Antithrombotic therapy for asymptomatic peripheral artery disease or intermittent claudication
Irrespective of the clinical features, patients with asymptomatic PAD or intermittent claudication are at high absolute atherosclerotic cardiovascular disease risk.
Antiplatelet drugs reduce the risk of cardiovascular events in patients with asymptomatic PAD or intermittent claudication. UseGerhard-Herman, 2017:
1aspirin 100 to 150 mg orally, daily European Stroke Organisation, 2011 aspirin aspirin aspirin
OR
1clopidogrel 75 mg orally, daily1. clopidogrel clopidogrel clopidogrel
Dual antiplatelet therapy (DAPT) does not have a significant benefit over antiplatelet monotherapy in patients with stable PAD; only use DAPT if the patient has another indication (eg acute coronary syndrome, insertion of a drug-eluting stent)European Stroke Organisation, 2011.
Adding low-intensity rivaroxaban therapy to aspirin monotherapy reduces the risk of major adverse limb events, myocardial infarction, stroke and cardiovascular death in patients with stable PAD or coronary artery diseaseEikelboom, 2017. Patients that derive the greatest benefit include those with polyvascular disease (ie more than one of PAD, coronary artery disease or cerebrovascular disease) or additional risk factors (eg chronic kidney disease, heart failure, diabetes).
The clinical criteria for low-intensity rivaroxaban therapy are complex—see the Pharmaceutical Benefits Scheme (PBS) website for current information.
Adding low-intensity rivaroxaban therapy increases bleeding risk (mostly gastrointestinal bleeding) compared with aspirin monotherapy. Consider the balance of potential harms and benefits; consult with or refer to a specialist before starting therapy. Use:
aspirin 100 mg orally, daily aspirin aspirin aspirin
PLUS
rivaroxaban 2.5 mg orally, twice daily. rivaroxaban rivaroxaban rivaroxaban
At the time of writing, rivaroxaban has not been studied in combination with clopidogrel for this indication.
If the patient is taking or develops an indication for DAPT, low-intensity rivaroxaban therapy should not be used.
If an indication for full-dose therapeutic anticoagulation arises in a patient with PAD, antiplatelet and low-intensity rivaroxaban therapy should usually be stopped when the full-dose anticoagulant is started; however, in some high-risk patients (eg recent coronary stenting), it may be appropriate to continue the antiplatelet drug with specialist advice. If full-dose therapeutic anticoagulation is only needed for a finite period (eg 3 months for treatment of venous thromboembolism), restart the therapy for PAD (antiplatelet monotherapy or the aspirin plus low-intensity rivaroxaban therapy) after the full-dose therapeutic anticoagulation is stopped.