title: Changes in glycoprotein IIb/IIIa inhibitor excess dosing with site-specific safety feedback in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) initiative.
abstract: BACKGROUND
  Glycoprotein (GP) IIb/IIIa inhibitors can improve outcomes in patients with non-ST-segment elevation acute coronary syndromes but raise the risk of bleeding, particularly if dosed in excess. The impact of GP IIb/IIIa dosing feedback on safety and major bleeding is unknown.
  
  
  METHODS
  Glycoprotein IIb/IIIa dosing feedback was added to the CRUSADE quarterly site reports in the first quarter of 2006. We describe GP IIb/IIIa use and dosing among 25,641 patients with non-ST-segment elevation acute coronary syndromes from the fourth quarter of 2005 to the fourth quarter of 2006.
  
  
  RESULTS
  Eleven thousand eight hundred forty-six patients received GP IIb/IIIa inhibitors, including 4,031 women and 2,609 elderly patients (age, ≥75 years). Among GP IIb/IIIa-treated patients, unadjusted rates of excess GP IIb/IIIa dosing declined overall (26.4%-22.4%, Ptrend=.01) and among the elderly (65.6%-52.1%, Ptrend<.001). After adjustment, declines in excess dosing remained significant only for the elderly, although more than half of GP IIb/IIIa-treated elderly patients continued to receive excess dosing at the end of the study period (64.1%-51.3%, Ptrend<.001). There were concurrent declines in unadjusted major bleeding rates overall (9.6%-8.0%, Ptrend=.02), but declines among women (14.4%-11.5%, Ptrend=.08) and the elderly (17.1%-11.0%, Ptrend=.05) did not reach statistical significance. After adjustment for baseline characteristics and excess dosing, declines in major bleeding rates were no longer significant overall or for any subgroup.
  
  
  CONCLUSIONS
  Within 9 months of initiating a safety feedback program, we observed early decreases in excess GP IIb/IIIa dosing among the elderly but minimal changes in excess dosing overall. Further work is needed to promote safe and effective medication use in vulnerable patients who are most at risk of harm.
authors.affiliation: Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC 27715, USA.
authors.forename: Daniel W
authors.initials: DW
authors.lastname: Mudrick
authors.forename: Anita Y
authors.initials: AY
authors.lastname: Chen
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.forename: L Kristin
authors.initials: LK
authors.lastname: Newby
authors.forename: W Brian
authors.initials: WB
authors.lastname: Gibler
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.forename: Karen P
authors.initials: KP
authors.lastname: Alexander
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000789:Angina, Unstable / Q000188:drug therapy* / Q000453:epidemiology; D018450:Disease Progression; D004305:Dose-Response Relationship, Drug; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000008:administration & dosage*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D019039:Platelet Glycoprotein GPIIb-IIIa Complex