PB1083 - Effect of Combining Antiplatelet Therapy with Anticoagulation without A Definitive Indication in Patients with Chronic Liver Disease

Background: Patients with chronic liver disease (CLD) have a high mortality and most of the deaths result from hemorrhage. Anticoagulant therapy initiated for thromboembolic conditions doubles the risk of hemorrhage in CLD patients. Data in general population show that the combination of antiplatelet therapy with anticoagulant therapy can further increase the risk of bleeding. These data may or may not apply to CLD patients given their unique hemostatic profile and bleeding risk factors.

Aims: We aimed to investigate the effect of combining antiplatelet therapy with anticoagulant therapy (without a definitive indication) on hemorrhage in a cohort of CLD patients.

Methods: Using the Veterans Administrative data, we identified patients with CLD (using a validated algorithm) started on anticoagulant therapy between 2002 and 2018. Using prescription data, we identified patients on antiplatelet therapy at the start of anticoagulation without a definitive indication (no recent myocardial infarction/no artificial heart valves). We identified variceal and non-variceal hemorrhage using previously validated ICD-9/10 codes, and performed a competing risk analysis to study the effect of combining antiplatelet therapy with anticoagulant therapy on the risk of hemorrhage while adjusting for potential confounders, and accounting for the competing risk of death.

Results: Among 2,827 CLD patients who started anticoagulation, 780 were also on antiplatelet therapy. Hemorrhage occurred in 216 patients within 12 months of starting anticoagulation (199 variceal and 17 non-variceal). Nine percent of the patients taking both antiplatelet and anticoagulant therapy experienced hemorrhage compared to seven percent of those on anticoagulant therapy alone. Combining antiplatelet therapy with anticoagulation without a definitive indication predicted 42% higher risk of hemorrhage at 12 months (Adjusted Hazards Ratio 1.42; 95% Confidence Interval 1.04-1.92) (Table 2).

Conclusion(s): Combining antiplatelet therapy with anticoagulation without a definitive indication multiplies the risk of hemorrhage in CLD patients. Deprescribing antiplatelet therapy may be appropriate if the anticipated risk exceeds benefit.