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Yang Y, Li Y, Li J. Letter: Incidence and Predictors of Major Gastrointestinal Bleeding in Patients on Aspirin, Low-Dose Rivaroxaban or the Combination: Secondary Analysis of the COMPASS Randomised Controlled Trial. Aliment Pharmacol Ther 2024. [PMID: 39367696 DOI: 10.1111/apt.18306] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2024] [Revised: 09/17/2024] [Accepted: 09/17/2024] [Indexed: 10/06/2024]
Affiliation(s)
- Yu Yang
- College of Integrative Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan, China
| | - Yaling Li
- Department of Pharmacy, The Affiliated Hospital, Southwest Medical University, Luzhou, Sichuan, China
| | - Jun Li
- Southwest Medical University, Luzhou, Sichuan, China
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2
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Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45:3314-3414. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Lee M, Cha JM. Real-World Bleeding Risk of Anticoagulant and Nonsteroidal Anti-inflammatory Drugs Combotherapy versus Anticoagulant Monotherapy. Gut Liver 2024; 18:824-833. [PMID: 38726558 PMCID: PMC11391146 DOI: 10.5009/gnl230541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 09/13/2024] Open
Abstract
Background/Aims The incidence of acute gastrointestinal bleeding (GIB) increases with the utilization of anticoagulant and nonsteroidal anti-inflammatory drugs (NSAIDs). This study aimed to compare the risk of GIB between anticoagulant and NSAIDs combotherapy and anticoagulant monotherapy in real-world practice. Methods We investigated the relative risk of GIB in individuals newly prescribed anticoagulant and NSAIDs combination therapy and that in individuals newly prescribed anticoagulant monotherapy at three hospitals using "common data model." Cox proportional hazard models and Kaplan-Meier estimation were employed for risk comparison after propensity score matching. Results A comprehensive analysis of 2,951 matched pairs showed that patients who received anticoagulant and NSAIDs combousers exhibited a significantly higher risk of GIB than those who received anticoagulant monousers (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.30 to 2.12; p<0.001). The risk of GIB associated with anticoagulant and NSAIDs combination therapy was also significantly higher than that associated with anticoagulant monotherapy in patients aged >65 years (HR, 1.53; 95% CI, 1.15 to 2.03; p=0.003) and >75 years (HR, 1.89; 95% CI, 1.23 to 2.90; p=0.003). We also found that the risk of GIB was significantly higher in the patients who received anticoagulant and NSAIDs combousers than that in patients who received anticoagulant monousers in both male (p=0.016) and female cohorts (p=0.010). Conclusions The risk of GIB is significantly higher in patients who receive anticoagulant and NSAIDs combotherapy than that in patients who receive anticoagulant monotherapy. In addition, the risk of GIB associated with anticoagulant and NSAIDs combotherapy was much higher in individuals aged >75 years. Therefore, physicians should be more aware of pay more attention to the risk of GIB when they prescribe anticoagulant and NSAIDs.
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Affiliation(s)
- Moonhyung Lee
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea
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Gries JJ, Chen B, Virk HUH, Khalid U, Jneid H, Birnbaum Y, Lavie CJ, Krittanawong C. Clinical implications of combination proton pump inhibitor and triple therapies in patients with atrial fibrillation following percutaneous intervention: a guide for clinicians. Expert Rev Cardiovasc Ther 2024:1-9. [PMID: 39267388 DOI: 10.1080/14779072.2024.2401865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 09/04/2024] [Indexed: 09/17/2024]
Abstract
INTRODUCTION Patients on systemic oral anticoagulation with vitamin K antagonists (VKA) or non-vitamin K oral anticoagulants (NOAC) often require triple therapy following percutaneous coronary intervention, substantially increasing the risk of bleeding. Gastroprotective agents like proton pump inhibitors (PPI) are often employed to mitigate this risk, despite potential competitive inhibition between P2Y12-receptor inhibitors, NOACs, and VKAs. While the interactions and clinical outcomes of PPIs and DAPT have been frequently explored in literature, not many studies have evaluated the same outcomes for triple therapy. AREAS COVERED This comprehensive narrative review of three studies on PPIs and triple from the PubMed/MEDLINE database supplemented by 23 other relevant studies aims to use the available literature to analyze the potential interactions between PPIs and triple therapy while shedding light on their mechanisms, clinical implications, and areas for optimization. EXPERT OPINION If triple therapy is indicated following PCI, then patients at high-risk for bleeding may benefit from transition to apixaban and a PPI to lower the risk of gastrointestinal bleeding. More research is needed to determine the role of PPIs in triple therapies in prevention of gastrointestinal bleeding or potentiation of other adverse outcomes.
