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4CPS-020 Anticoagulation therapy in haemodialysis – a clinical pharmacist experience in a primary care team

Background Anticoagulation (AC) is essential to haemodialysis (HD), however the uremic state itself can cause bleeding complications. Purpose The aims of this retrospective cohort study were: To evaluate our current anticoagulation practice focusing on bleeding risk in contrast to thromboembolic events. To analyse potentially severe drug–drug interactions (DIs) to determine drug combinations that should be avoided. Material and methods We reviewed the medical records of 101 chronic HD patients (55 men, age 69±12 years, HD vintage 31 months (IQR:45)) in our hospital. Each patient’s current medical treatment was evaluated by in-person interview and drug interactions were checked with Medscape. Statistical analysis was performed with the SPSS v18.0 software package. Data were expressed as mean ±SD, comparisons between groups were analysed by non-parametric tests, p<0.05 was considered statistically significant. Results A total of 69 patients received UFH and 31 got LMWH during HD as per dialysis protocol. For other indications 20 patients received LMWH and 11 patients received oral anticoagulation therapy (OAC) off-dialysis days. The majority of patients spent a longer time outside of target international normalisation ratio. Additionally, 41 patients took antiplatelet agents and 29 took NSAIDs. Overall, 34% of the total patients had experienced bleeding, while 30% had suffered thromboembolic complications. Forty-four (45%) patients had 83 severe/contraindicated DIs. The main severe potential drug-drug interactions were caused by combinations of NSAID/ASA (35%), dalteparin/UFH (29%) and dalteparin/clopidogrel (10%). Sixty-eight per cent of these patients (31 out of 45) had manifest bleedings, whereas among those without drug interactions bleeding was observed in 18% (p<0.001). More blood transfusions (64% vs 44% p=0.048) and higher erythropoietin substitution were needed for patients who had severe drug interactions (21409±10 991 vs 18500±11480 IU/month, p=0.197) compared to those patients who did not. Conclusion Dialysis patients may experience severe potential DIs. Their anticoagulant regime should be personalised. Clinicians should be cautious when prescribing drugs to them. Involving clinical pharmacists in the primary team is advisable to prevent DIs. References and/or acknowledgements https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4960860/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4765624/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5051256/ https://reference.medscape.com/drug-interactionchecker No conflict of interest.