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Wiedel NA, Sayles H, Larson J, Wardian JL, Hewlett A, McClay J, Ge J, Anzalone AJ. Associations between COVID-19 therapies and inpatient gastrointestinal bleeding: A multisite retrospective study. J Med Virol 2023; 95:e29100. [PMID: 37786247 PMCID: PMC11091798 DOI: 10.1002/jmv.29100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/17/2023] [Accepted: 09/05/2023] [Indexed: 10/04/2023]
Abstract
Little data is available regarding the incidence of gastrointestinal bleeding in adults hospitalized with COVID-19 infection and the influence of patient comorbidities and demographics, COVID-19 therapies, and typical medications used. In this retrospective study, we utilized the National COVID Cohort Collaborative to investigate the primary outcome of the development of gastrointestinal bleeding in 512 467 hospitalized US adults (age >18 years) within 14 days of a COVID-19 infection and the influence of demographics, comorbidities, and selected medications. Gastrointestinal bleeding developed in 0.44% of patients hospitalized with COVID-19. Comorbidities associated with gastrointestinal bleeding include peptic ulcer disease (adjusted odds ratio [aOR] 10.2), obesity (aOR 1.27), chronic kidney disease (aOR 1.20), and tobacco use disorder (aOR 1.28). Lower risk of gastrointestinal bleeding was seen among women (aOR 0.76), Latinx (aOR 0.85), and vaccinated patients (aOR 0.74). Dexamethasone alone or with remdesivir was associated with lower risk of gastrointestinal bleeding (aOR 0.69 and aOR 0.83, respectively). Remdesivir monotherapy was associated with upper gastrointestinal bleeding (aOR 1.25). Proton pump inhibitors were more often prescribed in patients with gastrointestinal bleeding, likely representing treatment for gastrointestinal bleeding rather than a risk factor for its development. In adult patients hospitalized with COVID-19, the use of dexamethasone alone or in combination with remdesivir is negatively associated with gastrointestinal bleeding. Remdesivir monotherapy is associated with increased risk of upper gastrointestinal bleeding.
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Affiliation(s)
- Noah A. Wiedel
- Department of Internal Medicine, Division of Hospital Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Harlan Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jessica Larson
- Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jana L. Wardian
- Department of Internal Medicine, Division of Hospital Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Alexander Hewlett
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - James McClay
- Department of Health Management & Informatics, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Jin Ge
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California at San Francisco, San Francisco, California, USA
| | - Alfred Jerrod Anzalone
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Hawkey C, Avery A, Coupland CAC, Crooks C, Dumbleton J, Hobbs FDR, Kendrick D, Moore M, Morris C, Rubin G, Smith M, Stevenson D. Helicobacter pylori eradication for primary prevention of peptic ulcer bleeding in older patients prescribed aspirin in primary care (HEAT): a randomised, double-blind, placebo-controlled trial. Lancet 2022; 400:1597-1606. [PMID: 36335970 DOI: 10.1016/s0140-6736(22)01843-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Peptic ulcers in patients receiving aspirin are associated with Helicobacter pylori infection. We aimed to investigate whether H pylori eradication would protect against aspirin-associated ulcer bleeding. METHODS We conducted a randomised, double-blind, placebo-controlled trial (Helicobacter Eradication Aspirin Trial [HEAT]) at 1208 primary care centres in the UK, using routinely collected clinical data. Eligible patients were aged 60 years or older who were receiving aspirin at a daily dose of 325 mg or less (with four or more 28-day prescriptions in the past year) and had a positive C13 urea breath test for H pylori at screening. Patients receiving ulcerogenic or gastroprotective medication were excluded. Participants were randomly assigned (1:1) to receive either a combination of oral clarithromycin 500 mg, metronidazole 400 mg, and lansoprazole 30 mg (active eradication), or oral placebo (control), twice daily for 1 week. Participants, their general practitioners and health-care providers, and the research nurses, trial team, adjudication committee, and analysis team were all masked to group allocation throughout the trial. Follow-up was by scrutiny of electronic data in primary and secondary care. The primary outcome was time to hospitalisation or death due to definite or probable peptic ulcer bleeding, and was analysed by Cox proportional hazards methods in the intention-to-treat population. This trial is registered with EudraCT, 2011-003425-96. FINDINGS Between Sept 14, 2012, and Nov 22, 2017, 30 166 patients had breath testing for H pylori, 5367 had a positive result, and 5352 were randomly assigned to receive active eradication (n=2677) or placebo (n=2675) and were followed up for a median of 5·0 years (IQR 3·9-6·4). Analysis of the primary outcome showed a significant departure from proportional hazards assumptions (p=0·0068), requiring analysis over separate time periods. There was a significant reduction in incidence of the primary outcome in the active eradication group in the first 2·5 years of follow-up compared with the control group (six episodes adjudicated as definite or probable peptic ulcer bleeds, rate 0·92 [95% CI 0·41-2·04] per 1000 person-years vs 17 episodes, rate 2·61 [1·62-4·19] per 1000 person-years; hazard ratio [HR] 0·35 [95% CI 0·14-0·89]; p=0·028). This advantage remained significant after adjusting for the competing risk of death (p=0·028) but was lost with longer follow-up (HR 1·31 [95% CI 0·55-3·11] in the period after the first 2·5 years; p=0·54). Reports of adverse events were actively solicited; taste disturbance was the most common event (787 patients). INTERPRETATION H pylori eradication protects against aspirin-associated peptic ulcer bleeding, but this might not be sustained in the long term. FUNDING National Institute for Health and Care Research Health Technology Assessment.
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Affiliation(s)
- Chris Hawkey
- STAR (Simple Trials for Academic Research) Unit, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Anthony Avery
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Carol A C Coupland
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Colin Crooks
- STAR (Simple Trials for Academic Research) Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jennifer Dumbleton
- STAR (Simple Trials for Academic Research) Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Denise Kendrick
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael Moore
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | | | - Gregory Rubin
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Murray Smith
- Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - Diane Stevenson
- STAR (Simple Trials for Academic Research) Unit, School of Medicine, University of Nottingham, Nottingham, UK
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Calderone D, Greco A, Ingala S, Agnello F, Franchina G, Scalia L, Buccheri S, Capodanno D. Efficacy and Safety of Aspirin for Primary Cardiovascular Risk Prevention in Younger and Older Age: An Updated Systematic Review and Meta-analysis of 178,310 Subjects from 21 Randomized Studies. Thromb Haemost 2021; 122:445-455. [PMID: 34638150 DOI: 10.1055/a-1667-7427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 01/04/2023]
Abstract
AIMS The efficacy and safety of aspirin for primary cardiovascular disease (CVD) prevention is controversial. The aim of this study was to investigate the efficacy and safety of aspirin in subjects with no overt CVD, with a focus on age as a treatment modifier. METHODS AND RESULTS Randomized trials comparing aspirin use versus no aspirin use or placebo were included. The primary efficacy outcome was all-cause death. The primary safety outcome was major bleeding. Secondary ischemic and bleeding outcomes were explored. Subgroup analyses were conducted to investigate the consistency of the effect sizes in studies including younger and older individuals, using a cut-off of 65 years. A total of 21 randomized trials including 173,810 individuals at a mean follow-up of 5.3 years were included. Compared with control, aspirin did not reduce significantly the risk of all-cause death (risk ratio: 0.96; 95% confidence interval: 0.92-1.00, p = 0.057). Major adverse cardiovascular events were significantly reduced by 11%, paralleled by significant reductions in myocardial infarction and transient ischemic attack. Major bleeding, intracranial hemorrhage, and gastrointestinal bleeding were significantly increased by aspirin. There was a significant age interaction for death (p for interaction = 0.007), with aspirin showing a statistically significant 7% relative benefit on all-cause death in studies including younger patients. CONCLUSION The use of aspirin in subjects with no overt CVD was associated with a neutral effect on all-cause death and a modest lower risk of major cardiovascular events at the price of an increased risk in major bleeding. The benefit of aspirin might be more pronounced in younger individuals.
