1
|
Alali AA, Almadi MA, Barkun AN. Review article: Advances in the management of lower gastrointestinal bleeding. Aliment Pharmacol Ther 2024; 59:632-644. [PMID: 38158721 DOI: 10.1111/apt.17859] [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: 09/01/2023] [Revised: 10/15/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved. AIMS To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion. RESULTS The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients. CONCLUSIONS The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.
Collapse
Affiliation(s)
- Ali A Alali
- Department of Medicine, Faculty of Medicine, Kuwait University, Jabriya, Kuwait
| | - Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
- Division of Clinical Epidemiology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
| |
Collapse
|
2
|
Jung YS, Park JH, Park CH. Impact of proton pump inhibitors on the risk of small bowel or colorectal bleeding: A systematic review and meta-analysis. United European Gastroenterol J 2023; 11:861-873. [PMID: 37553807 PMCID: PMC10637122 DOI: 10.1002/ueg2.12448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/17/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Several studies have suggested that the mucosal protective effects of proton pump inhibitors (PPIs) do not extend beyond the duodenum; however, PPIs may cause lower gastrointestinal (LGI) injury, although these relationships have not yet been fully elucidated. METHODS We searched all the relevant studies published until September 2022 that examined the risk of PPIs for LGI bleeding. We performed a meta-analysis of the risk of LGI bleeding (small bowel (SB) or colorectal bleeding) between PPI users and non-users. A subgroup analysis of patients consuming aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) was also performed. RESULTS Twelve studies with 341,063 participants were included in this meta-analysis. The use of PPIs was associated with the risk of LGI bleeding (odds ratio [OR] [95% confidence interval [CI]] = 1.42 [1.16-1.73]; hazard ratio [HR] [95% CI] = 3.23 [1.56-6.71]). An association between PPI use and the risk of LGI bleeding was also identified in the subgroup of aspirin or NSAID users (OR [95% CI] = 1.64 [1.49-1.80]; HR [95% CI] = 6.55 [2.01-21.33]). In the bleeding site-specific analyses, the risk of SB bleeding was associated with PPI use (OR [95% CI] = 1.54 [1.30-1.84]). CONCLUSIONS PPI use was associated with an increased risk of LGI bleeding, particularly SB bleeding. This association was particularly pronounced among aspirin and NSAID users. Inappropriate PPI prescriptions should be avoided in patients with LGI bleeding and a low risk of upper gastrointestinal disease.
Collapse
Affiliation(s)
- Yoon Suk Jung
- Department of Internal MedicineKangbuk Samsung HospitalSungkyunkwan University School of MedicineSeoulKorea
| | - Jung Ho Park
- Department of Internal MedicineKangbuk Samsung HospitalSungkyunkwan University School of MedicineSeoulKorea
| | - Chan Hyuk Park
- Department of Internal MedicineHanyang University Guri HospitalHanyang University College of MedicineGuriKorea
| |
Collapse
|
3
|
Geisler T, Poli S, Huber K, Rath D, Aidery P, Kristensen SD, Storey RF, Ball A, Collet JP, Berg JT. Resumption of Antiplatelet Therapy after Major Bleeding. Thromb Haemost 2023; 123:135-149. [PMID: 35785817 DOI: 10.1055/s-0042-1750419] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Major bleeding is a common threat in patients requiring antiplatelet therapy. Timing and intensity with regard to resumption of antiplatelet therapy represent a major challenge in clinical practice. Knowledge of the patient's bleeding risk, defining transient/treatable and permanent/untreatable risk factors for bleeding, and weighing these against thrombotic risk are key to successful prevention of major adverse events. Shared decision-making involving various disciplines is essential to determine the optimal strategy. The present article addresses clinically relevant questions focusing on the most life-threatening or frequently occurring bleeding events, such as intracranial hemorrhage and gastrointestinal bleeding, and discusses the evidence for antiplatelet therapy resumption using individual risk assessment in high-risk cardiovascular disease patients.
