Antiplatelet-related major bleeding risk increases with age

Last Updated: 2017-06-26

By Will Boggs MD

NEW YORK (Reuters Health) - The risk of major bleeding associated with the use of antiplatelet medications, including aspirin, increases substantially with age, but routine proton pump inhibitor (PPI) use can prevent such bleeding, according to results from the Oxford Vascular Study.

Antiplatelet drugs are known to increase the risk of major bleeding, particularly upper gastrointestinal bleeds, but PPIs can reduce that risk by 70-90%. Their co-prescription is not routine, however, because of concerns about adverse effects.

The risk of upper gastrointestinal bleeding associated with antiplatelet use increases with age, but it remains unclear whether old age alone justifies routine co-prescription of PPIs.

For the study, online June 13 in The Lancet, Dr. Peter M. Rothwell and colleagues from the University of Oxford, U.K., analyzed data on more than 3,100 patients, 1,582 of whom were aged 75 years or older and 577 of whom were 85 years or older.

The risk of nonmajor bleeds was unrelated to age, and the risk of major bleeds did not increase with age among patients younger than 70 years.

In contrast, the annual risk of major bleeds increased steeply above age 70 years and was significantly higher in patients aged 75 years or older at baseline than in those younger than 75 years at three years (2.73-fold increased risk) and at 10 years (3.10-fold increased risk).

Patients aged 75 years or older had more severe bleeds and worse outcomes of nonfatal bleeds, compared with those younger than 75 years.

With increasing age, the risk of major bleeds estimated to be attributable to antiplatelet treatment approached the risk of ischemic events estimated to have been prevented.

Based on a previous meta-analysis where PPI use reduced upper gastrointestinal bleeding by 74%, the number needed to treat (NNT) with PPIs to prevent one major upper gastrointestinal bleed at five years’ follow-up decreased with increasing age: from 80 for patients under 65, to 75 for patients aged 65-74 years, 23 for patients aged 75-84 years and 21 for patients aged 85 years or older.

The NNT with PPIs to prevent one disabling or fatal upper gastrointestinal bleed followed a similar pattern.

“Given that half of the major bleeds in patients aged 75 years or older were upper gastrointestinal, the estimated NNT for routine PPI use to prevent major upper gastrointestinal bleed is low and co-prescription should be considered in future secondary prevention guidelines,” the researchers conclude.

“More research is still required into how best to identify patients at high risk of bleeding, how to reduce the risk of non-upper gastrointestinal bleeds, and into the overall balance of risks and benefits of long-term antiplatelet treatment at older ages in both primary and secondary prevention,” they add.

Dr. Hans-Christoph Diener from University Duisburg-Essen, in Essen, Germany, who wrote a linked editorial, told Reuters Health by email, "The long-term GI bleeding risk in elderly patients on antiplatelet therapy is much higher than described earlier.”

He recommended PPIs for “patients above the age of 75 years and patients with a prior history of GI ulcer or GI bleed who are on aspirin.”

The study had no commercial funding.

Dr. Rothwell did not respond to a request for comments.

SOURCE: http://bit.ly/2sVYLbB and http://bit.ly/2scAY2E

Lancet 2017.