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Affiliation(s)
- Dario Calderone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Salvatore Ingala
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Gabriele Franchina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Sergio Buccheri
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
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Fongnzossie Fedoung E, Biwole AB, Nyangono Biyegue CF, Ngansop Tounkam M, Akono Ntonga P, Nguiamba VP, Essono DM, Forbi Funwi P, Tonga C, Nguenang GM, Kemeuze V, Sonwa DJ, Tsabang N, Bouelet IS, Tize Z, Boum AT, Momo Solefack MC, Betti JL, Nouga Bissoue A, Lehman LG, Mapongmetsem PM, Nneme Nneme L, Ngono Ngane RA, Ngogang Yonkeu J. A review of Cameroonian medicinal plants with potentials for the management of the COVID-19 pandemic. ADVANCES IN TRADITIONAL MEDICINE 2021. [PMCID: PMC7994110 DOI: 10.1007/s13596-021-00567-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Evariste Fongnzossie Fedoung
- Laboratory of Forest Resources and Wood Valorization, University of Douala, PO Box 1872, Douala, Cameroon
- Laboratory of Process Engineering, University of Douala, PO Box 1872, Douala, Cameroon
- Millenium Ecologic Museum, PO Box 8038, Yaoundé, Cameroon
- Cameroon Ethnobotany Network, PO Box 8038, Yaoundé, Cameroon
- Advanced Technical Teachers Training School for Technical Education, University of Douala,, PO Box 1872, Douala, Cameroon
| | - Achille Bernard Biwole
- Laboratory of Forest Resources and Wood Valorization, University of Douala, PO Box 1872, Douala, Cameroon
| | | | - Marlene Ngansop Tounkam
- Laboratory of Botany, University of Yaoundé 1, PO Box 812, Yaoundé, Cameroon
- Millenium Ecologic Museum, PO Box 8038, Yaoundé, Cameroon
| | - Patrick Akono Ntonga
- Laboratory of Animal Biology, Department of Animal Biology, Faculty of Science, University of Douala, P.O. Box 2701, Douala, Cameroon
| | - Véronique Priscille Nguiamba
- Advanced Technical Teachers Training School for Technical Education, University of Douala,, PO Box 1872, Douala, Cameroon
| | - Damien Marie Essono
- Laboratory of Botany, University of Yaoundé 1, PO Box 812, Yaoundé, Cameroon
| | - Preasious Forbi Funwi
- Laboratory of Botany, University of Yaoundé 1, PO Box 812, Yaoundé, Cameroon
- Millenium Ecologic Museum, PO Box 8038, Yaoundé, Cameroon
| | - Calvin Tonga
- Laboratory of Animal Biology, Department of Animal Biology, Faculty of Science, University of Douala, P.O. Box 2701, Douala, Cameroon
| | - Guy Merlin Nguenang
- Laboratory of Botany, University of Yaoundé 1, PO Box 812, Yaoundé, Cameroon
- Cameroon Ethnobotany Network, PO Box 8038, Yaoundé, Cameroon
| | - Victor Kemeuze
- Millenium Ecologic Museum, PO Box 8038, Yaoundé, Cameroon
- Cameroon Ethnobotany Network, PO Box 8038, Yaoundé, Cameroon
| | - Denis Jean Sonwa
- Center for International Forestry Research, PO Box 2008, Messa, Yaoundé, Cameroon
| | - Nole Tsabang
- Millenium Ecologic Museum, PO Box 8038, Yaoundé, Cameroon
- Cameroon Ethnobotany Network, PO Box 8038, Yaoundé, Cameroon
| | | | - Zra Tize
- Laboratory of Process Engineering, University of Douala, PO Box 1872, Douala, Cameroon
| | | | - Marie Caroline Momo Solefack
- Cameroon Ethnobotany Network, PO Box 8038, Yaoundé, Cameroon
- Laboratory of Applied Botany, University of Dschang, PO Box 67, Dschang, Cameroon
| | - Jean Lagarde Betti
- Laboratory of Plant Biology and Physiology, University of Douala, P.O. Box 24157, Douala, Cameroon
| | - Achille Nouga Bissoue
- Laboratory of Process Engineering, University of Douala, PO Box 1872, Douala, Cameroon
| | - Leopold Gustave Lehman
- Laboratory of Animal Biology, Department of Animal Biology, Faculty of Science, University of Douala, P.O. Box 2701, Douala, Cameroon
| | - Pierre Marie Mapongmetsem
- Millenium Ecologic Museum, PO Box 8038, Yaoundé, Cameroon
- Cameroon Ethnobotany Network, PO Box 8038, Yaoundé, Cameroon
| | - Leandre Nneme Nneme
- Advanced Technical Teachers Training School for Technical Education, University of Douala,, PO Box 1872, Douala, Cameroon
| | | | - Jeanne Ngogang Yonkeu
- Cameroon Ethnobotany Network, PO Box 8038, Yaoundé, Cameroon
- Cameroon Academy of Science, Douala, Cameroon
- Université des Montagnes, Bangangté, Cameroon
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5
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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.
