Risk of Lower and Upper Gastrointestinal Bleeding, Transfusions, and Hospitalizations With Complex Antithrombotic Therapy in Elderly Patients

Abstract

Background-Complex antithrombotic therapy (CAT) prescribed to elderly patients increases the risk of gastrointestinal bleeding. We quantified upper (UGIE) and lower gastrointestinal (LGIE) events, transfusions, and hospitalizations in a national cohort of elderly veterans prescribed CAT. Methods and Results-Veterans ≥60 years of age prescribed anticoagulant-antiplatelet, aspirin (ASA)-antiplatelet, ASAanticoagulant, or triple therapy (ie, TRIP, anticoagulant-antiplatelet-ASA) were identified from the national pharmacy database (October 1, 2002 to September 30, 2008. Prescription-fill data were linked to Veteran Affairs and Medicare encounter files, each person-day of follow-up was assessed for CAT exposure, and outcomes were defined by using diagnostic code algorithms derived following chart abstraction. Incidence density ratios (compared with the reference category of no CAT) and survival analysis was conducted. Among 78 133 veterans (98.6% white; mean age, 72.3 [standard deviation 7.7]), 64% were prescribed ASA-antiplatelet and anticoagulant-antiplatelet and 6% were prescribed TRIP. The incidence of UGIE was 20.1/1000 patient-years, and the incidence of LGIE was 70.1/1000 patient-years. ASA-anticoagulant and TRIP were associated with the highest incidence of transfusion and hospitalization. A 40% to 60% increased risk of UGIE was observed with all strategies.LGIE was 30% higher with anticoagulant-antiplatelet, and transfusion increased with ASA-anticoagulant (hazard ratio, 6.1; 95% confidence interval, 5.2-7.1) and TRIP (hazard ratio, 5.0; 95% confidence interval, 4.2-5.8). Increased risk of hospitalization was noted with all strategies. The number needed to harm for UGIE or LGIE ranged from 52 to 65 and 15 to 23, respectively. The number needed to harm for hospitalization was 39 (anticoagulant-antiplatelet), 34 (ASA-anticoagulant), 67 (ASA-antiplatelet), and 45 (TRIP) patients. Conclusions-Among

Risk of Upper and Lower Gastrointestinal Bleeding in Patients Taking Nonsteroidal Anti-inflammatory Drugs, Antiplatelet Agents, or Anticoagulants

“…Yet, PPI use is usually a strong marker of worse overall comorbidity. 11 Nevertheless, new studies should further investigate this effect, because recent experimental animal data suggest that PPI can alter the microbiota of the small bowel and potentiate the damaging effect of NSAIDs on the intestinal mucosa. 20 This study has strengths and weaknesses.…”

“…9 Evidence on the risk of lower gastrointestinal bleeding (LGIB) associated with other non-aspirin antiplatelet or anticoagulant agents is related only to diverticular bleeding and is also very scarce, 10 whereas it is clear that use of these drugs is growing in a progressively elderly population. 11 Different studies have shown that the use of proton pump inhibitors (PPIs) prevents upper GI damage and the risk of upper GI complications but is unable to prevent NSAID-associated small bowel mucosal damage. 1,6 No data are available concerning the impact of PPI use on lower GI complications.…”

Distinct Clinical Factors in Hospitalized Patients with Diverticular Bleeding and Diverticulitis

“…We found that patients with diverticular bleeding used significantly more PPIs than patients with diverticulitis and the controls, but we did not find that PPIs increased the risk of diverticular bleeding in the multivariate logistic analysis of significant risk factors. PPIs are some of the most commonly prescribed medications and are often a strong indicator of worse overall comorbidities [19]. Nagata et al [20] also demonstrated that PPIs did not lead to an increased risk of lower gastrointestinal bleeding in a large case-control study.…”

Risk of bleeding after hospitalization for a serious coronary event: a retrospective cohort study with nested case-control analyses

“…In addition to reducing cardiovascular risk, however, antiplatelet therapies confer an increased risk of bleeding in general [6–8] and of upper gastrointestinal bleeding (UGIB) in particular [10–12]. The risk of lower gastrointestinal bleeding (LGIB) associated with antiplatelet therapies, however, has rarely been studied and only in small populations [13–15] or elderly patients [16]. …”