and intervention.

Publication Date


Presented At:

Virtual Florida Residency Conference

Content Type



Laura Neubauer - Pharmacy Resident PGY2

Author Credentials

Laura Neubauer, Pharm.D., BCPS

Radhan Gopalani, Pharm.D., BCPS

Kristen de Almeida, Pharm.D., BCCP

Open Access

Available to all.