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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
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6
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Incidence of Upper and Lower Gastrointestinal Bleeding in New Users of Low-Dose Aspirin. Clin Gastroenterol Hepatol 2019; 17:887-895.e6. [PMID: 29908361 DOI: 10.1016/j.cgh.2018.05.061] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/17/2018] [Accepted: 05/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There are few data on the incidence of upper and lower gastrointestinal bleeding (UGIB and LGIB) from observational studies of low-dose aspirin users. We aimed to estimate incidence rates of UGIB and LGIB in a large cohort of new users of low-dose aspirin in the United Kingdom, with subanalyses of hospitalization status and fatalities. METHODS We performed a population-based study of 199,079 new users of low-dose aspirin (median age, 64.0 years) identified from the Health Improvement Network primary care database (2000-2012). Individuals were followed for a median 5.4 years (maximum, 14 years) to identify new cases of UGIB and LGIB. Following multistep validation, we calculated overall and age- and sex-specific incidence rates; we performed subanalyses for health care use and death within 30 days of GIB. We also estimated rates within a matched (1:1) cohort of nonusers of low-dose aspirin at the start of the follow-up period. RESULTS The low-dose aspirin users had 1115 UGIB events and 1936 LGIB events; most subjects with UGIB events (58.9%) were hospitalized, whereas most subjects with LGIB events were referred to secondary care (72.8%). Crude incidence rates of GIB per 1000 person-years were 0.97 for subjects with UGIB (95% CI, 0.91-1.02) and 1.68 for subjects with LGIB (95% CI, 1.60-1.75). Incidence rates per 1000 person-years for patients hospitalized for GIB were 0.57 for UGIB (95% CI, 0.53-0.61) and 0.45 for LGIB (95% CI, 0.42-0.49); for referred (but not hospitalized) cases, these values were 0.39 for UGIB (95% CI, 0.36-0.43) and 1.22 for LGIB (1.16-1.29). Incidence rates per 1000 person-years were 0.06 for fatal UGIB (95% CI, 0.04-0.07), 0.01 for fatal LGIB (95% CI, 0.01-0.02), 0.91 for nonfatal UGIB (95% CI, 0.86-0.97), and 1.66 for nonfatal LGIB (95% CI, 1.59-1.74). Among nonusers of low-dose aspirin, incidence rates per 1000 person-years were 0.67 (95% CI, 0.63-0.75) for UGIB and 0.76 (95% CI, 0.72-0.82) for LGIB. CONCLUSION In a population-based study of low-dose aspirin users, the incidence of LGIB was higher than the incidence of UGIB. However, incidence rates of hospitalized GI bleeds and 30-day mortality rates were lower for LGIB than for UGIB. These estimates are valuable for benefit-risk assessments of low-dose aspirin for cardiovascular and colorectal cancer prevention.
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7
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García Rodríguez LA, Lanas A, Soriano-Gabarró M, Cea Soriano L. Low-dose aspirin and risk of upper/lower gastrointestinal bleeding by bleed severity: a cohort study with nested case-control analysis using primary care electronic health records from the United Kingdom. Ann Med 2019; 51:182-192. [PMID: 31025592 PMCID: PMC7856917 DOI: 10.1080/07853890.2019.1591635] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Introduction: Risks of low-dose aspirin-associated upper and lower gastrointestinal bleeds (UGIB/LGIB) may vary by severity and presence of cardiovascular disease (CVD). No study has quantified these risks for UGIB and LGIB in the same real-world study population. Patients and methods: Using UK primary care data, 199,049 new users of low-dose aspirin (75-300 mg/day) and 1:1 matched non-users were followed to identify incident UGIB (N = 1843)/LGIB (N = 2763) cases. Nested case-control analyses compared current low-dose aspirin vs. non-use on UGIB/LGIB risk. Results: Adjusted incidence rate ratios (ORs; 95% CIs) were 1.62 (1.42-1.86) for non-fatal UGIB, 1.63 (1.47-1.81) for non-fatal LGIB, 0.77 (0.51-1.16) for fatal UGIB, 1.29 (0.50-3.36) for fatal LGIB. For hospitalizations, adjusted ORs (95% CIs) were 1.55 (1.32-1.81) for UGIB and 1.89 (1.58-2.27) for LGIB; for referred only cases, they were 1.52 (1.26-1.84) for UGIB and 1.54 (1.37-1.73) for LGIB. In primary CVD prevention, adjusted ORs (95% CI) were 1.62 (1.38-1.90) for UGIB and 1.60 (1.42-1.81) for LGIB; in secondary CVD prevention, they were 1.16 (0.89-1.50) for UGIB and 1.67 (1.34-2.09) for LGIB. Conclusion: Low-dose aspirin was associated with increased risks of non-fatal but not fatal UGIB/LGIB. Key message Low-dose aspirin is associated with an increased risks of non-fatal UGIB/LGIB but not fatal UGIB/LGIB.
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Affiliation(s)
| | - Angel Lanas
- b Servicio de Aparato Digestivo , Hospital Clínico, University of Zaragoza , IIS Aragón , Zaragoza , Spain.,c CIBERehd , Madrid , Spain
| | | | - Lucía Cea Soriano
- a Spanish Centre for Pharmacoepidemiologic Research (CEIFE) , Madrid , Spain.,e Department of Public Health and Maternal Child Health, Faculty of Medicine , Complutense University of Madrid , Madrid , Spain
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8
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Sokoloff A, Picard F, Degrell P, Varenne O. [Antiplatelet duration in the elderly patients after percutaneous coronary intervention]. Ann Cardiol Angeiol (Paris) 2018; 67:411-416. [PMID: 30360900 DOI: 10.1016/j.ancard.2018.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Ischemic heart disease is a leading cause of death in Europe. At the same time, older patients are at high risk for coronary heart disease and represent an increasing proportion of patients in the catheterization laboratory in the context of an ageing population. The elderly patients are also at higher bleeding risk, and were poorly represented in major randomized trials. Duration of dual antiplatelet therapy (DAPT), after percutaneous coronary intervention (PCI) should be modulated in a personalized way taking into account hemorrhagic and ischemic risk factors, using risk scores based on the latest recommendations of the European Society of Cardiology. Even if the optimal duration of DAPT after PCI is 6 months in case of stable coronary disease and 12 months in case of an acute coronary syndrome, it can be drastically reduced, up to one month in case of high hemorrhagic risk, or can be prolonged for more than 12 months in case of high ischemic risk. The use of latest generation drug eluting stents associated with a short duration of DAPT has thus demonstrated its safety compared to these durations. In case of triple therapy treatment, associating DAPT and anticoagulation therapy, DAPT is recommended to be as short as possible, potentially reduced to 1 month. Finally, the concomitant prescription of proton pump inhibitor is essential to prevent gastrointestinal bleedings. This literature review will discuss the hemorrhagic risk stratification and choice of DAPT in elderly patients.
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Affiliation(s)
- A Sokoloff
- Cardiology department, Cochin hospital, Assistance publique des hôpitaux de Paris, Paris, France
| | - F Picard
- Cardiology department, Cochin hospital, Assistance publique des hôpitaux de Paris, Paris, France; Université Paris Descartes, Université Sorbonne Paris Cité, Paris, France
| | - P Degrell
- Cardiology department, Cochin hospital, Assistance publique des hôpitaux de Paris, Paris, France; Université Paris Descartes, Université Sorbonne Paris Cité, Paris, France
| | - O Varenne
- Cardiology department, Cochin hospital, Assistance publique des hôpitaux de Paris, Paris, France; Université Paris Descartes, Université Sorbonne Paris Cité, Paris, France.