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Affiliation(s)
- Jacob J Gries
- Department of Internal Medicine, Geisinger Medical Center, Danville, PA, USA
| | - Bing Chen
- Department of Gastroenterology, Hepatology, and Nutrition, Geisinger Medical Center, Danville, PA, USA
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Umair Khalid
- Michael E. DeBakey VA Medical Center, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston, TX, USA
| | - Yochai Birnbaum
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
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5
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Almadi MA, Lu Y, Alali AA, Barkun AN. Peptic ulcer disease. Lancet 2024; 404:68-81. [PMID: 38885678 DOI: 10.1016/s0140-6736(24)00155-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/22/2023] [Accepted: 01/24/2024] [Indexed: 06/20/2024]
Abstract
Annual prevalence estimates of peptic ulcer disease range between 0·12% and 1·5%. Peptic ulcer disease is usually attributable to Helicobacter pylori infection, intake of some medications (such as aspirin and non-steroidal anti-inflammatory medications), or being critically ill (stress-related), or it can be idiopathic. The clinical presentation is usually uncomplicated, with peptic ulcer disease management based on eradicating H pylori if present, the use of acid-suppressing medications-most often proton pump inhibitors (PPIs)-or addressing complications, such as with early endoscopy and high-dose PPIs for peptic ulcer bleeding. Special considerations apply to patients on antiplatelet and antithrombotic agents. H pylori treatment has evolved, with the choice of regimen dictated by local antibiotic resistance patterns. Indications for primary and secondary prophylaxis vary across societies; most suggest PPIs for patients at highest risk of developing a peptic ulcer, its complications, or its recurrence. Additional research areas include the use of potassium-competitive acid blockers and H pylori vaccination; the optimal approach for patients at risk of stress ulcer bleeding requires more robust determinations of optimal patient selection and treatment selection, if any. Appropriate continuation of PPI use outweighs most possible side-effects if given for approved indications, while de-prescribing should be trialled when a definitive indication is no longer present.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada
| | - Yidan Lu
- Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada
| | - Ali A Alali
- Department of Medicine, Faculty of Medicine, Kuwait University, Jabriyah, Kuwait
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada.
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May JE, Moll S. How I treat the co-occurrence of venous and arterial thromboembolism: anticoagulation, antiplatelet therapy, or both? Blood 2024; 143:2351-2362. [PMID: 38364188 DOI: 10.1182/blood.2023021638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/17/2024] [Accepted: 02/12/2024] [Indexed: 02/18/2024] Open
Abstract
ABSTRACT Arterial and venous thromboses are classically considered distinct disease states, with arterial thrombosis mediated predominantly by platelets and therefore, treated with antiplatelet therapy, and venous thrombosis mediated by the plasmatic coagulation system and treated with anticoagulation. However, co-occurrence of arterial and venous events is common, and there is increasing evidence of shared risk factors and pathophysiologic overlap. This presents a management challenge: does the patient with venous and arterial thrombosis, require anticoagulation, antiplatelet therapy, or both? Herein, we present a structured approach to the evaluation and management of patients with venous thrombosis who are also at risk for or have a history of an arterial thromboembolic event. We emphasize the importance of defining the indications for antithrombotic therapy, as well as the evaluation of factors that influence both thrombotic and bleeding risk, including disorder-specific and patient-specific factors, as well as the inherent risk balance of antithrombotic therapy regimens. We illustrate this approach in 4 cases, discussing the unique considerations and recent updates in the management of venous thrombosis, acute noncardioembolic ischemic stroke, coronary artery disease and acute myocardial infarction, and peripheral artery disease after revascularization.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Stephan Moll
- Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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7
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Kurlander JE, Helminski D, Yuan L, Krein SL, Lanham MS, Henstock JL, Kidwell KM, De Vries R, Resnicow K, Sholl H, Kim JJ, Perry LK, Parsons J, Ha N, Froehlich JB, Aikens JE, Richardson CR, Saini SD, Barnes GD. Feasibility and acceptability of patient- and clinician-level antithrombotic stewardship interventions to reduce gastrointestinal bleeding risk in patients using warfarin (Anticoagulation with Enhanced Gastrointestinal Safety): a factorial randomized controlled pilot trial. Res Pract Thromb Haemost 2024; 8:102421. [PMID: 38827255 PMCID: PMC11143904 DOI: 10.1016/j.rpth.2024.102421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/04/2024] [Indexed: 06/04/2024] Open
