In Reply

Dr. Carron raises the question that patients receiving thromboprophylaxis with low molecular weight heparins (LMWH) and antiplatelet drugs acetylsalicylic acid (ASA) might have an increased bleeding risk if exposed to sugammadex. He referred to the study by Davidson et al.¹  that showed an increased bleeding risk for the combination of antithrombotic and antiplatelet drugs. In contrast to the study discussed here, Davidson’s study was assessing a nonsurgical scenario in which therapeutic doses of oral anticoagulants instead of prophylactic LMWHs were used.

In our trial, roughly 12% of the study population of 1,184 patients, or 144 patients (73 randomized to sugammadex and 71 randomized to usual care), were treated with concomitant LMWH and ASA. There were very few bleeding events in this subgroup, with only four among those that received sugammadex and two in those that received usual care; these numbers are too low to allow for a meaningful comparison of bleeding rates in patients treated with sugammadex versus those treated with usual care. Very few patients were treated with concomitant ASA only (n = 29 total, including 15 in the sugammadex group and 14 in the usual care group); of those patients on ASA only, there were no bleeding events in either the sugammadex or the usual care groups.

Of note, the addition of ASA to LMWH did not increase the bleeding risk among patients who received usual care (4.3% bleeding rate in patients on LMWH compared with 2.8% in patients on LMWH plus ASA who received usual care). Thus, the overall bleeding risk is low in patients receiving LMWH that are randomized to either sugammadex or usual care, and despite the limited experience in this study, it appears that the addition of ASA likely does not confer additional bleeding risk compared with that seen with background LMWH treatment.

As a result, the data of this trial give no reason to interrupt required treatment with ASA in a similar clinical scenario.