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9
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Negovan A, Iancu M, Moldovan V, Sàrkàny K, Bataga S, Mocan S, Țilea I, Banescu C. The contribution of clinical and pathological predisposing factors to severe gastro-duodenal lesions in patients with long-term low-dose aspirin and proton pump inhibitor therapy. Eur J Intern Med 2017; 44:62-66. [PMID: 28576397 DOI: 10.1016/j.ejim.2017.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 05/16/2017] [Accepted: 05/17/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Preventive strategies developed to avoid the complications of antiplatelet therapies recommend the evaluation of risk factors for gastrointestinal events and indicated gastroprotective strategies. AIM We aimed to assess the impact of predisposing factors - histological findings, concomitant drug consumption, comorbidities, symptoms, social habits, Helicobacter pylori infection - on severe gastro-duodenal lesions in patients with low-dose aspirin and concomitant protective therapy with proton pump inhibitors (PPI). METHOD We enrolled 237 patients with LDA and PPI therapy, referred for upper digestive endoscopy, divided into two groups according to the severity of their endoscopic lesions (172 patients with no or mild endoscopic lesions and 65 patients with severe endoscopic lesions). RESULTS In the univariate logistic regression model, the factors associated with severe gastro-duodenal lesions were gender (OR=1.87, 95% CI: 1.04-3.41), anticoagulants (OR=2.40, 95% CI: 1.26-4.53), gastric atrophy and/or intestinal metaplasia (OR=1.85, 95% CI: 1.04-3.32), congestive heart failure (OR=2.59, 95% CI: 1.16-6.62), anaemia (OR=3.01, 95% CI: 1.67-5.47) and smoking (OR=4.29, 95% CI: 1.57-12.32). In the final model, anticoagulants (p=0.041<0.05) and anaemia (p=0.019<0.05) were risk factors for severe lesions via multivariate regression analysis, while for active/inactive chronic gastritis and smoking a positive dependency with a tendency towards statistical significance (p<0.10) was noticed for severe gastric lesions. CONCLUSIONS In patients treated with low-dose aspirin and gastroprotective therapy with proton pump inhibitors we have enough evidence to consider co-treatment with anticoagulants and anaemia important predictors for severe endoscopic lesions, while other factors such as inflammation in gastric biopsies, congestive heart failure, co-treatment with clopidogrel and smoking tended to have a positive influence on risk for severe gastro-duodenal lesions.
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Affiliation(s)
- Anca Negovan
- University of Medicine and Pharmacy, Clinical Science-Internal Medicine, Gheorghe Marinescu 38, Tirgu Mureș 540139, Romania
| | - Mihaela Iancu
- University of Medicine and Pharmacy "Iuliu Hațieganu", Department of Medical Informatics and Biostatistics, Louis Pasteur St, no. 6, 400349 Cluj-Napoca, Romania.
| | - Valeriu Moldovan
- University of Medicine and Pharmacy, Morphological Science, Gheorghe Marinescu 38, Tirgu Mureș 540139, Romania
| | - Kinga Sàrkàny
- Emergency County Hospital, IIIrd Medical Clinic, Gheorghe Marinescu 50, Tirgu Mures 540136, Mures, Romania
| | - Simona Bataga
- University of Medicine and Pharmacy, Clinical Science-Internal Medicine, Gheorghe Marinescu 38, Tirgu Mureș 540139, Romania
| | - Simona Mocan
- Emergency County Hospital, Pathological Department, Gheorghe Marinescu 50, Tirgu Mures 540136, Mures, Romania
| | - Ioan Țilea
- University of Medicine and Pharmacy, Clinical Science-Internal Medicine, Gheorghe Marinescu 38, Tirgu Mureș 540139, Romania
| | - Claudia Banescu
- University of Medicine and Pharmacy, Morphological Science, Gheorghe Marinescu 38, Tirgu Mureș 540139, Romania
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10
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Li L, Geraghty OC, Mehta Z, Rothwell PM. Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: a population-based cohort study. Lancet 2017; 390. [PMID: 28622955 PMCID: PMC5537194 DOI: 10.1016/s0140-6736(17)30770-5] [Citation(s) in RCA: 260] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lifelong antiplatelet treatment is recommended after ischaemic vascular events, on the basis of trials done mainly in patients younger than 75 years. Upper gastrointestinal bleeding is a serious complication, but had low case fatality in trials of aspirin and is not generally thought to cause long-term disability. Consequently, although co-prescription of proton-pump inhibitors (PPIs) reduces upper gastrointestinal bleeds by 70-90%, uptake is low and guidelines are conflicting. We aimed to assess the risk, time course, and outcomes of bleeding on antiplatelet treatment for secondary prevention in patients of all ages. METHODS We did a prospective population-based cohort study in patients with a first transient ischaemic attack, ischaemic stroke, or myocardial infarction treated with antiplatelet drugs (mainly aspirin based, without routine PPI use) after the event in the Oxford Vascular Study from 2002 to 2012, with follow-up until 2013. We determined type, severity, outcome (disability or death), and time course of bleeding requiring medical attention by face-to-face follow-up for 10 years. We estimated age-specific numbers needed to treat (NNT) to prevent upper gastrointestinal bleeding with routine PPI co-prescription on the basis of Kaplan-Meier risk estimates and relative risk reduction estimates from previous trials. FINDINGS 3166 patients (1582 [50%] aged ≥75 years) had 405 first bleeding events (n=218 gastrointestinal, n=45 intracranial, and n=142 other) during 13 509 patient-years of follow-up. Of the 314 patients (78%) with bleeds admitted to hospital, 117 (37%) were missed by administrative coding. Risk of non-major bleeding was unrelated to age, but major bleeding increased steeply with age (≥75 years hazard ratio [HR] 3·10, 95% CI 2·27-4·24; p<0·0001), particularly for fatal bleeds (5·53, 2·65-11·54; p<0·0001), and was sustained during long-term follow-up. The same was true of major upper gastrointestinal bleeds (≥75 years HR 4·13, 2·60-6·57; p<0·0001), particularly if disabling or fatal (10·26, 4·37-24·13; p<0·0001). At age 75 years or older, major upper gastrointestinal bleeds were mostly disabling or fatal (45 [62%] of 73 patients vs 101 [47%] of 213 patients with recurrent ischaemic stroke), and outnumbered disabling or fatal intracerebral haemorrhage (n=45 vs n=18), with an absolute risk of 9·15 (95% CI 6·67-12·24) per 1000 patient-years. The estimated NNT for routine PPI use to prevent one disabling or fatal upper gastrointestinal bleed over 5 years fell from 338 for individuals younger than 65 years, to 25 for individuals aged 85 years or older. INTERPRETATION In patients receiving aspirin-based antiplatelet treatment without routine PPI use, the long-term risk of major bleeding is higher and more sustained in older patients in practice than in the younger patients in previous trials, with a substantial risk of disabling or fatal upper gastrointestinal bleeding. Given that half of the major bleeds in patients aged 75 years or older were upper gastrointestinal, the estimated NNT for routine PPI use to prevent such bleeds is low, and co-prescription should be encouraged. FUNDING Wellcome Trust, Wolfson Foundation, British Heart Foundation, Dunhill Medical Trust, National Institute of Health Research (NIHR), and the NIHR Oxford Biomedical Research Centre.
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Affiliation(s)
- Linxin Li
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Olivia C Geraghty
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Ziyah Mehta
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.
