GI tract

NSAIDs plus anticoagulants are double trouble for GI bleeds

With one in three anticoagulant-treated patients also taking NSAIDs, the potential for “double trouble” with GI bleeding is significant,  US researchers warn.

A post-hoc analysis of a subset of 2270 atrial fibrillation patients who took concomitant non-selective NSAIDs with anticoagulants found they had a 50% higher risk (HR 1.48) of major GI bleeds compared to non users of NSAIDs.

Rates of major GI bleeding were 1.85%/year for NSAID users compared with 1.2%/year for no NSAID use.

The two year randomised controlled trial of anticoagulant therapy for AF also showed that an increase in major GI bleeding was seen with warfarin and the novel oral anticoagulant dabigatran.

Rates of non-GI major bleeding were also significantly higher among anticoagulated patients taking NSAIDs (2.7% vs 1.9%/year). Concomitant use of NSAIDs and anticoagulants was also associated with higher rates of stroke and hospitalisation, but no differences were seen in myocardial infraction or mortality between NSAID users and non-users.

The mechanism for the increased bleeding risk associated with NSAIDs was likely a result of both the antiplatelet effects to induce and prolong bleeding, and tissue injury at the gastric mucosa, the study authors said in the Journal of the American College of Cardiology.

An accompanying commentary said the findings highlighted the dilemma of how to manage patients with AF and osteoarthritis given the lack of non-NSAID anti-inflammatories.

The authors said the risk of GI bleeding could be reduced in anticoagulated patients by using a COX-2 inhibitor drug instead of a non-selective NSAID, and also by using  gastroprotective PPI therapy.

They noted that only 17% of patients in the AF trial had been co-prescribed a PPI despite this strategy being recommended in guidelines.

If patients stop taking their anticoagulant stroke prophylaxis because of NSAIDs, this could lead to higher rates of thrombotic events, they warned.

“Unfortunately, we have double trouble but no single way out … until safe and effective non-NSAID, nonopioid analgesics are available, we are stuck with the high stakes, common question of how to manage patients with AF and OA,” they conclude.

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