Long-term daily ASA use linked to higher-than-expected risk of bleeding in over 75s

In people age 75 or older, long-term daily use of ASA is linked to a higher-than-expected risk of disabling or fatal bleeding, according to a new study in the Lancet.The authors said patients over 75 who take ASA on a daily basis should be prescribed a proton-pump inhibitor (PPI) to reduce the risk of bleeding.Lifelong treatment with antiplatelet drugs is recommended for patients who have previously had a heart attack or stroke, based on trials mostly done in patients younger than 75, with a followup of approximately two to four years. Previous studies have shown there is a causal link between antiplatelet treatment and upper gastrointestinal bleeding, and although the risk is known to increase with age, estimates on the size of the risk vary widely and there are few data on whether severity of bleeding also increases with age.“We have known for some time that (ASA) increases the risk of bleeding for elderly patients. 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,” study co-author Dr. Peter Rothwell, a professor of clinical neurology at the University of Oxford in England, said in a news release. “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 (ASA) use in people aged 75 or over if a proton-pump inhibitor is not co-prescribed.”The Oxford Vascular Study followed 3,166 patients who had previously had a stroke or heart attack and were prescribed antiplatelet drugs (mostly ASA). Half the patients were age 75 or older at the start of the study. Over 10 years of the study, a total of 314 patients were admitted to hospital for bleeding. The risk of bleeding, in particular the risk of fatal or disabling bleeding, increased with age.For patients under 65 taking daily ASA, the annual rate of bleeds requiring hospital admission was approximately 1.5%. For patients ages 75 to 84, the annual rate rose to approximately 3.5% and to 5% for patients over 85.Similarly, the risk of disabling or fatal bleeding increased with age. For patients under 65, the annual rate of life-threatening or fatal bleeds was less than 0.5%. For patients ages 75 to 84, the rate rose to approximately 1.5%, and to nearly 2.5% for patients age 85 or older.The outcome of non-fatal bleeds was also worse at older ages. The proportion of survivors for whom a bleed resulted in a new or sustained increase in disability rose from 3% for people under 75, to 25% for people over 75. Overall, the risk of disabling or fatal bleeding over 10 years was 10 times higher at ages 75 years or older, compared with younger patients.Although the risk of heart attacks and strokes also increases with age, the authors concluded that for patients age 75 or older, major upper gastrointestinal bleeding as a result of antiplatelet therapy was at least as likely to be disabling or fatal as recurrent ischemic stroke, if a PPI is not co-prescribed.PPIs could reduce upper gastrointestinal bleeding by 70% to 90% in patients receiving long-term antiplatelet treatment. The estimated number of patients that would need to take a PPI to prevent one disabling or fatal upper gastrointestinal bleed over five years fell from 338 for individuals younger than 65 years, to 25 for individuals age 85 years or older.“In patients receiving (ASA)-based antiplatelet treatment without routine PPI use, the long-term risk of major bleeding is higher and more sustained in older patients in practice than in the younger patients in previous trials, with a substantial risk of disabling or fatal upper gastrointestinal bleeding,” the researchers concluded. “Given that half of the major bleeds in patients aged 75 years or older were upper gastrointestinal, the estimated (number needed to treat) for routine PPI use to prevent such bleeds is low, and co-prescription should be encouraged.”About one-third of patients in the study were taking PPIs, but the analysis did not take into account the potential impact of any adverse effects linked to long-term use.The majority of patients in the study were taking ASA (75 mg enteric coat), with only a few patients taking clopidogrel.

Long-term daily ASA use linked to higher-than-expected risk of bleeding in over 75s

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