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Parvizi J, Huang R, Restrepo C, Chen AF, Austin MS, Hozack WJ, Lonner JH. Low-Dose Aspirin Is Effective Chemoprophylaxis Against Clinically Important Venous Thromboembolism Following Total Joint Arthroplasty: A Preliminary Analysis. J Bone Joint Surg Am 2017; 99:91-98. [PMID: 28099298 DOI: 10.2106/jbjs.16.00147] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Aspirin is a safe and effective prophylaxis for the prevention of venous thromboembolism following total joint arthroplasty. The optimal dose of aspirin prophylaxis is unknown. Our hypothesis was that lower-dose aspirin is as effective as higher-dose aspirin for the prevention of venous thromboembolism and is associated with fewer gastrointestinal side effects. METHODS In a prospective, crossover study, we analyzed 4,651 primary total joint arthroplasty cases performed from July 2013 to June 2015. For 4 weeks, 3,192 patients received enteric-coated 325-mg aspirin twice daily (the 325-mg aspirin group) and 1,459 patients received 81-mg aspirin twice daily (the 81-mg aspirin group). There were no significant differences (p > 0.05) in sex, body mass index, or Charlson Comorbidity Index between the two patient populations. Recorded complications occurring within 90 days postoperatively included symptomatic venous thromboembolism (deep venous thrombosis and pulmonary embolism), gastrointestinal complications, acute periprosthetic joint infection, and death. RESULTS The incidence of venous thromboembolism of 0.1% (95% confidence interval [CI], 0% to 0.3%) in the 81-mg aspirin group (1 with deep venous thrombosis and 1 with pulmonary embolism) was not significantly different (p = 0.345) from 0.3% (95% CI, 0.1% to 0.6%) in the 325-mg aspirin group (7 with deep venous thrombosis and 5 with pulmonary embolism). The incidence of gastrointestinal bleeding or ulceration of 0.3% (95% CI, 0% to 0.5%) in the 81-mg aspirin group was slightly, but not significantly (p = 0.66), lower than the 0.4% (95% CI, 0.2% to 0.6%) in the 325-mg aspirin group. The incidence of acute periprosthetic joint infection was 0.2% (95% CI, 0% to 0.4%) in the 81-mg aspirin group compared with 0.5% (95% CI, 0.2% to 0.7%) in the 325-mg aspirin group (p = 0.28). The 90-day mortality rate was similar in both groups at 0.1% (95% CI, 0% to 0.2%) in the 81-mg aspirin group and 0.1% (95% CI, 0% to 0.2%) in the 325-mg aspirin group (p = 0.78). CONCLUSIONS Our study demonstrates that low-dose aspirin is not inferior to high-dose aspirin for venous thromboembolism prophylaxis following total joint arthroplasty. This is not unexpected, as the available literature demonstrates that low-dose aspirin is as effective as higher-dose aspirin in the prevention of acute coronary syndrome and cerebrovascular events. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Javad Parvizi
- 1Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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12
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García Rodríguez LA, Martín-Pérez M, Hennekens CH, Rothwell PM, Lanas A. Bleeding Risk with Long-Term Low-Dose Aspirin: A Systematic Review of Observational Studies. PLoS One 2016; 11:e0160046. [PMID: 27490468 PMCID: PMC4973997 DOI: 10.1371/journal.pone.0160046] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 05/30/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Low-dose aspirin has proven effectiveness in secondary and primary prevention of cardiovascular events, but is also associated with an increased risk of major bleeding events. For primary prevention, this absolute risk must be carefully weighed against the benefits of aspirin; such assessments are currently limited by a lack of data from general populations. METHODS Systematic searches of Medline and Embase were conducted to identify observational studies published between 1946 and 4 March 2015 that reported the risks of gastrointestinal (GI) bleeding or intracranial hemorrhage (ICH) with long-term, low-dose aspirin (75-325 mg/day). Pooled estimates of the relative risk (RR) for bleeding events with aspirin versus non-use were calculated using random-effects models, based on reported estimates of RR (including odds ratios, hazard ratios, incidence rate ratios and standardized incidence ratios) in 39 articles. FINDINGS The incidence of GI bleeding with low-dose aspirin was 0.48-3.64 cases per 1000 person-years, and the overall pooled estimate of the RR with low-dose aspirin was 1.4 (95% confidence interval [CI]: 1.2-1.7). For upper and lower GI bleeding, the RRs with low-dose aspirin were 2.3 (2.0-2.6) and 1.8 (1.1-3.0), respectively. Neither aspirin dose nor duration of use had consistent effects on RRs for upper GI bleeding. The estimated RR for ICH with low-dose aspirin was 1.4 (1.2-1.7) overall. Aspirin was associated with increased bleeding risks when combined with non-steroidal anti-inflammatory drugs, clopidogrel and selective serotonin reuptake inhibitors compared with monotherapy. By contrast, concomitant use of proton pump inhibitors decreased upper GI bleeding risks relative to aspirin monotherapy. CONCLUSIONS The risks of major bleeding with low-dose aspirin in real-world settings are of a similar magnitude to those reported in randomized trials. These data will help inform clinical judgements regarding the use of low-dose aspirin in prevention of cardiovascular events.
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Affiliation(s)
| | - Mar Martín-Pérez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain
| | - Charles H. Hennekens
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States of America
| | - Peter M. Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Angel Lanas
- University of Zaragoza, University Clinic Hospital, IIS Aragón, CIBERehd, Zaragoza, Spain
- * E-mail:
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13
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Cea Soriano L, Soriano-Gabarró M, García Rodríguez LA. The Protective Effect of Low-Dose Aspirin against Colorectal Cancer Is Unlikely Explained by Selection Bias: Results from Three Different Study Designs in Clinical Practice. PLoS One 2016; 11:e0159179. [PMID: 27428004 PMCID: PMC4948817 DOI: 10.1371/journal.pone.0159179] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 06/28/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND We conducted three differently designed nested case-control studies to evaluate whether the protective effect of low-dose aspirin against colorectal cancer (CRC) is explained by selection bias. METHODS Using a large validated UK primary care database, we followed different cohorts of patients, who varied in their demographic and clinical characteristics, to identify first ever cases of CRC. In Studies 1 and 2, two cohorts were followed, i) new users of low-dose aspirin at start of follow-up (N = 170,336 in Study 1, N = 171,527 in Study 2) and either ii) non-users of low-dose aspirin (Study 1, N = 170,336) or new users of paracetamol (Study 2, N = 149,597) at start of follow-up. In Study 3 a single cohort of individuals näive to low-dose aspirin at the start of observation was followed. Controls were selected using incidence sampling and logistic regression used to obtain an unbiased estimate of the incidence rate ratio (RR) with 95% confidence intervals (CIs). Low-dose aspirin exposure was analyzed 'as-treated' before the index date (CRC date for cases, random date for controls). RESULTS In the three studies, median (maximum) follow-up was 5.1 (12), 5.8 (12) and 7.5 (13) years, respectively. 3033 incident CRC cases were identified in Study 1, 3174 in Study 2, and 12,333 in Study 3. Current use of low-dose aspirin was associated with a significantly reduced risk of 34%, 29% and 31% in the three studies, respectively; corresponding RRs (95% CIs) were 0.66 (0.60-0.73), 0.71 (0.63-0.80) and 0.69 (0.64-0.74). In each study, significantly reduced risks of CRC were seen when low-dose aspirin was used for primary or secondary cardiovascular disease prevention, in both sexes, and across all age groups evaluated. CONCLUSION Low-dose aspirin is associated with a significantly reduced risk of CRC. The consistency of our findings across different studies makes selection bias an unlikely explanation.
