{"id":1072,"date":"2016-06-17T15:40:19","date_gmt":"2016-06-17T15:40:19","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1072"},"modified":"2017-08-21T10:53:26","modified_gmt":"2017-08-21T10:53:26","slug":"primary-care-corner-with-geoffrey-modest-md-continue-aspirin-after-lower-gi-bleeds","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/06\/17\/primary-care-corner-with-geoffrey-modest-md-continue-aspirin-after-lower-gi-bleeds\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Continue Aspirin After Lower GI Bleeds?"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>A rather common clinical conundrum in patients with\/at high risk for cardiovascular disease\u00a0is whether to reinstate aspirin after a GI bleed. A recent retrospective study from Hong Kong suggested that the benefit outweighs\u00a0the risk for lower GI bleeds (see\u00a0doi.10.1053\/j.gastro.2016.04.013). They reviewed their data on patients with documented lower GI bleed (melena or hematochezia and absence of upper GI source) from 2001-2008.<\/p>\n<p>Details:<\/p>\n<ul>\n<li>295 patients who were on aspirin at the time of the lower GI\u00a0bleed, followed up to 5 years<\/li>\n<li>93% were considered to be of &#8220;high cardiovascular risk&#8221;, using the Antithrombotic Trialists&#8217; Collaborative definition: history of unstable angina, acute MI, prior MI, stroke, or TIA<\/li>\n<li>Non-users were defined as taking aspirin &lt;20% of the follow-up period (n=121; 87% actually took\u00a0aspirin &lt;10% of the follow-up period); users were those with cumulative use &gt;50% of that period (n=174; 84% took\u00a0aspirin &gt;75% of the follow-up period). Aspirin use was determined by prescription patterns.<\/li>\n<li>All used &lt;=160mg aspirin, and 88% used only 80 mg\/d<\/li>\n<li>Non-users were older (76.7 vs 73.1 years, p=0.003), fewer smokers (26.4% vs 42.0%, p=0.006), and more needed transfusion of &gt;= 2 units (54.5% vs 39.7%)<\/li>\n<li>Predefined covariables at baseline: age, sex, alcohol consumption, smoking, severity of comorbidities, history of\u00a0GI bleeding (upper and lower),\u00a0blood transfusion, meds (anticoagulants, steroids, non-aspirin antiplatelet drugs) within the 30 days prior to index bleed.<\/li>\n<li>Outcomes assessed: recurrent lower GI bleed, serious cardiovascular events (nonfatal MI, nonfatal stroke, death from vascular cause), and deaths from other causes<\/li>\n<li>Results, comparing non-users to users:\n<ul>\n<li>Lower GI bleeding recurred in 18.9% of those on aspirin\u00a0vs 6.9% of non-users (SHR 2.76; p=0.011) [SHR is subdistribution hazard ratios, which from my understanding is the probability of an event due to aspirin at a moment in time, comparing cause-specific cumulative incidences of different effects]\n<ul>\n<li>Overt bleeding in 6.6% of non-users (n=8) vs 17.8% of users\u00a0(n=31). both groups were transfused\u00a0a median of 2 units of blood<\/li>\n<li>Occult bleeding in 1.7% (n=2) of non-users vs 6.9% of users\u00a0(n=12)<\/li>\n<\/ul>\n<\/li>\n<li>Serious cardiovascular events occurred in 22.8% of those on aspirin vs 36.5% of non-users (SHR 0.59; p=0.019)<\/li>\n<li>2% of aspirin users died from other causes vs 26.7% of non-users (SHR 0.33; p=0.001): 42 patients overall died, including 22 from sepsis, 10 from cancer, and 6 from renal failure<\/li>\n<li>Multivariable analysis: <strong>aspirin use was an independent predictor of rebleeding but protected\u00a0 against major cardiovascular events and deaths<\/strong><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>A large number of people are on aspirin, up to 50% of men &gt;40 yo. The major GI toxicity is upper GI, which can be decreased by concomitant use of a proton pump inhibitor (though that has its concerns: see\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/02\/25\/primary-care-corner-with-geoffrey-modest-md-ppi-use-and-dementia\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/02\/25\/primary-care-corner-with-geoffrey-modest-md-ppi-use-and-dementia\/<\/a> which comments on a couple of articles on potential\u00a0PPI-associated dementia and includes\u00a0references to PPI-associated microbiome changes, MIs in those without prior history of heart disease, chronic kidney disease, pneumonia and a variety of GI infections, decreased bone density, etc.).\u00a0But there is somewhat more concern about the lower GI bleeding: several observational studies have documented an increase in aspirin-associated\u00a0lower GI bleeding (where PPIs are unlikely to be protective, so continued aspirin use is more dangerous). And those hospitalized for lower GI bleeding actually have a higher mortality than those with upper\u00a0GI bleed.<\/li>\n<li>It is hard to draw clear conclusions from a retrospective study, given that the nonusers were older (which perhaps explains their increase in noncardiovascular deaths), though fewer were smokers. So, the multivariate analysis may have not fully compensated for differences in all risk factors\/biases.<\/li>\n<li>But, I would add a few points:\n<ul>\n<li>This article highlights the <strong>very likely conclusion that those with a lower GI bleed but\u00a0at high cardiovascular risk are more likely to get benefit over harm by continuing aspirin use<\/strong>. The issue with the more common adverse event of aspirin-associated\u00a0upper GI bleeding is a bit easier given\u00a0the potential of adding acid suppression therapy to minimize recurrent risk<\/li>\n<li>I think it is also important to stress that aspirin may have real benefits in preventing cancer (see below). The data on this has been accumulating for many decades (I remember seeing data on aspirin or NSAIDs decreasing colonic adenomas\/cancer dates back to the 1970s, with the support of a really large number of suggestive epidemiologic and animal studies), though potential cancer prevention\u00a0was\u00a0only recently incorporated into mainstream recommendations (see USPSTF guideline link below).<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/09\/09\/primary-care-corner-with-geoffrey-modest-md-low-dose-aspirin-and-colon-cancer-risk\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/09\/09\/primary-care-corner-with-geoffrey-modest-md-low-dose-aspirin-and-colon-cancer-risk\/<\/a> looks at the data on colon cancer prevention by low dose aspirin with links to other blogs on ovarian, prostate and other cancers.<\/p>\n<p><a href=\"http:\/\/www.uspreventiveservicestaskforce.org\/Page\/Document\/UpdateSummaryFinal\/aspirin-to-prevent-cardiovascular-disease-and-cancer?ds=1&amp;s=aspirin\">http:\/\/www.uspreventiveservicestaskforce.org\/Page\/Document\/UpdateSummaryFinal\/aspirin-to-prevent-cardiovascular-disease-and-cancer?ds=1&amp;s=aspirin<\/a> is a link to the USPSTF 2016 aspirin recommendations, which highlights using\u00a0low dose aspirin in the\u00a0primary prevention of both cardiovascular disease and colorectal cancer (i.e., not just for cardiovascular protection)<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Continue Aspirin After Lower GI Bleeds?  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/06\/17\/primary-care-corner-with-geoffrey-modest-md-continue-aspirin-after-lower-gi-bleeds\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1072","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1072","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1072"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1072\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1072"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1072"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1072"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}