Australian researchers are going against the grain, recommending clinicians increase proton pump inhibitor (PPI) use in elderly low-dose aspirin patients to prevent upper gastrointestinal bleeding (UGIB).

For years, physicians have had a tumultuous relationship with PPIs, which have reportedly been overused, for too long, at too-high doses and linked to increased risk of microscopic colitis; acute gastroenteritis; all-cause mortality; and other adverse events. These outcomes have led to stricter PBS access criteria and deprescribing campaigns.

Now, researchers led by Associate Professor Oyekoya Ayonrinde, gastroenterologist and hepatologist at Fiona Stanley Hospital in Western Australia are backing their use for gastroprotection, where relevant, in older patients on low-dose aspirin who are at higher risk of UGIB.

Their study of 133 suspected UGIB patients attending the hospital found low-dose aspirin users aged 70 years and older had a ninefold increased risk (95% CI: 1.15–70.74, P = 0.04) of haematemesis and/or melaena compared with non-users, a risk which was reduced by 90% with regular PPI intake (adjusted odds ratio: 0.10, 95% CI: 0.01–0.75, P = 0.03).

Of assessed patients, 43% were on aspirin prior to UGIB and 19%, PPIs. The remainder, were on non-aspirin antiplatelet or anticoagulant medications, which weren’t significantly associated with overt UGIB.

Despite older aspirin users’ increased risk of UGIB and the non-statistically significant risk in those under 70 (odds ratio: 1.94, 95% CI: 0.37–10.21), concurrent PPI use was associated with younger age [20% of under 70s versus 6% of older patients, P = 0.02].

Notably, for those on PPIs or aspirin, no significant difference was seen in endoscopic lesion severity versus non-users (P > 0.05). This may be due to the natural history of bleeding ulcers and the “common use of intravenous PPI prior to the endoscopy”, the authors suggested.

Patients on and off aspirin had similar mean haemoglobin (84 (3.0) g/L vs 86 (3.1) g/L, P = 0.62), systolic blood pressure (124 (3) mmHg vs 120 (2) mmHg, P = 0.40) and pulse rate (84 (3)/min vs 89 (2)/min, P = 0.14).

Aspirin users, however, had higher risk features for adverse outcomes, including older age, higher volume of blood cells transfused and a trend toward longer hospitalisation.

“While there have been concerns regarding the costs and potential risks of adverse events associated with high rates of prescribed long-term oral PPI in Australia, there is likely under-prescription of PPI for gastroprotection in aspirin-treated older people with comorbidity,” the authors wrote in Internal Medicine Journal.

“Most concerns regarding risks of PPI use have not been borne out in a large randomised clinical trial with 3-year follow up,” they added.

In spite of the study’s limitations, including its small, single-centre sample and failure to assess aspirin or PPI duration from clinical records or whether aspirin was taken with food, the authors called for a shift to “more judicious and safer prescription of low-dose aspirin in older people”.

“As older people are at increased risk of gastroduodenal ulceration and bleeding related to low-dose aspirin, decisions regarding initiation of aspirin in older people should weigh the risks and benefits, and gastroprotection should be provided where relevant,” they concluded.