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14
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Cea Soriano L, Soriano-Gabarró M, García Rodríguez LA. Validation of low-dose aspirin prescription data in The Health Improvement Network: how much misclassification due to over-the-counter use? Pharmacoepidemiol Drug Saf 2015; 25:392-8. [PMID: 26660710 PMCID: PMC5064646 DOI: 10.1002/pds.3926] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 11/16/2022]
Abstract
Purpose We aimed to quantify the extent of over‐the‐counter (OTC) low‐dose aspirin use among patients in The Health Improvement Network (THIN) in the UK. Methods In September 2013, a random sample of low‐dose aspirin users (75 past users and 75 never users) was identified based on prescriptions recorded in THIN. Primary care practitioners (PCPs) were sent questionnaires to provide information on patients' use of OTC low‐dose aspirin. Results One hundred and forty valid questionnaires were received (93.30% [95%CI: 88.16–96.34] response rate). Current use of low‐dose aspirin was reported by PCPs in 4.23% (95%CI: 1.45–11.70) (n = 3) of past users (OTC use in one patient) and in 2.9% (95%CI: 0.78–9.70) (n = 2) of never users (OTC use in one patient). In addition, PCPs reported past use of low‐dose aspirin in 88.70% (95%CI: 79.31–94.18) (n = 63) of past users (all prescribed; none as OTC) and in 2.82% (95%CI: 0.78–9.70) (n = 2) of never users (as OTC). Among past users, PCPs reported the indication for low‐dose aspirin as primary cardiovascular disease (CVD) prevention in 63.16% (95%CI: 50.18–74.48) of patients and secondary CVD prevention in 31.58% (95%CI: 21.00–44.48) of patients. Corresponding percentages based on THIN were 78.95% (95%CI: 66.71–87.53) and 21.1% (95%CI: 12.47–33.29), respectively. Conclusion Our findings show the small impact of potential misclassification of low‐dose aspirin use in THIN due to unrecorded OTC use. The small proportion of false negatives confirms the utility of THIN for utilization and outcome studies of low‐dose aspirin. © 2015 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.
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Affiliation(s)
- Lucía Cea Soriano
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain
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15
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Cai G, Zhou W, Lu Y, Chen P, Lu Z, Fu Y. Aspirin resistance and other aspirin-related concerns. Neurol Sci 2015; 37:181-9. [PMID: 26573589 DOI: 10.1007/s10072-015-2412-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/26/2015] [Indexed: 12/16/2022]
Abstract
Aspirin is a widely used medication and has become a cornerstone for treating cardiovascular disease. Aspirin can significantly reduce the incidence of cardiovascular ischemic events, recurrence and mortality, thereby improving the long-term prognosis of patients. However, there has been a staggering increase in the volume of literature addressing the issue of so-called "aspirin resistance" in recent years, and for some patients, it is difficult to avoid adverse reactions to aspirin. In this review, we present both the historical aspects of aspirin use and contemporary developments in its clinical use.
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Affiliation(s)
- Gaoyu Cai
- Department of Neurology and Institute of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China
| | - Weijun Zhou
- Department of Emergency, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China
| | - Ya Lu
- Shanghai Wusong Street Community Health Service Center, Shanghai, 200940, China
| | - Peili Chen
- Department of Emergency, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China
| | - Zhongjiao Lu
- Department of Neurology and Institute of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China
| | - Yi Fu
- Department of Neurology and Institute of Neurology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China.
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Gastrointestinal bleeding in patients receiving oral anticoagulation: Current treatment and pharmacological perspectives. Thromb Res 2015; 136:1074-81. [PMID: 26508464 DOI: 10.1016/j.thromres.2015.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 10/06/2015] [Accepted: 10/07/2015] [Indexed: 02/07/2023]
Abstract
Gastrointestinal bleeding (GIB) is a potentially fatal and avoidable medical condition that poses a burden on global health care costs. The rate of major GIB related to the use of some direct acting oral anticoagulant drugs (DOACs), is higher than that detected in warfarin users. Current strategies in the treatment of GIBs in patients receiving warfarin or DOACs (vitamin K, activated charcoal; hemodialysis; recombinant factor VIIa; [activated] prothrombin complex concentrates) including indications for the treatment of bleeding based on different degrees of severity of the episodes, is reported in this article. Potential preventive strategies to mitigate the risk of GIBs (e.g. upper endoscopy/biopsy, colon cancer screening; eradication of Helicobacter pylori prior to starting anticoagulation; use of proton-pump inhibitors, identification of risk factors for bleeding) are also reported as well as the fact that some of them have not been tested so far in patients receiving DOACs. Antidotes that experimentally reverse the anti-coagulant effect of dabigatran (Idarucizumab; BI 655075; Boehringer Ingelheim); of rivaroxaban, apixaban, or edoxaban (Andexanet alfa, r-Antidote, PRT064445; Portola Pharmaceuticals) or of all DOACs (Aripazine, PER-977, ciraparantag; Perosphere Inc.) are discussed. Likewise, population pharmacokinetics modeling related to the rate of major DOACs-related GIBs is presented. It is also emphasized that the occurrence of GIB reflects the presence of patients at the highest risk for adverse outcomes. Finally, the implications of the concept that patient characteristics and the severity of illness (i.e. comorbidities) exert a greater impact on the risk of GIB than the type of antithrombotic agent employed, are analyzed.
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Management of low-dose aspirin and clopidogrel in clinical practice: a gastrointestinal perspective. J Gastroenterol 2015; 50:626-37. [PMID: 25595209 DOI: 10.1007/s00535-015-1038-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 12/26/2014] [Indexed: 02/04/2023]
Abstract
Low-dose aspirin, alone or combined with other antiplatelet agents, is increasingly prescribed for cardiovascular prevention. However, the cardiovascular benefits should be evaluated together with the gastrointestinal risks. Low-dose aspirin is associated with upper and lower gastrointestinal injury, although lower gastrointestinal effects are poorly characterized. This gastrointestinal risk differs among antiplatelets drugs users. The most important risk factors are history of peptic ulcer, older age, and concomitant use of non-steroidal anti-inflammatory drugs or dual antiplatelet therapy. Effective upper gastrointestinal prevention strategies are available and should be used in at-risk patients taking low-dose aspirin or clopidogrel. Proton pump inhibitors seem to be the best gastroprotective agents, whereas the benefits of Helicobacter pylori eradication are still unclear. Low-dose aspirin has additional effects in the gastrointestinal tract. A large body of evidence indicates that it can protect against different cancers, in particular colorectal cancer. This effect could modify the future indications for use of low-dose aspirin and the risk-benefit balance.
