PPI and Aspirin Co-Prescription May Reduce Long-Term Bleeding Risk
Long-term antiplatelet therapy following a vascular event is associated with an increased risk of bleeding in adults aged 75 years or older, according to a recent study. However, a co-prescription for proton-pump inhibitors (PPIs) was found to decrease this risk significantly for older patients.
The prospective population-based cohort study included 3166 patients who were treated with antiplatelet therapy, primarily aspirin, following their first transient ischemic attack, ischemic stroke, or myocardial infarction. Patients were recruited from the Oxford Vascular Study from 2002 to 2012, with follow-up until 2013.
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Bleeding severity, type, outcomes (such as disability or death), and time course requiring medical attention was determined for the 10 years of follow-up. In addition, age-specific numbers needed to treat (NNT) to prevent upper gastrointestinal bleeding with routine PPI co-prescription was estimated.
A total of 1582 patients (50%) were 75 years of age or older, and 577 (18%) were 85 years of age or older.
Over the 10 years of follow-up, first-time bleeding events occurred in 405 patients, of which 314 patients (78%) required hospitalization. Of those requiring hospitalization, 117 patients (37%) were missed by administrative coding. Gastrointestinal bleeding occurred in 218 patients, intracranial bleeding occurred in 45 patients, and other types of bleeding occurred in142 patients.
While the risk of non-major bleeding was not related to age, the risk for major bleeding increased significantly with age—specifically the risk for fatal bleeds. This risk was sustained throughout follow-up and was similar for major upper gastrointestinal bleeding—particularly if disabling or fatal.
For patients aged 75 years or older, major upper gastrointestinal bleeds were mostly disabling or fatal and were more common than fatal or disabling intracerebral hemorrhages (45 patients vs 18 patients, respectively).
In addition, the estimated NNT for routine PPI co-prescription to prevent a disabling or fatal upper gastrointestinal bleed over 5 years fell from 338 for patients younger than 65 years to 25 for those aged 85 years or older.
“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,” the researchers concluded.
“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.”
—Melissa Weiss
Reference:
Li L, Geraghty OC, Mehta Z, Rothwell PM; the Oxford Vascular Study. Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: a population-based cohort study [published online June 13, 2017]. Lancet. http://dx.doi.org/10.1016/S0140-6736(17)30770-5.