Summary of the example
All Dorset CCG GP Practices were asked to audit all patients taking anti-platelets (clopidogrel, prasugrel and ticagrelor), as part of a dual anti-platelet (anti-platelet plus aspirin) regime, to ensure that the duration of therapy is appropriate and that all prescriptions of limited duration have a stop date. While dual anti-platelet therapy has benefits in terms of reducing cardiovascular morbidity and mortality the risk of bleeding increases with increasing length of dual therapy.
All 87 practices in the CCG completed the audit and showed that of the 2957 patients identified as taking Dual Antiplatelet Therapy (DAPT), 38% had been taking it for more than 13 months and 15% had no valid indication to take it for longer than 12 months. 51% of patients did have a stop date in their notes and on their prescription.
Why we think it’s important
Aspirin should be offered to all people after an MI and continued indefinitely unless they are aspirin intolerant or have an indication for anticoagulation. Depending on the condition a second antiplatelet, such as ticagrelor, prasugrel or clopidogrel, may be offered in combination with aspirin for a defined period of time, generally up to 12 months. There have been many reports of people continuing on dual antiplatelet therapy beyond the recommended time limit because of a lack of clarity about the duration of co-prescribing. This can lead to adverse consequences for the person taking the dual antiplatelets. In addition doses of prasugrel vary according to the age of the person and ticagrelor has different dose regimes depending on the indication.
Learn more about the example
Aims and objectives of the work
The aim of this audit was to ensure that 100% of patients had a stop date on their second antiplatelet prescription unless there was a valid indication to continue.
Any patient found to be taking a combination of clopidogrel, ticagrelor and prasugrel was immediately flagged for a review as combinations of these medicines are not recommended.
As part of the Dorset CCG GP medicines optimisation plan 2017-18, practices were asked to audit all patients taking antiplatelets (clopidogrel, prasugrel and ticagrelor) as part of a dual antiplatelet (antiplatelet plus aspirin) regime.
The MOPs in the GP practices used the audit template developed by the Medicines Management team at Dorset CCG, to collate the data and review the patients whose records were not up to date or who had been taking the dual antiplatelet therapy for longer than indicated.
Key findings include:
- All 87 practices in the CCG completed the audit.
- 2957 patients were identified as taking DAPT
- 38% (996) had been taking for more than 13 months
- 15% (433) had no valid indication to take longer than a year
- 73% (1902) patients had been taking DAPT for less than 13 months
- 51% (1508) patients had a stop date in their notes and on their prescription
- 4% (129) had been instructed to take for more than 12 months
When assessing the final submissions for all practices:
- 47% (41) achieved the 100% target for a stop date or long term indication documented in the notes and on the prescription
- 55% (26) had zero patients who had taken DAPT for longer than indicated (>13 months with no valid indication)
- 25% (22) practices achieved both of these indicators
The audit prompted practices to review patients, meaning that up to 433 patients who had taken their DAPT for longer than indicated as well as the 265 patients who had no stop date recorded, were reviewed. The audit was only one cycle and did not ask how many patients had their DAPT stopped as a result of the review, nor did it request the practices describe any actions taken.
An in-focus bulletin and audit template from Dorset CCG are attached below.
National guidance, data and publications
While dual anti-platelet therapy has benefits in terms of reducing cardiovascular morbidity and mortality the risk of bleeding increases with increasing length of dual therapy. There are a number of conditions where dual antiplatelets are used in the initial management of the condition; relative background guidance includes:
- NICE CG 94 Unstable angina and NSTEMI: early management, March 2010
- NICE CG 167 Myocardial infarction with ST-segment elevation: acute management
- NICE TA 152, Drug-eluting stents for the treatment of coronary artery disease
- NICE Stroke and transient ischaemic attack in over 16s: diagnosis and initial management, March 2017
Inappropriate continuation of dual antiplatelet therapy beyond the recommended duration leads to increased risks of bleeding and adverse effects in patients.
Links to the various relevant guidance are provided below.
Interim co-director, South West Medicines Information and Training, NHS England South