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Di Minno A, Spadarella G, Prisco D, Scalera A, Ricciardi E, Di Minno G. Antithrombotic drugs, patient characteristics, and gastrointestinal bleeding: Clinical translation and areas of research. Blood Rev 2015; 29:335-43. [PMID: 25866382 DOI: 10.1016/j.blre.2015.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/04/2015] [Indexed: 02/07/2023]
Abstract
Gastrointestinal bleeding (GIB) is a potentially fatal and avoidable medical condition that poses a burden on global health care costs. Current understanding of the roles of platelet activation and thrombin generation/activity in vascular medicine has led to the development of effective antithrombotic treatments. However, in parallel with a sustained coronary and cerebral flow patency, the increasingly intensive treatment with warfarin; direct oral anticoagulant drugs [DOACs], and/or with aspirin ± clopidogrel (or ± prasugrel or ± ticagrelor), has increased the burden of GIBs related to the use of antithrombotic agents. Compelling evidence concerning this issue is accumulating to indicate that: 1) the risk of GIB related to the use of antithrombotic drugs dramatically differs in different clinical settings; and 2) the characteristics of patients (e.g., severity of illness, comorbidities) in whom it is used exert a greater impact on the risk of GIB than the type of antithrombotic agent employed. The latter concept argues for the occurrence of GIB as reflecting the presence of patients at the highest risk for adverse outcomes. The HAS-BLED score identifies subjects at risk of bleeding among those untreated and those treated with warfarin, DOACs and/or low-dose aspirin. Its use within the frame of a severity score (e.g., the CHA2DS2-VASc score in patients with atrial fibrillation) helps balance the benefits and the risks of an antithrombotic treatment and identify those patients in whom the absolute gain (vascular events prevented) outweighs the risk of GIB. Potential implications of the latter information in settings other than atrial fibrillation is thoroughly discussed.
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Affiliation(s)
- Alessandro Di Minno
- Department of Farmacia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Gaia Spadarella
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Domenico Prisco
- Department of Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Largo Brambilla 3, 50134 Firenze, Italy
| | - Antonella Scalera
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Elena Ricciardi
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giovanni Di Minno
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy.
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Cohen A, Imfeld S, Markham J, Granziera S. The use of aspirin for primary and secondary prevention in venous thromboembolism and other cardiovascular disorders. Thromb Res 2015; 135:217-25. [DOI: 10.1016/j.thromres.2014.11.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 10/30/2014] [Accepted: 11/01/2014] [Indexed: 01/23/2023]
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20
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Ruigómez A, Johansson S, Nagy P, Martín-Pérez M, Rodríguez LAG. Risk of uncomplicated peptic ulcer disease in a cohort of new users of low-dose acetylsalicylic acid for secondary prevention of cardiovascular events. BMC Gastroenterol 2014; 14:205. [PMID: 25492031 PMCID: PMC4272555 DOI: 10.1186/s12876-014-0205-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 11/21/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The aim of this study was to analyse the risk of uncomplicated peptic ulcer disease (PUD) in a cohort of new users of low-dose acetylsalicylic acid (ASA) for secondary prevention of cardiovascular events in a UK primary care setting. METHODS New users of low-dose ASA for secondary prevention of cardiovascular events, aged 50-84 years in 2000-2007, were identified from The Health Improvement Network. Among those 38,975 individuals, 309 patients were considered to be incident cases of uncomplicated PUD. Incidence of uncomplicated PUD was calculated and a nested case-control analysis adjusted for potential confounding factors was performed to calculate the odds ratios (ORs) for the association of potential risk factors with uncomplicated PUD. RESULTS The crude incidence of uncomplicated PUD was 1.41 per 1000 person-years (95% confidence interval [CI], 1.26-1.58). Individuals with a history of PUD were more likely to develop uncomplicated PUD than those without such a history (hazard ratio [HR], 2.22, 95% CI, 1.60-3.09). In nested case-control analyses, the risk of uncomplicated PUD was associated with current use of non-steroidal anti-inflammatory drugs, oral steroids or acid suppressants. Other risk factors for developing uncomplicated PUD included smoking, stress, depression, anaemia and social deprivation. CONCLUSION Our results indicate that several risk factors significantly increase the risk of development of uncomplicated PUD in new users of low-dose ASA. Therefore, physicians should monitor ASA users for gastrointestinal symptoms and signs of ulcer, particularly if they have additional risk factors.
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Affiliation(s)
- Ana Ruigómez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Almirante 28-2, E 28004, Madrid, Spain.
| | - Saga Johansson
- AstraZeneca R&D, Pepparedsleden 1, Mölndal, SE-431 83, Sweden.
| | - Péter Nagy
- AstraZeneca R&D, Pepparedsleden 1, Mölndal, SE-431 83, Sweden.
| | - Mar Martín-Pérez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Almirante 28-2, E 28004, Madrid, Spain.
| | - Luis A García Rodríguez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Almirante 28-2, E 28004, Madrid, Spain.
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21
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Mainous AG, Tanner RJ, Shorr RI, Limacher MC. Use of aspirin for primary and secondary cardiovascular disease prevention in the United States, 2011-2012. J Am Heart Assoc 2014; 3:e000989. [PMID: 25023071 PMCID: PMC4310388 DOI: 10.1161/jaha.114.000989] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/09/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Aspirin use has been shown to be an effective tool in cardiovascular disease (CVD) prevention among high-risk patients. The patient-reported physician recommendation for aspirin as preventive therapy among high- and low-risk patients is unknown. METHODS AND RESULTS We conducted an analysis of the National Health and Nutrition Examination Survey 2011-2012 to examine the use of aspirin for CVD prevention. Patients without previously diagnosed CVD were classified into high and low risk based on their Framingham Risk Score (10-year coronary heart disease risk). Among patients without previously diagnosed CVD, 22.5% were classified as high risk. Of the high-risk individuals, 40.9% reported being told by their physician to take aspirin, with 79.0% complying. Among those who were at low risk, 26.0% were told by their physician to take aspirin, with 76.5% complying. Logistic regression analysis indicated that age, access to a regular source of care, education, and insurance status were significant predictors of patient-reported physician recommendations for aspirin use for primary prevention. Among high-risk patients, age, race, and insurance status were significant predictors of reported recommendations for aspirin use. Among low-risk patients, age, education, obesity, and insurance status were significant predictors of reported recommendations for aspirin use. CONCLUSIONS Patient reports indicate nonideal rates of being told to take aspirin, for both high- and low-risk patients for primary prevention. Clinical decision support tools that could assist physicians in identifying patients at risk may increase patient reports of physician recommendations for aspirin use.
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Affiliation(s)
- Arch G. Mainous
- Department of Health Services Research Management, and Policy, University of Florida, Gainesville, FL (A.G.M., R.J.T.)
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL (A.G.M.)
| | - Rebecca J. Tanner
- Department of Health Services Research Management, and Policy, University of Florida, Gainesville, FL (A.G.M., R.J.T.)
| | - Ronald I. Shorr
- Geriatric Research Education & Clinical Center, Malcom Randall VAMC and Department of Epidemiology, University of Florida, Gainesville, FL (R.I.S.)
| | - Marian C. Limacher
- Division of Cardiology, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL (M.C.L.)
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22
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Duffy D, Kelly E, Trang A, Whellan D, Mills G. Aspirin for cardioprotection and strategies to improve patient adherence. Postgrad Med 2014; 126:18-28. [PMID: 24393748 DOI: 10.3810/pgm.2014.01.2721] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in North America. Aspirin therapy has proven clinical effectiveness in the prevention and treatment of CVD and is one of the most widely used drugs nationwide. However, despite the medication's popularity and utility, adherence to a proper aspirin regimen is suboptimal, resulting in adverse health outcomes and increased health care costs. Our review outlines current knowledge on aspirin therapy adherence, causes of nonadherence, and strategies available to increase adherence to aspirin and medications in general. We demonstrate that, indeed, aspirin adherence rates are suboptimal, ranging from 72% to 92%, and that a combination of patient- and medication-related factors contribute to nonadherence. A multidimensional approach involving patient education and medication innovations to reduce aspirin side effects is imperative to improving rates of aspirin therapy adherence.
