–Routine PPI use might cut the risk of major bleeds in people over 75.
Older people who take aspirin to prevent a recurrent cardiovascular event should take a proton-pump inhibitor to lower their risk of serious bleeding complications, say the authors of a new study published in the Lancet.
After a transient ischemic attack, ischemic stroke, or myocardial infarction, aspirin is commonly taken to prevent a recurrent event. Although aspirin is taken by 40% to 60% of people over 75, the studies demonstrating the safety of aspirin were performed in trials with younger participants.
Researchers in Oxford, led by Peter Rothwell, MD, PhD, followed 3,166 people taking antiplatelet therapy, predominantly aspirin, following a CV event. About half the patients were over the age of 75. The risk of major bleeding, including fatal bleeds and major upper GI bleeds, increased dramatically with age. Further, a higher proportion of GI bleeding events were disabling or fatal in older patients, and these events outnumbered disabling or fatal intracerebral hemorrhage.
“Although the risks of major bleeding in patients aged younger than 75 years were similar to the risks in previous trials of aspirin and other antiplatelet drugs, the risks at older ages were higher and more sustained than at younger ages, and the functional outcome was much worse, with a substantial risk of disabling or fatal upper gastrointestinal bleeding,” the authors wrote.
The authors calculated that the number need to treat (NNT) for a PPI to prevent one disabling or fatal upper GI bleed over 5 years decreased from 338 in people under 65 years of age to 25 for people 85 years or older.
“While there is some evidence that long-term PPI use might have some small risks, this study shows that the risk of bleeding without them at older ages is high, and the consequences significant,” Rothwell said in a press release. “In other words, these new data should provide reassurance that the benefits of PPI use at older ages will outweigh the risks.”
“We have known for some time that aspirin increases the risk of bleeding for elderly patients,” Rothwell said. “But our new study gives us a much clearer understanding of the size of the increased risk and of the severity and consequences of bleeds. Previous studies have shown there is a clear benefit of short-term antiplatelet treatment following a heart attack or stroke. But our findings raise questions about the balance of risk and benefit of long-term daily aspirin use in people aged 75 or over if a proton-pump inhibitor is not co-prescribed.”
In an accompanying editorial, Hans-Christoph Diener, MD, PhD, of the University of Duisburg-Essen in Germany, wrote that physicians “obsess about the association between benefit and bleeding risk” in patients taking oral anticoagulants for stroke prevention but not in patients taking antiplatelet therapy. But “major bleeding complications are a major issue in elderly patients with ischemic vascular disease treated with antiplatelet therapy.”
He recommended that physicians re-evaluate the risk-benefit ratio every 3 to 5 years in patients over the age of 75. He also agreed with the study authors that PPIs should be used more often in older people taking antiplatelet therapy.