Collapse
Affiliation(s)
- Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls-University Tuebingen, Tuebingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Dominik Rath
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Parwez Aidery
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Steen D Kristensen
- Department of Cardiology, Aarhus University Hospital, Faculty of Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Alex Ball
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Sorbonne Université, Paris, France
| | - Jurriën Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| |
Collapse
|
4
|
Wang X, Zhu Q, Wu Y, Li H, Deng X, Cheng J, Zhang Z, Ma Y, Shi T. Effect of body weight on bleeding events of aspirin in ischemic stroke or transient ischemic attack patients. J Clin Pharm Ther 2022; 47:1684-1689. [PMID: 35748660 DOI: 10.1111/jcpt.13722] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/17/2022] [Accepted: 05/29/2022] [Indexed: 01/04/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVES Bleeding is the most common adverse reaction to aspirin and can lead to drug discontinuation or even be life-threatening in the secondary prevention of stroke or transient ischemic attack. The aim of this study was to evaluate risk factors for bleeding adverse reaction of aspirin in ischemic stroke or transient ischemic attack. METHODS This retrospective analysis included patients treated with aspirin (100 mg) as a secondary prevention for ischemic stroke or transient ischemic attack. The bleeding events that occurred during the first year were collected, including gastrointestinal, skin, nasal cavity, gum, and urinary tract bleeding events. Then, univariate and multivariate logistic regression analyses were used to identify independent factors associated with bleeding events of aspirin. RESULTS AND DISCUSSION A total of 578 patients were enrolled in this study, and 58 patients developed bleeding during the first year of secondary prevention. Body weight and combination with selective serotonin reuptake inhibitors were found to be significant risk factors for overall bleeding (p = 0.025 and 0.012). Body weight below 60 kg was a risk factor for overall bleeding and gastrointestinal bleeding events. WHAT IS NEW AND CONCLUSION Patients weighing less than 60 kg were at increased risk of bleeding with 100 mg aspirin for secondary prevention of cerebral infarction transient ischemic attack.
Collapse
Affiliation(s)
- Xiaoyu Wang
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Qidong Zhu
- Anhui Provincial Children's Hospital, Hefei, China
| | - Yan Wu
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Huiting Li
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Xiaomei Deng
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Juan Cheng
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Zhetao Zhang
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yini Ma
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Tianlu Shi
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| |
Collapse
|
5
|
Kedir HM, Sisay EA, Abiye AA. Enteric-Coated Aspirin and the Risk of Gastrointestinal Side Effects: A Systematic Review. Int J Gen Med 2021; 14:4757-4763. [PMID: 34466020 PMCID: PMC8403009 DOI: 10.2147/ijgm.s326929] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/06/2021] [Indexed: 01/14/2023] Open
Abstract
Introduction Aspirin appeared as a medicine to deal with aches and inflammation, but due to its antiplatelet properties, it has evolved into a drug mainly used to avert cardiovascular disease. Regardless of its therapeutic uses, the limiting aspect for aspirin use has been its affiliation with gastrointestinal (GI) toxicity, classifying from acute mucosal damage to GI problems and death. Objective The aim of this systematic review is to address the question regarding the ECA effect on the gastric mucosa. Methods A systematic search of the literature was conducted in the PubMed electronic databases from April 10th to April 23rd, 2020. Eligibility has been set, and based on those criteria, initially a total of 637 results were obtained, from these 58 of them were not written in English. Then, 168 articles which were free from duplication were screened and all the included articles were RCTs published after 2000. Based on these, final number of articles included on this review was 6. Results Data were obtained from 6 published articles which reported on 15,621 participants. The reports were from 3 different countries. Most of the studies revealed that enteric-coated aspirin (ECA) treatment was not an effective mechanism against GI protection. ECA administration with omeprazole can hugely reduce the incidence of endoscopic GI damage compared to the impact of ECA used alone. Even short-term administration of a low dose of ECA was significantly associated with an apparent small bowel injury. Conclusion ECA treatment is not an effective mechanism against GI protection, and it is highly associated with small bowel injury. So the coating does not reduce risk of GI complications.
Collapse
Affiliation(s)
- Hanan Muzeyin Kedir
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, Collage of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eskinder Ayalew Sisay
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, Collage of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alfoalem Araba Abiye
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, Collage of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| |
Collapse
|
6
|
Radwan MF, El-Moselhy MA, Alarif WM, Orif M, Alruwaili NK, Alhakamy NA. Optimization of Thymoquinone-Loaded Self-Nanoemulsion for Management of Indomethacin-Induced Ulcer. Dose Response 2021; 19:15593258211013655. [PMID: 33994890 PMCID: PMC8113367 DOI: 10.1177/15593258211013655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/18/2022] Open
Abstract
To improve the water solubility of thymoquinone (TQ), a major constituent of Nigella sativa seed oil, a TQ-loaded self-nanoemulsifying drug delivery system (SNEDDS) was prepared. The SNEDDS formulation was optimized using almond oil (AO) (Oil; X1), tween 80 (surfactant; X2) and polyethylene glycol 200 (PEG 200) (cosurfactant; X3) compounds as independent variables. The results showed that the globule size ranged from 65 to 320 nm. In addition, a strong agreement was reached between the system estimation and the experimental values of globule size. To evaluate the gastroprotective effect of optimized TQ-loaded SNEDDS against indomethacin (Indo.)-induced gastric ulcers in comparison with non-emulsified TQ, the ulcer index and histopathological changes were estimated. Optimized TQ-loaded SNEDDS showed improved gastroprotective activity against Indo.-induced ulcers relative to the non-emulsified TQ. In addition, the gastroprotective index was improved by 2-fold in TQ-loaded SNEDDS as compared to non-emulsified TQ. This is attributed to the strong antioxidant and the cytoprotective activities of the TQ. These results demonstrate enhancement of the efficacy of TQ through the optimized SNEDDS.
