Current study: life-threatening bleeding risk with long-term aspirin use

Current study: life-threatening bleeding risk with long-term aspirin use

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Long-term aspirin intake increases the risk of gastrointestinal bleeding
Aspirin (active ingredient acetylsalicylic acid) is one of the most commonly used drugs worldwide. Originally used primarily as a pain reliever, aspirin is now used for aftercare after a stroke or heart attack due to its anticoagulant effect. In the long term, however, aspirin intake can increase the risk of life-threatening bleeding, according to a recent study. Patients over 75 years of age experience more gastrointestinal bleeding when they regularly take aspirin.

The low-dose aspirin intake is often used to prevent strokes and heart attacks, since the active ingredient acetylsalicylic acid inhibits blood clotting. However, this can be associated with a significantly increased risk of life-threatening internal bleeding, especially in older people, scientists from Oxford University report on their current study results. The study results were published in the renowned specialist magazine "The Lancet".

Aspirin is often used to prevent heart attacks and strokes
In the U.S. and Europe, around 40 to 60 percent of adults age 75 and older take aspirin or other antiplatelet medications daily to prevent heart attacks or strokes, Oxford University reports. Life-long treatment with antiplatelet medication (so-called secondary prevention) is recommended for patients who have previously had a heart attack or stroke. However, the drugs also have unpleasant side effects. This includes the increased risk of gastrointestinal bleeding.

The risk of gastrointestinal bleeding in the elderly is still unclear
Previous studies had already shown that there is a causal link between antiplatelet therapy and upper gastrointestinal bleeding, the scientists report. Although it is known that this risk increases with age, the estimates of the actual size of the risk have so far been very different. The scientists have now investigated to what extent the bleeding severity increases in patients over the age of 75 in a comprehensive cohort study.

Almost 3,200 subjects examined
A total of 3,166 patients who had previously had a stroke or heart attack and then received antiplatelet medication (mostly aspirin) were observed over a period of ten years in the current study. "Half of the patients were 75 years or older at the start of the study," the scientists report. During the study period, 314 patients were hospitalized for bleeding and the risk of fatal bleeding increased significantly with age.

Increasing risk of bleeding in old age
Scientists found that patients under the age of 65 years who received aspirin daily had an annual probability of around 1.5 percent for hospital treatment for bleeding. "For patients aged 75 to 84 years, the annual disease rate rose to about 3.5 percent," the researchers report. In patients over the age of 85, it reached 5 percent. At the same time, the risk of fatal gastrointestinal bleeding increases with age. While the probability was still 0.5 percent per year in patients up to 65 years of age, the rate rose to about 1.5 percent between the ages of 75 and 84 years and almost 2.5 percent in patients aged 85 and over the scientists report.

Weigh risk and benefit
“We have known for some time that aspirin increases the risk of bleeding for the elderly. But our new study gives us a much clearer understanding of the magnitude of the increased risk and the severity and consequences of the bleeding, ”said Professor Peter Rothwell, leading author from Oxford University. In previous studies, a clear advantage of short-term antiplatelet therapy after a heart attack or stroke had been demonstrated. However, given the current findings, questions arise about the relationship between risk and benefit in long-term daily aspirin use at the age of 75 or more.

Proton pump inhibitors reduce the risk
The scientists also found that prescribing so-called proton pump inhibitors (PPI) counteracts the risk of gastrointestinal bleeding. Taking the PPI reduced the risk of upper gastrointestinal bleeding in patients receiving long-term antiplatelet therapy by 70 to 90 percent, the researchers report. Taking the PPI also brings with it the risk of side effects, but according to the scientists, this is rather moderate in relation to the impending gastrointestinal bleeding.

Also PPI with side effects
"While there is some evidence that PPIs may have long-term risks," the current study shows, "the risk of bleeding without them is high in older age groups and the consequences are significant," said Professor Rothwell. Using the PPI to reduce the risk of internal bleeding in older patients therefore seems to be worth considering when considering the risk-benefit ratio.

Consequences for practice
In a commentary on the current study, Professor Hans-Christoph Diener from the University of Duisburg-Essen emphasized that, in view of the new findings, the benefit-risk ratio of long-term antiplatelet therapy in patients over the age of 75 was re-evaluated every 3 to 5 years should be. In addition, the accompanying treatment with PPI in patients with antiplatelet therapy over the age of 75 and an earlier history of gastrointestinal bleeding should be reconsidered. (fp)

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