ubmslateNT-logo-ubm

NT Mobile Menu

Search form

Topics:

How Safe is Long-term Antiplatelet Rx After a Vascular Event?

How Safe is Long-term Antiplatelet Rx After a Vascular Event?

  • Here is new evidence that people aged 75 and older who take aspirin-based antiplatelet treatment for secondary prevention should also take PPIs.
  • Should PPIs Be Routine with Aspirin?
    o Guidelines recommend lifelong antiplatelet therapy after an MI or ischemic stroke[1,2]
    . Recommendations mainly based on trials in people <75 years
    o Aspirin (ASA) is associated with major bleeding, especially upper GI bleeds
    . Concomitant proton pump inhibitors (PPIs) can decrease upper GI bleeds by 70%-90%
    o PPIs not routinely co-prescribed with ASA
    . Concerns about adverse effects with long-term PPI use
    . GI bleeds thought to have low case-fatality rate, or mostly non-disabling
    . Guidelines for secondary prevention of vascular events do not recommend concomitant PPIs

  • Oxford Vascular Study[3]
    o Prospective cohort study in 9 general practices in Oxfordshire, UK between 2002-2012
    o 3166 participants on antiplatelet therapy after first TIA, ischemic stroke, or MI:
    . <75 years (n=1584): 97% on ASA
    . ≥75 years (n=1582): 95% on ASA
    o Overall 30% on antiplatelet therapy without concomitant PPI
    o Face to face follow-up for 10 years

  • ASA-Associated Fatal or Disabling Bleeding Increases with Age
    o Major Upper GI Bleeds: Annual risk over 4 times higher in ≥75 years vs <75 years (HR 4.13, 2.60–6.57; p<0.0001)
    o Disabling Bleeds: Annual risk over 7.5 times higher in ≥75 years vs <75 years (HR 7.60, 3.74-15.47, p<0.0001)
    o Fatal Bleeds: Annual risk 5.5 times higher in ≥75 years vs <75 years (HR 5.53, 2.65–11.54; p<0·0001)
    o Disabling or Fatal Bleeds Combined: Annual risk over 10 times higher in ≥75 years vs <75 years (HR 10.26, 4.37-24.13; p<0.0001)

  • With Age Disability from Bleeds Increases, NNT with PPIs Decreases
    o Odds of bleeds resulting in new or increased disability almost 13 times higher in ≥75 years vs <75 years (OR 12.8, 95% CI 4.5–36.6; p<0·0001)
    . In ≥75 years, 62% (45/73) of major upper GI bleeds resulted in disability or death
    . In >75 years, estimated 5-yr risk of major bleeds thought attributable to ASA approached the risk of ischemic events thought prevented by ASA
    o Number needed to treat (NNT) with PPIs to prevent one disabling or fatal upper GI bleed over 5 years decreases with age:
    . <65 years: NNT 338
    . ≥ 85 years:  NNT 25

  • Limitations
    o Observational design: cannot definitively say ASA caused increased risk of disabling/fatal bleeding risk with increasing age
    o No estimate of number needed to harm due to adverse effects of PPIs
    o Adjusted for known age, sex, risk factors for major and upper GI bleeding, residual confounding possible
    . OTC NSAIDs may not have been included
    o Predominant form of ASA, 75 mg enteric coated; results may not generalize to other antiplatelet therapy or countries that use other doses of ASA

  • People ≥75 Years Who Are on ASA Should Take PPIs
    o Older patients on ASA without routine PPIs after TIA, MI, or stroke have a long-term risk for fatal or disabling bleeds that is higher than previously thought, compared to younger patients
    o Risk of disabling and fatal bleeds associated with ASA increases with age, and may outweigh protective effect of ASA on ischemic events
    o Authors propose an age-based criterion:
    . Individuals aged 75 or older may be at high-risk for ASA-associated bleeding and should take PPIs

  • Take Home Points
    o Real-world results from the Oxford Vascular Study showed annual risk of disabling or fatal bleeds associated with ASA for secondary prevention increases with age
    o The odds that bleeds associated with ASA will result in new or increased disability are almost 13 times higher in ≥75 years vs <75 years
    o Over half of major upper GI bleeds in people aged ≥75 years who are on ASA for secondary prevention result in disability or death
    o The number needed to treat with PPIs to prevent one fatal or disabling upper GI bleed decreases with age
    o Individuals who are age 75 or over and on ASA for secondary prevention should take PPIs

Add new comment

 
Loading comments...

By clicking Accept, you agree to become a member of the UBM Medica Community.