Abstract
Background Overuse of antiplatelet therapy and underuse of gastroprotection contribute to preventable bleeding in patients taking anticoagulants. Objectives (1) Determine the feasibility of a factorial trial testing patient activation and clinician outreach to reduce gastrointestinal (GI) bleeding risk in patients prescribed warfarin-antiplatelet therapy without proton pump inhibitor gastroprotection and (2) assess intervention acceptability. Methods Pragmatic 2 × 2 factorial cluster-randomized controlled pilot comparing (1) a patient activation booklet vs usual care and (2) clinician notification vs clinician notification plus nurse facilitation was performed. The primary feasibility outcome was percentage of patients completing a structured telephone assessment after 5 weeks. Exploratory outcomes, including effectiveness, were evaluated using chart review, surveys, and semistructured interviews. Results Among 47 eligible patients, 35/47 (74.5%; 95% CI, 58.6%-85.7%) met the feasibility outcome. In the subset confirmed to be high risk for upper GI bleeding, 11/29 (37.9%; 95% CI, 16.9%-64.7%) made a medication change, without differences between intervention arms. In interviews, few patients reported reviewing the activation booklet; barriers included underestimating GI bleeding risk, misunderstanding the booklet's purpose, and receiving excessive health communication materials. Clinicians responded to notification messages for 24/47 patients (51.1%; 95% CI, 26.4%-75.4%), which was lower for surgeons than nonsurgeons (22.7% vs 76.0%). Medical specialists but not surgeons viewed clinician notification as acceptable. Conclusion The proposed trial design and outcome ascertainment strategy were feasible, but the patient activation intervention is unlikely to be effective as designed. While clinician notification appears promising, it may not be acceptable to surgeons, findings which support further refinement and testing of a clinician notification intervention.
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Affiliation(s)
- Jacob E. Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Danielle Helminski
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Liyang Yuan
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Sarah L. Krein
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Michael S.M. Lanham
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- University of Michigan Office of Clinical Informatics, Ann Arbor, Michigan, USA
| | - Jennifer L. Henstock
- Health Information Technology and Services, University of Michigan, Ann Arbor, Michigan, USA
| | - Kelley M. Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Raymond De Vries
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kenneth Resnicow
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, USA
| | - Haden Sholl
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Joyce J. Kim
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Linda K. Perry
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Jacqueline Parsons
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Nghi Ha
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - James B. Froehlich
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - James E. Aikens
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Sameer D. Saini
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Geoffrey D. Barnes
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
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Yamamoto T, Mizokami Y, Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Suzuki S, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Inoue H. Gastrointestinal bleeding in elderly patients with atrial fibrillation: prespecified All Nippon Atrial Fibrillation in the Elderly (ANAFIE) Registry subgroup analysis. Sci Rep 2024; 14:9688. [PMID: 38678096 PMCID: PMC11055876 DOI: 10.1038/s41598-024-59932-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/16/2024] [Indexed: 04/29/2024] Open
Abstract
Gastrointestinal (GI) bleeding control is critical in elderly patients with atrial fibrillation (AF) receiving oral anticoagulants (OAC). This subgroup analysis aimed to clarify the actual state and significance of GI bleeding in elderly non-valvular AF (NVAF) patients. We evaluated the incidence and risk factors of GI bleeding during the 2-year follow-up and examined the GI bleeding impact on mortality. Of the 32,275 patients in the ANAFIE Registry, 1139 patients (3.5%) experienced GI bleeding (incidence rate, 1.92 events per 100 person-years; mean follow-up, 1.88 years); 339 upper and 760 lower GI bleeding events occurred. GI bleeding risk factors included age ≥ 85 years, body mass index ≥ 25.0 kg/m2, prior major bleeding, hyperuricaemia, heart failure, P-glycoprotein inhibitor use, GI disease, and polypharmacy (≥ 5 drugs). No significant differences in GI bleeding risk were found between direct OAC (DOAC) vs warfarin users (adjusted hazard ratios [95% confidence interval], 1.01 [0.88-1.15]). The 1-year post-GI bleeding mortality rate was numerically higher in patients with upper (19.6%) than lower GI bleeding (8.9%). In elderly Japanese NVAF patients, this large-scale study found no significant difference in GI bleeding risk between DOAC vs. warfarin users or 1-year mortality after upper or lower GI bleeding.