Collapse
Affiliation(s)
- Mohamed F Radwan
- Department of Chemistry, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohamed A El-Moselhy
- Department of Pharmacology, School of Pharmacy, Ibn Sina National College, Jeddah, Saudi Arabia
| | - Walied M Alarif
- Department of Marine Chemistry, Faculty of Marine Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohamed Orif
- Department of Marine Chemistry, Faculty of Marine Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nabil K Alruwaili
- Department of Pharmaceutics, Faculty of Pharmacy, Al-Jouf University, Sakaka, Saudi Arabia
| | - Nabil A Alhakamy
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,Center of Excellence for Drug Research and Pharmaceutical Industries, King Abdulaziz University, Jeddah, Saudi Arabia.,Mohamed Saeed Tamer Chair for Pharmaceutical Industries, King Abdulaziz University, Jeddah, Saudi Arabia
| |
Collapse
|
7
|
Mogul A, Leppien EE, Laughlin E, Spinler SA. Aspirin for primary prevention of cardiovascular disease: a review of recent literature and updated guideline recommendations. Expert Opin Pharmacother 2020; 22:83-91. [PMID: 32924644 DOI: 10.1080/14656566.2020.1817389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Recent clinical trials evaluating the efficacy of aspirin in primary prevention of atherosclerotic cardiovascular disease (ASCVD) have suggested the risk of aspirin may outweigh its benefit in individuals once thought to be candidates for aspirin therapy. These results led to the publication of updated guideline recommendations in 2019 for aspirin use in primary prevention of cardiovascular disease from the American College of Cardiology (ACC) and American Heart Association (AHA). AREAS COVERED Recent clinical trials and guidelines relevant to aspirin for primary prevention of ASCVD were identified using PubMed® (July 1, 2016 to April 1, 2019). Studies were limited to randomized, controlled clinical trials. The most current clinical practice guidelines were prioritized. EXPERT OPINION Recent clinical trials demonstrated an increased risk of bleeding associated with aspirin use, which often outweighed cardiovascular risk reduction. In light of this new evidence, the ACC/AHA guidelines recommend aspirin for primary prevention in patients 40-70 years of age at a high ASCVD risk and low bleeding risk, who are unable to optimally control modifiable ASCVD risk factors.
Collapse
Affiliation(s)
- Amanda Mogul
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences , Binghamton, NY, USA
| | - Emily E Leppien
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences , Binghamton, NY, USA
| | - Elizabeth Laughlin
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences , Binghamton, NY, USA
| | - Sarah A Spinler
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences , Binghamton, NY, USA
| |
Collapse
|
8
|
Optimized Ellagic Acid-Ca Pectinate Floating Beads for Gastroprotection against Indomethacin-Induced Gastric Injury in Rats. Biomolecules 2020; 10:biom10071006. [PMID: 32640741 PMCID: PMC7408148 DOI: 10.3390/biom10071006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/23/2020] [Accepted: 07/01/2020] [Indexed: 01/18/2023] Open
Abstract
A peptic ulcer is an alimentary tract injury that leads to a mucosal defect reaching the submucosa. This work aimed to optimize and maximize ellagic acid (EA) loading in Ca pectinate floating beads to maximize the release for 24 h. Three factors were selected: Ca pectinate concentration (X1, 1–3 w/v %), EA concentration (X2, 1–3 w/v %) and the dropping time (X3, 10–30 min). The factorial design proposed eight formulations. The optimized EA–Ca pectinate formulation was evaluated for the gastric ulcer index and the oxidative stress parameter determination of gastric mucosa. The results indicated that the optimum EA–Ca pectinate formula significantly improved the gastric ulcer index in comparison with raw EA. The protective effect of the optimized EA–Ca pectinate formula was further indicated by the histopathological features of the stomach. The results of the study indicate that an EA formulation in the form of Ca pectinate beads would be effective for protection against gastric ulcers because of Nonsteroidal anti-inflammatory drugs (NSAID) administration.
