The risk of lower gastrointestinal bleeding in low‐dose aspirin users

Chen, W.-C.; Lin, Kung‐Hung; Huang, Yu‐Tung; Tsai, Tzung‐Jiun; Sun, Wei; Chuah, Seng‐Kee; Wu, Deng‐Chyang; Hsu, Ping‐I

doi:10.1111/apt.14079

Cited by 56 publications

(53 citation statements)

References 35 publications

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“…Anticoagulant and antiplatelet agents are reported to be the risk factors for lower GI bleeding [32,33], but still some authors stated that antiplatelet agents were not associated with LGI bleeding [34]. In our study, we found that LGI bleeding had no association with antiplatelet agents and anticoagulants.…”

Section: Gastroenterology Research and Practicecontrasting

confidence: 62%

Hemodialysis Increases the Risk of Lower Gastrointestinal Bleeding and Angiodysplasia Bleeding: A Nationwide Population Study

Tsai

Chen

Huang

et al. 2020

Gastroenterology Research and Practice

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Background. Patients with chronic kidney disease (CKD) with or without hemodialysis were considered to have bleeding tendency and higher risk for gastrointestinal (GI) bleeding. Previous studies had documented that hemodialysis may increase the gastroduodenal ulcer bleeding. Few studies evaluated the relationship between CKD and lower GI bleeding. Materials and Methods. An observational cohort study design was conducted. The end-stage renal disease (ESRD) patients receiving regular hemodialysis (dialysis CKD), CKD patients without dialysis (dialysis-free CKD), and controls were selected from 1 million randomly sampled subjects in the National Health Insurance Research Database of Taiwan. These three group subjects were matched by age, sex, comorbidity, and enrollment time in a 1 : 2 : 2 ratio. The Cox proportional hazard regression models were used to identify the potential risk factors for lower gastrointestinal bleeding. Results. Dialysis CKD patients (n = 574) had a higher incidence of lower GI bleeding than dialysis-free CKD patients (n = 1148) and control subjects (n = 1148) (12.9% vs. 3.6% and 2.8%; both P < 0:001). Multivariate analysis showed that extreme old age (age ≥ 85), male gender, dialysis-free CKD, and dialysis CKD were independent factors of lower GI bleeding. Additionally, dialysis CKD patients also had a higher incidence of angiodysplasia bleeding compared to dialysis-free CKD patients and control subjects (1.1% vs. 0.1% and 0.1%, respectively; both P = 0:003). Conclusion. Hemodialysis may have higher risk of lower GI bleeding and angiodysplasia bleeding.

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Section: Gastroenterology Research and Practicecontrasting

confidence: 62%

Hemodialysis Increases the Risk of Lower Gastrointestinal Bleeding and Angiodysplasia Bleeding: A Nationwide Population Study

Tsai

Chen

Huang

et al. 2020

Gastroenterology Research and Practice

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“…2 Moreover, the literature cited in the paper's introduction linking UC "flares" to stress, is now quite old (most pre 2000) and thus likely to be inaccurate, as disease activity was judged on symptoms alone.…”

Section: Acknowledg Ementmentioning

confidence: 99%

“…Aspirin use remained an independent risk factor for LGIB after adjustments for age, gender, comorbidities, nonsteroidal anti-inflammatory drugs (NSAIDs), clopidogrel, ticlopidine, warfarin, steroids and selective serotonin reuptake inhibitors. 2 This indicates that aspirin is significantly associated with…”

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confidence: 98%

Editorial: lower gastrointestinal bleeding and low‐dose aspirin—authors’ reply

Chen¹,

Lin

Huang

et al. 2017

Aliment Pharmacol Ther

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We deeply appreciate the comments from Dr. Taha concerning our recent work.1,2 The risk of lower gastrointestinal bleeding (LGIB) in aspirin users is usually investigated in case-control studies. 3 However, little is known about the incidence and prevalence rates of LGIB among aspirin users. Therefore, we collected a cohort of new aspirin users and matched controls to estimate the actual risk of LGIB. We agree that, ideally, patients using drugs with bleeding potential should be excluded to avoid the confounding effects upon LGIB. However, the proportion of pro-bleeding drug use in clopidogrel users was higher than that in clopidogrel non-users in a nationwide study. 4 It is possible that users of antiplatelet agents might seek medical help for comorbidities, thus increasing the probability of pro-bleeding drug use. Finally, we chose to control the confounding factors via statistical methods because we believed that these samples were more close to patients in practice. Aspirin use remained an independent risk factor for LGIB after adjustments for age, gender, comorbidities, nonsteroidal anti-inflammatory drugs (NSAIDs), clopidogrel, ticlopidine, warfarin, steroids and selective serotonin reuptake inhibitors. 2 This indicates that aspirin is significantly associated withLGIB although the risk might be overestimated when patients using drugs with bleeding potential were not excluded. More studies excluding patients with bleeding diathesis and using pro-bleeding drugs are needed to clarify the actual risk of aspirin-induced LGIB. The second comment raised is the impact of antisecretory agents on LGIB in aspirin users.There is growing evidence on the association between proton pump inhibitors (PPIs) and LGIB. 5 Nevertheless, the association does not necessarily suggest that PPIs directly cause LGIB because PPI use usually indicates a poor comorbidity status, which increases the probability ofLGIB. However, more small intestinal injury has been observed in patients using PPIs plus NSAIDs than patients using NSAIDs alone. 6 PPIs might also exacerbate NSAID and low-dose aspirin-associated small bowel injury by inducing changes in the intestinal microbiota. 7,8 Moreover, probiotic use significantly decreases the incidence of small intestine mucosal injury in patients using PPIs and aspirin. 8 These studies indicate that PPIs might indirectly induce injury of the lower GI tract and predispose the mucosa towards bleeding in aspirin users. Another important issue is to decrease the risk of LGIB in aspirin users in whom PPI therapy may be considered. Prostaglandin analogue use is an alternative strategy to prevent aspirin-induced peptic ulcers and was effective in the treatment of aspirin-induced enteropathy in a pilot study. 9 Dr. Taha has conducted an interesting randomised controlled trial on healing of small bowel mucosal ulcers in response to misoprostol in aspirin or NSAIDs users 10 and we look forward to the results. Finally, identifying low-dose aspirin users at low risk for upper GI bleeding to avoid inappropri...

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“…These are known to increase the risk of both upper and lower GI bleeding. 12,13 Thus, this information becomes crucial when evaluating a patient with upper and lower GI bleed. Unfortunately, this data has not been clearly shown in the present study.…”

mentioning

confidence: 99%

Etiological Spectrum of Lower Gastrointestinal Bleeding: Geographical Location Does Matter

Sinha

Singh

2019

Journal of Digestive Endoscopy

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The risk of lower gastrointestinal bleeding in low‐dose aspirin users

Abstract: The risk of LGIB was higher in low-dose aspirin users than in aspirin nonusers in this nationwide cohort. Low-dose aspirin, NSAIDs, steroids, SSRIs, PPIs and H2RAs were independent risk factors for LGIB.

Cited by 56 publications

References 35 publications

Hemodialysis Increases the Risk of Lower Gastrointestinal Bleeding and Angiodysplasia Bleeding: A Nationwide Population Study

Hemodialysis Increases the Risk of Lower Gastrointestinal Bleeding and Angiodysplasia Bleeding: A Nationwide Population Study

Editorial: lower gastrointestinal bleeding and low‐dose aspirin—authors’ reply

Etiological Spectrum of Lower Gastrointestinal Bleeding: Geographical Location Does Matter

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