Fatal GI bleed risk higher than expected in elderly on long-term antiplatelet therapy

Last Updated: 2017-06-21

By Marilynn Larkin

NEW YORK (Reuters Health) - Long-term daily aspirin use was linked to a higher than expected risk of serious or fatal bleeding in adults aged 75 or over in a recent study.

Therefore, a proton pump inhibitor (PPI) should be prescribed to patients in that age group who are on long-term antiplatelet therapy after a cardiovascular event, the researchers say.

“In the first-ever large population-based study of the risks, severity, and outcome of bleeds in patients taking mostly aspirin-based antiplatelet treatment after heart attack or stroke, we showed that the risk of major bleeding over 10 years was several fold higher at ages 75 years or older compared to younger patients and that many of the upper-GI bleeds at older ages were disabling or fatal,” Dr. Peter Rothwell of the University of Oxford told Reuters Health.

Dr. Rothwell and colleagues analyzed data from patients with a first transient ischemic attack, ischemic stroke or heart attack between 2002 and 2012 who were treated with antiplatelet drugs (typically aspirin) without routine PPI therapy, with follow-up through 2013.

As reported online June 13 in The Lancet, during 13,509 patient-years of follow-up, 3,166 patients, half of whom were at least 75, had 405 first bleeding events: 218, gastrointestinal; 45, intracranial; and 142, other cause.

Of the 78% with bleeds who were admitted to the hospital, 37% were missed by administrative coding.

The risk of non-major bleeding was not related to age. The risk of major bleeding, however, did increase steeply with age (hazard ratio 3.10 for patients 75 and older) - especially for fatal bleeds (HR 5.53) - and was sustained during long-term follow-up.

The risk of major upper gastrointestinal bleeding was also increased in the 75-and-older group (HR 4.13), particularly for disabling or fatal GI bleeds (HR 10.26; absolute risk 9.15 per 1,000 patient years).

At 75 or older, major upper gastrointestinal bleeds were disabling or fatal in 62% of cases, whereas recurrent ischemic stroke was disabling or fatal in only 47% of cases.

Major upper GI bleeds also outnumbered fatal intracerebral hemorrhage in this age group, occurring in 45 patients versus 18.

The estimated numbers needed to treat for routine PPI use to prevent one disabling or fatal upper gastrointestinal bleed over five years fell from 338 for those under age 65, to 25 for those 85 or older, according to the authors.

“PPI drugs reduce upper gastrointestinal bleeding risk by 70% to 90%, but co-prescription is not routine, partly because of uncertainty about the risks and severity of bleeding in routine practice in older patients,” Dr. Rothwell noted.

He added, “Although long-term PPI use might also have some risks, the risk of bleeding without them at older ages is sufficiently high, and the consequences so significant, that the benefits of routine PPI use are likely to outweigh and risks.”

Editorialist Dr. Hans-Christoph Diener of University Duisburg-Essen, Germany, concurred by email that “major bleeding complications, in particular gastrointestinal bleedings, are a major issue in elderly patients with ischemic vascular disease treated with antiplatelet therapy.”

In his editorial, he called for more research into the identification of patients at high risk, how to reduce the risks and how to balance risks and benefits of long-term antiplatelet treatment.

SOURCE: http://bit.ly/2sVYLbB

Lancet 2017.