Collapse
|
9
|
García Rodríguez LA, Soriano-Gabarró M, Vora P, Cea Soriano L. Low-dose aspirin and risk of gastric and oesophageal cancer: A population-based study in the United Kingdom using The Health Improvement Network. Int J Cancer 2020; 147:2394-2404. [PMID: 32329063 PMCID: PMC7540378 DOI: 10.1002/ijc.33022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 04/03/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022]
Abstract
There is increasing interest regarding potential protective effects of low‐dose aspirin against various gastrointestinal cancers. We aimed to quantify the association between use of low‐dose aspirin and risk of gastric/oesophageal cancer using a population‐based primary care database in the UK. Between January 2005 and December 2015, we identified a cohort of 223 640 new users of low‐dose aspirin (75‐300 mg/day) and a matched cohort of nonusers at the start of follow‐up from The Health Improvement Network. Cohorts were followed to identify incident cases of gastric/oesophageal cancer. Nested case‐control analyses were conducted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for current vs nonuse of low‐dose aspirin using logistic regression. Current use was defined as when low‐dose aspirin lasted 0 to 90 days before the index date (event date for cases, random date for controls) and previous duration was ≥1 year. We identified 727 incident cases of gastric cancer and 1394 incident cases of oesophageal cancer. ORs (95% CIs) were 0.46 (0.38‐0.57) for gastric cancer and 0.59 (0.51‐0.69) for oesophageal cancer. The effect remained consistent with no clear change seen between previous duration of low‐dose aspirin use of 1‐3, 3‐5 or >5 years. The reduced risks was seen with 75 mg/day, and effects were consistent in lag‐time analyses. In conclusion, our results indicate that use of low‐dose aspirin is associated with a 54% reduced risk of gastric cancer and a 41% reduced risk of oesophageal cancer as supported by mechanistic data. What's new? Low‐dose aspirin may help protect against the development of gastric and oesophageal cancers. This population‐based study using data from primary care electronic health records in the United Kingdom lends further support to that idea. Compared with no use of low‐dose aspirin, daily use of low‐dose aspirin (75–300 mg) for at least one year was associated with a 54 percent reduction in gastric cancer risk and a 41 percent reduction in oesophageal cancer risk. No clear difference in effect was observed between low‐dose aspirin use for one to three years versus more than three years.
Collapse
Affiliation(s)
| | | | - Pareen Vora
- Department of Epidemiology, Bayer AG, Berlin, Germany
| | - Lucía Cea Soriano
- Department of Public Health and Maternal and Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| |
Collapse
|
10
|
García Rodríguez LA, Lanas A, Soriano-Gabarró M, Vora P, Cea Soriano L. Effect of Proton Pump Inhibitors on Risks of Upper and Lower Gastrointestinal Bleeding among Users of Low-Dose Aspirin: A Population-Based Observational Study. J Clin Med 2020; 9:jcm9040928. [PMID: 32231106 PMCID: PMC7230296 DOI: 10.3390/jcm9040928] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 12/14/2022] Open
Abstract
Estimates of the effect of proton pump inhibitors (PPIs) on risks of upper and lower gastrointestinal bleeding (UGIB and LGIB) among low-dose aspirin users in routine clinical practice are variable (UGIB) or lacking (LGIB). We aimed to establish these risks in the same observational study population. Using UK primary care data, we followed 199,049 new users of low-dose aspirin (75–300 mg/day) and matched non-users at start of follow-up to identify incident UGIB/LGIB cases. In nested case–control analyses, adjusted odds ratios (ORs) were calculated for concomitant PPI use vs. past (discontinued) PPI use among current low-dose aspirin users. For UGIB (n = 987), ORs (95% CIs) were 0.69 (0.54–0.88) for >1 month PPI use and 2.65 (1.62–4.3) for ≤1 month PPI use. Among the latter group, ORs (95% CIs) were 3.05 (1.75–5.33) for PPI initiation after start of aspirin therapy, and 1.66 (0.63–4.36) for PPI initiation on/before start of aspirin therapy. For LGIB (n = 1428), ORs (95% CIs) were 0.98 (0.81–1.17) for >1 month PPI use and 1.12 (0.73–1.71) for ≤1 month PPI use. Among low-dose aspirin users, maintaining PPI use (>1 month) was associated with a significantly reduced UGIB risk. Neither short nor long-term PPI use affected LGIB risk.
Collapse
Affiliation(s)
- Luis A. García Rodríguez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), 28004 Madrid, Spain;
- Correspondence: ; Tel.: +34-91-531-3404
| | - Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico, University of Zaragoza, 50009 IIS Aragón, Zaragoza, Spain;
- CIBERehd, Av. Monforte de Lemos 3–5, Pabellón 11, Planta 0, 28029 Madrid, Spain
| | | | - Pareen Vora
- Epidemiology, Bayer AG, 13353 Berlin, Germany; (M.S.-G.) (P.V.)
| | - Lucía Cea Soriano
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), 28004 Madrid, Spain;
- Department of Public Health and Maternal and Child Health, Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
| |
Collapse
|