The risk of gastrointestinal bleeds have been significantly underestimated in elderly patients treated with aspirin for secondary prevention of stroke and heart attack, a large UK study has found.
What was previously considered to be an unwanted side effect of the antiplatelet therapy is likely to be just as disabling or fatal in patients aged over the age of 75 as the recurrent stroke the therapy is meant to prevent, the British researchers have warned.
The Oxford vascular study, published in The Lancet this week, followed 3166 patients who had previously had a stroke or heart attack and were prescribed antiplatelet drugs, mostly aspirin. Half the patients were aged 75 or over at the start of the study.
Over 10 years of the study, a total of 314 patients were admitted to hospital for bleeding.
The consequence of the bleeds increased steadily with age – at age 75 years or older, major upper gastrointestinal (GI) bleeds were mostly disabling or fatal and outnumbered disabling or fatal intracerebral haemorrhage.
Given that half of the major bleeds reported in the study were upper gastrointestinal, the investigators argue that secondary prevention guidelines should recommend the co-prescription of proton pump inhibitors to counter the risk.
They say PPIs could reduce upper GI bleeding by 70-90% in patients receiving long-term antiplatelet treatment.
Professor Christopher Reid, Associate Director of the Monash Centre of Cardiovascular Research and Education, and a chief investigator for the Aspirin in Reducing Events in the Elderly (ASPREE) Study said despite its observational nature the study was an important addition to the literature.
“This is an area where we really don’t have a lot of good evidence and its particularly interesting because it includes data from patients right up to age of 85,” he told the limbic.
Long-term antiplatelet treatment was recommended after ischaemic vascular events on the basis of trials done mainly in patients younger than 75 years, he noted.
“We’re a population now who are surviving our first infarct or ischaemic stroke and patients need to be appropriately treated to reduce not just the risks of future events but the risk of all types of major side effects,” he said.
“This study shows that those GI bleeds in older people are quite a lot more significant than we thought in terms of the health impact.”
But the jury was still out on whether the benefits of routine long-term PPI use in the elderly were enough to outweigh their risks.
Professor Reid said clinicians would need to make a decision based on the patient’s individual clinical circumstances, noting that this but wasn’t always an easy thing to do.
“Getting that risk-benefit ratio right, especially in the elderly who have high levels of comorbidity… it’s an art,” he said.
“Hopefully there’ll be more science in terms of evidence for the benefit of treatment but in the absence of a crystal ball we simply don’t have enough to make a firm recommendation.”
Writing in a linked Comment, Professor Hans-Christoph Diener, University Duisburg-Essen, Germany advised that elderly patients on long-term antiplatelet therapy should be evaluated every 3-5 years.
He also argued that the study supported the need for routine PPI use in older patients on antiplatelet thearpy.
“PPIs are underused in patients on antiplatelet therapy, perhaps because the consequences of upper gastrointestinal bleeds were underestimated in elderly patients who were treated with aspirin,” he wrote.