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Affiliation(s)
- Danielle Duffy
- Assistant Professor, Division of Cardiology, Jefferson Medical College.
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23
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Cryer B, Mahaffey KW. Gastrointestinal ulcers, role of aspirin, and clinical outcomes: pathobiology, diagnosis, and treatment. J Multidiscip Healthc 2014; 7:137-46. [PMID: 24741318 PMCID: PMC3970722 DOI: 10.2147/jmdh.s54324] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Peptic ulcer disease is a major cause of morbidity and mortality in the US with more than six million diagnoses annually. Ulcers are reported as the most common cause of hospitalization for upper gastrointestinal (GI) bleeding and are often a clinical concern due to the widespread use of aspirin and nonsteroidal anti-inflammatory drugs, both of which have been shown to induce ulcer formation. The finding that Helicobacter pylori infection (independent of aspirin use) is associated with the development of ulcers led to a more thorough understanding of the causes and pathogenesis of ulcers and an improvement in therapeutic options. However, many patients infected with H. pylori are asymptomatic and remain undiagnosed. Complicating matters is a current lack of understanding of the association between aspirin use and asymptomatic ulcer formation. Low-dose aspirin prescriptions have increased, particularly for cardioprotection. Unfortunately, the GI side effects associated with aspirin therapy continue to be a major complication in both symptomatic and asymptomatic patients. These safety concerns should be important considerations in the decision to use aspirin and warrant further education. The medical community needs to continue to improve awareness of aspirin-induced GI bleeding to better equip physicians and improve care for patients requiring aspirin therapy.
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Affiliation(s)
- Byron Cryer
- University of Texas Southwestern Medical School, Dallas, TX, USA
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24
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Onuchina EV. [Antiplatelet therapy with acetylsalicylic acid: approaches to reducing the frequency of gastrointenstinal adverse reactions]. TERAPEVT ARKH 2014; 86:98-103. [PMID: 25804049 DOI: 10.17116/terarkh2014861298-103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Acetylsalicylic acid (ASA) is highly effective in preventing cardiovascular events, but associated with increased risk for digestive adverse reactions. The paper provides an update on the epidemiology, mechanisms, and risk factors of esophagogastroduodeno- and enteropathies during long-term low-dose ACA therapy. It outlines the key principles of their prevention.
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25
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Valkhoff VE, Sturkenboom MCJM, Hill C, Veldhuyzen van Zanten S, Kuipers EJ. Low-dose acetylsalicylic acid use and the risk of upper gastrointestinal bleeding: a meta-analysis of randomized clinical trials and observational studies. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 27:159-67. [PMID: 23516680 PMCID: PMC3732153 DOI: 10.1155/2013/596015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 08/18/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Low-dose acetylsalicylic acid (LDA, 75 mg/day to 325 mg/day) is recommended for primary and secondary prevention of cardiovascular events, but has been linked to an increased risk of upper gastrointestinal bleeding (UGIB). OBJECTIVE To analyze the magnitude of effect of LDA use on UGIB risk. METHODS The PubMed and Embase databases were searched for randomized controlled trials (RCTs) reporting UGIB rates in individuals receiving LDA, and observational studies of LDA use in patients with UGIB. Studies were pooled for analysis of UGIB rates. RESULTS Eighteen studies were included. Seven RCTs reported UGIB rates in individuals randomly assigned to receive LDA (n=22,901) or placebo (n=22,923). Ten case-control studies analyzed LDA use in patients with UGIB (n=10,816) and controls without UGIB (n=30,519); one cohort study reported 207 UGIB cases treated with LDA only. All studies found LDA use to be associated with an increased risk of UGIB. The mean number of extra UGIB cases associated with LDA use in the RCTs was 1.2 per 1000 patients per year (95% CI 0.7 to 1.8). The number needed to harm was 816 (95% CI 560 to 1500) for RCTs and 819 (95% CI 617 to 1119) for observational studies. Meta-analysis of RCT data showed that LDA use was associated with a 50% increase in UGIB risk (OR 1.5 [95% CI 1.2 to 1.8]). UGIB risk was most pronounced in observational studies (OR 3.1 [95% CI 2.5 to 3.7]). CONCLUSIONS LDA use was associated with an increased risk of UGIB.
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Affiliation(s)
- Vera E Valkhoff
- Department of Gastroenterology & Hepatology, Erasmus MC – University Medical Center, Rotterdam, The Netherlands
- Department of Medical Informatics, Erasmus MC – University Medical Center, Rotterdam, The Netherlands
| | - Miriam CJM Sturkenboom
- Department of Medical Informatics, Erasmus MC – University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC – University Medical Center, Rotterdam, The Netherlands
| | - Catherine Hill
- Research Evaluation Unit, Oxford PharmaGenesis Ltd, Oxford, United Kingdom
| | | | - Ernst J Kuipers
- Department of Gastroenterology & Hepatology, Erasmus MC – University Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC – University Medical Center, Rotterdam, The Netherlands
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26
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Risk factors for gastrointestinal bleeding associated with low-dose aspirin. Best Pract Res Clin Gastroenterol 2012; 26:125-40. [PMID: 22542151 DOI: 10.1016/j.bpg.2012.01.011] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 12/16/2011] [Accepted: 01/19/2012] [Indexed: 01/31/2023]
Abstract
Low-dose aspirin use is associated with an increased risk for gastrointestinal ulceration and bleeding. At-risk low-dose aspirin users are therefore recommended to take proton-pump inhibitors. However, it is poorly understood which aspirin users are at risk to develop such complications. It is assumed that the known risk factors for NSAID-induced upper gastrointestinal events also apply to low-dose aspirin users. The conventional risk factors for upper gastrointestinal complications associated with aspirin therapy include: (1) a history of peptic ulcer disease or gastrointestinal bleeding, (2) older age, (3) concomitant use of NSAIDs, including coxibs, (4) concomitant use of anticoagulants or other platelet aggregation inhibitors, (5) the presence of severe co-morbidities, and (6) high aspirin dose. In patients with a history of peptic ulcer disease, Helicobacter pylori infection should be assessed and treated. This review focuses on the evidence for upper gastrointestinal risk factors in aspirin users.
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27
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Cea Soriano L, Bueno H, Johansson S, García Rodríguez LA. Predictors and time trends in clopidogrel and proton pump inhibitor coprescription with low-dose acetylsalicylic acid. Pharmacoepidemiol Drug Saf 2012; 21:463-9. [DOI: 10.1002/pds.3195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 11/14/2011] [Accepted: 11/28/2011] [Indexed: 12/23/2022]
Affiliation(s)
- Lucía Cea Soriano
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE); Madrid Spain
| | - Héctor Bueno
- Department of Cardiology; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | - Saga Johansson
- AstraZeneca R&D; Mölndal Sweden
- Institute of Medicine, Sahlgrenska Academy; Gothenburg University; Gothenburg Sweden
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