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National guidance

Anticoagulants recommended over aspirin for stroke prevention

NICE concludes that aspirin is not an effective stroke prevention therapy for atrial fibrillation patients

This undated handout picture shows Elisabeth Perzborn who is responsible for the planning, execution and coordination of the exploration of Rivaroxaban holding several blood samples in Wuppertal, Germany. The team around Perborn developed a tablet contain

Source: Ansgar Pudenz/German Future Prize

Developed as an anticoagulant by researchers in Germany, rivaroxaban is one of NICE’s preferred treatments for preventing stroke in patients with atrial fibrillation

Aspirin should no longer be used to prevent stroke in patients with atrial fibrillation (AF), the National Institute for Health and Care Excellence (NICE) recommends in new guidance published on 18 June 2014.

NICE points out that patients with AF are up to five times more likely to suffer a stroke because of the condition. Currently, those who cannot tolerate warfarin are commonly given aspirin instead, in line with previous guidance from NICE.

However, following a review of new evidence, NICE has concluded that aspirin is not as effective as anticoagulants at preventing stroke and that its safety profile, regarding bleeding, is not as favourable as previously thought. NICE also argues that the use of aspirin is thwarting the effective use of oral anticoagulants. 

NICE highlights the value of the new generation oral anticoagulants — apixaban, dabigatran and rivaroxaban, known as NOACs (new or novel oral anticoagulants) — particularly for patients who find it difficult to control blood clotting with warfarin or who are intolerant of warfarin.

NOACs were approved for NHS use by NICE in 2012 and early 2013, but NICE says they have not been as widely prescribed as expected.

“Around 7,000 strokes and 2,000 premature deaths could be avoided every year through effective detection and protection with anticoagulant drugs,” says Mark Baker, NICE’s director of clinical practice. “Unfortunately, only half of those who should be getting these drugs, are.”

“Implementing the NICE guidance will be key to saving lives,” says Helen Williams, a consultant pharmacist and the Royal Pharmaceutical Society spokesperson on cardiovascular medicines. “For too long, too many people with this rhythm disorder have been receiving inferior treatments, but now there is robust clinical research demonstrating the effectiveness of anticoagulant therapies,” she adds.

The guidance also recommends the use of a new assessment tool — called CHA2DS2-VASc — to gauge the risk of stroke in AF patients. Patients with a score of 2 or above should be given anticoagulation therapy, and therapy should be considered for men with a score of 1. Personalised care and information is another priority in the updated guidance and NICE will be piloting a patient decision aid to help patients weigh up the benefits and risks of the treatment options for AF. 

To support implementation of the guidance, the NICE Implementation Collaborative (NIC) has produced its first “consensus statement”. The NIC was set up in 2012 to identify barriers to implementing NICE guidance and to ensure that patients get easy access to approved treatments.   

A key aim is to increase the use of apixaban, dabigatran and rivaroxaban in patients for whom these medicines are indicated. They should be used as an alternative to warfarin in cases when it is inadequate despite adherence, or in patients who have allergic reactions or intolerance.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.20065378

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