Preventing major gastrointestinal bleeding in elderly patients

Abstract Published online June 13, 2017 1 Antiplatelet therapy is the most frequently recommended treatment to prevent recurrent ischaemic events in patients who have had an ischaemic stroke, an acute coronary syndrome, or symptomatic peripheral arterial disease. The most frequently used drugs are aspirin or clopidogrel. Most guidelines recommend lifelong intake of antiplatelet therapy. However, randomised trials that have investigated the benefit of antiplatelet therapy had an observation period of between 2 years and 4 years. Therefore, we lack data on the long-term benefit and risk of antiplatelet therapy across long time periods, particularly in elderly patients. In The Lancet, Linxin Li and colleagues report bleeding events and outcomes in 3166 patients with first transient ischaemic attack, ischaemic stroke, or myocardial infarction who were treated with antiplatelet drugs (mainly aspirin) and were followed prospectively for 10 years. Half of the patients (n=1582) were aged 75 years or older. Major bleeding and fatal bleeding were significantly related to age and showed a steep increase in incidence above the age of 75 years. The hazard ratio for major upper gastrointestinal bleeds was 4·13 for age 75 years or older and 10·26 for those bleeds that were disabling or fatal. The proportion of gastrointestinal bleeding events that were disabling or fatal was higher than the proportion of ischaemic stroke or intracerebral haemorrhage. At age 75 years or older, most major upper gastrointestinal bleeds were disabling or fatal (62% vs 25% of patients younger than 75 years), outnumbering disabling or fatal intracerebral haemorrhage (45 vs 18), with an absolute risk of 9·15 (95% CI 6·67–12·24) per 1000 patient-years. 1 year after the qualifying ischaemic event, 33% of the survivors were on proton-pump inhibitors (PPIs). The number needed to treat to prevent one disabling or fatal upper gastrointestinal bleed over 5 years with the use of PPIs was 338 for individuals younger than 65 years and 25 for individuals aged 85 years or older. What are the practical consequences of this important study? In patients with stroke with a cardiac source of embolism who qualify for oral anticoagulation we obsess about the association between benefit and bleeding risk. Specific risk scores were developed to assess the bleeding risk for patients with atrial fibrillation who qualified for anticoagulation (HAS-BLED). Similar risk scores are not applied for patients who undergo long-term prevention with antiplatelet therapy. We have learned from the studies in elderly patients with atrial fibrillation that aspirin carries a similar risk of major bleeding than warfarin. Therefore, the first consequence of Li and colleagues’ study is that the benefit–risk association in long-term antiplatelet therapy should be evaluated every 3–5 years in patients older than 75 years. We need to consider that patients on dual antiplatelet therapy have a higher risk of bleeding than patients on monotherapy. The bleeding risk is further increased if patients with atrial fibrillation and atherosclerotic disease receive a combination of anticoagulation and antiplatelet therapy. The second consequence of Li and colleagues’ study is its support for the need to use PPIs in patients on antiplatelet therapy aged 75 years or older or in patients with a history of gastrointestinal bleeds. PPIs are underused in patients on antiplatelet therapy, perhaps because the consequences of upper gastrointestinal bleeds were underestimated in elderly patients who were treated with aspirin. Both physicians and patients were shocked by a small underpowered publication in 2016, which assumed a correlation between the use of PPIs and dementia. Unfortunately, this paper was reported widely in the media and created a lot of confusion and angst. Finally physicians are much more influenced by what they observe in their clinical practice than by what they Preventing major gastrointestinal bleeding in elderly patients

DOI: 10.1016/S0140-6736(17)31507-6

Cite this paper

@article{Diener2017PreventingMG, title={Preventing major gastrointestinal bleeding in elderly patients}, author={H-C Diener}, journal={The Lancet}, year={2017}, volume={390}, pages={435-437} }