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Affiliation(s)
- Takatsugu Yamamoto
- Department of Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan.
| | - Yuji Mizokami
- Department of Gastroenterology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Fushimi-ku, Kyoto, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Ota-ku, Tokyo, Japan
| | - Yukihiro Koretsune
- National Hospital Organization Osaka National Hospital, Chuo Ward, Osaka, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Minami-ku, Kumamoto, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tama Nagayama Hospital, Tama, Tokyo, Japan
| | - Shinya Suzuki
- The Cardiovascular Institute, Minato-ku, Tokyo, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Atsushi Hirayama
- Department of Medicine, Osaka Fukujyuji Hospital, Neyagawa, Osaka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine, Fukuoka Neurosurgical Hospital, Minami-ku, Fukuoka, Japan
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Chuo-ku, Tokyo, Japan
| | - Yoshiyuki Morishima
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Chuo-ku, Tokyo, Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., Shinagawa-ku, Tokyo, Japan
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Drusch S, Neumann A, Michelon H, Pépin M, Zureik M, Herr M. Do Proton Pump Inhibitors Reduce Upper Gastrointestinal Bleeding in Older Patients with Atrial Fibrillation Treated with Oral Anticoagulants? A Nationwide Cohort Study in France. Drugs Aging 2024; 41:65-76. [PMID: 38114724 PMCID: PMC10769917 DOI: 10.1007/s40266-023-01085-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are largely used in older adults and data are needed in off-label indications, such as the prevention of upper gastrointestinal bleeding (UGIB) in patients receiving oral anticoagulants (OACs). This study aimed to assess whether PPIs reduce the risk of UGIB in patients initiating oral anticoagulation. METHODS We conducted a longitudinal study based on the French national health database. The study population included 109,693 patients aged 75-110 years with a diagnosis of atrial fibrillation who initiated OACs [vitamin K antagonist (VKA) or direct OAC (DOAC)] between 2012 and 2016. We used multivariable Cox models weighted by inverse of probability of treatment to estimate the adjusted hazard ratio (aHR) of UGIB between PPI users and nonusers over a 6- and 12-month follow-up. RESULTS PPI users represented 23% of the study population (28% among VKA initiators and 17% among DOAC initiators). The mean age (83 ± 5.3 years) and proportion of women (near 60%) were similar between groups. The risk of UGIB in the first 6 months after initiation of OAC decreased by 20% in PPI users compared with PPI nonusers [aHR6 months = 0.80, 95% confidence interval (CI) 0.65-0.98], but was not significantly modified when the follow-up was extended to 12 months (aHR12 months = 0.90, 95% CI 0.76-1.07), with a stronger effect among patients treated with vitamin K antagonists (aHR6 months = 0.73, 95% CI 0.58-0.93; aHR12 months = 0.81, 95% CI 0.67-0.99). CONCLUSIONS This study suggests that PPIs were associated with reduced risk of gastrointestinal bleeding after initiation of oral anticoagulation in older patients with atrial fibrillation, particularly within 6 months after initiation of an antivitamin K antagonist.
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Affiliation(s)
- Solene Drusch
- EPI-PHARE, Epidemiology of Health Products (French National Agency for Medicines and Health Products Safety, and French National Health Insurance), Saint-Denis, France.
- Anti-Infective Evasion and Pharmacoepidemiology, University of Paris-Saclay, UVSQ, Inserm, Montigny-le-Bretonneux, France.
| | - Anke Neumann
- EPI-PHARE, Epidemiology of Health Products (French National Agency for Medicines and Health Products Safety, and French National Health Insurance), Saint-Denis, France
| | - Hugues Michelon
- Pharmacy Department, Sainte-Périne Hospital, GHU AP-HP, University of Paris-Saclay, Paris, France
| | - Marion Pépin
- Geriatrics Department, Ambroise Paré Hospital, GHU AP-HP, University of Paris-Saclay, Boulogne-Billancourt, France
- Clinical Epidemiology, University of Paris-Saclay, UVSQ, Inserm, Villejuif, France
| | - Mahmoud Zureik
- EPI-PHARE, Epidemiology of Health Products (French National Agency for Medicines and Health Products Safety, and French National Health Insurance), Saint-Denis, France
- Anti-Infective Evasion and Pharmacoepidemiology, University of Paris-Saclay, UVSQ, Inserm, Montigny-le-Bretonneux, France
| | - Marie Herr
- Anti-Infective Evasion and Pharmacoepidemiology, University of Paris-Saclay, UVSQ, Inserm, Montigny-le-Bretonneux, France
- Epidemiology and Public Health department, Raymond Poincaré Hospital, GHU AP-HP, University of Paris-Saclay, Garches, France
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10
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Kurlander JE, Laine L. The Reply. Am J Med 2023; 136:e79-e80. [PMID: 36958908 DOI: 10.1016/j.amjmed.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 03/25/2023]
Affiliation(s)
- Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor; VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Mich.
| | - Loren Laine
- Yale School of Medicine, New Haven, Conn; VA Connecticut Healthcare System, West Haven
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11
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Imanishi R, Shimoda T, Kou N, Okamura Y, Ito H, Shimojo N. Long-Term Effects of PPIs During Anticoagulation Therapy. Am J Med 2023; 136:e78. [PMID: 36958907 DOI: 10.1016/j.amjmed.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/04/2022] [Indexed: 03/25/2023]
Affiliation(s)
- Ryusuke Imanishi
- College of Medicine, School of Medicine and Health Sciences, University of Tsukuba
| | - Tomonari Shimoda
- College of Medicine, School of Medicine and Health Sciences, University of Tsukuba
| | - Noriaki Kou
- College of Medicine, School of Medicine and Health Sciences, University of Tsukuba
| | - Yui Okamura
- College of Medicine, School of Medicine and Health Sciences, University of Tsukuba
| | - Hiroshi Ito
- Division of General Internal Medicine, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center.
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12
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Kurlander JE, Barnes GD, Fisher A, Gonzalez JJ, Helminski D, Saini SD, Sengupta N, Yang YX, Scheiman J, Laine L. Association of Antisecretory Drugs with Upper Gastrointestinal Bleeding in Patients Using Oral Anticoagulants: A Systematic Review and Meta-Analysis. Am J Med 2022; 135:1231-1243.e8. [PMID: 35679879 PMCID: PMC10031639 DOI: 10.1016/j.amjmed.2022.05.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND The role of antisecretory drugs for the prevention of upper gastrointestinal bleeding in patients using anticoagulants is unclear. We investigated this question in a systematic review and meta-analysis. METHODS We searched Embase, PubMed, Web of Science, Scopus, the Cochrane Library, and clinicaltrials.gov thru April 2021 for controlled randomized trials and observational studies evaluating the association of proton pump inhibitors (PPIs) or H2-receptor antagonists with overt upper gastrointestinal bleeding in patients using anticoagulants. Independent duplicate review, data extraction, and risk of bias assessment were performed. Observational studies were included only if they provided results controlled for at least 2 variables. Meta-analyses were performed using random effects models. RESULTS Six observational studies and 1 randomized trial were included. All but 1 study had low risk of bias. None of the studies excluded patients with concomitant aspirin or nonsteroidal anti-inflammatory drug use. For PPIs, the pooled relative risk of upper gastrointestinal bleeding was 0.67 (95% confidence interval 0.61, 0.74) with low statistical heterogeneity (I2 = 15%). Individual studies showed greater treatment effect in patients with higher risk for upper gastrointestinal bleeding (eg, nonsteroidal anti-inflammatory drug or aspirin use, elevated bleeding risk score). A single observational study evaluating the association of H2-receptor antagonists with upper gastrointestinal bleeding found a relative risk of 0.69 (95% confidence interval 0.24-2.02). CONCLUSIONS Evidence drawn mostly from observational studies with low risk of bias demonstrate that PPIs reduce upper gastrointestinal bleeding in patients prescribed oral anticoagulants. The benefit appears to be most clearcut and substantial in patients with elevated risk of upper gastrointestinal bleeding.
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Affiliation(s)
- Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor; VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Mich.
| | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan, Ann Arbor; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor; Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Aaron Fisher
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Juan J Gonzalez
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Sameer D Saini
- Department of Internal Medicine, University of Michigan, Ann Arbor; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor; VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Mich
| | - Neil Sengupta
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, Ill
| | - Yu-Xiao Yang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - James Scheiman
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville
| | - Loren Laine
- Yale School of Medicine, New Haven, Conn; VA Connecticut Healthcare System, West Haven, Conn
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