Concomitant antiplatelet/NSAID use requires caution

Identifying and treating the potentially life-threatening problem of gastrointestinal complications in patients who use the combinations of antiplatelet therapy and NSAIDs are the focus of a new scientific statement by the American College of Cardiology Foundation, the American College of Gastroenterology and the American Heart Association.

Practical clinical guidance for reducing the risk of ulceration and related bleeding  including the use of gastroprotection, either with protein pump inhibitor therapy or treatment of Helicobacter Pylori infection  was included in the consensus document.

Ulceration and gastrointestinal bleeding are recognizable risks in individuals who use antiplatelet agents and NSAIDs, with these patients having up to a fourfold increased risk of such complications, compared with those who are not using the medications as per the document cochair, and his colleagues on the consensus document writing committee.

Since NSAIDs, including aspirin, are the most widely used class of medication in the United States, and more Americans are living with heart disease in addition to conditions that require them to take NSAIDs (such as arthritis, inflammation, and related muscoloskeletal pain), the management of GI risk will become an increasingly important part of cardiovascular care, according to an American College of Cardiology (ACC) statement on the consensus document.

Doctors are uncertain about how best to prevent bleeding complications in patients receiving antiplatelet therapy and NSAIDs, which are both commonly used, and can cause erosions in the stomach lining as noted in the statement by the chief of cardiology at VA Boston Healthcare System. These recommendations represent the collective expertise of leading cardiologists and gastroenterologists, as well as an extensive review of the literature, and provide specialists with practical measures to manage competing risks and help improve patient safety.

In addition, the immediate past president of the American College of Gastroenterology and professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, Norfolk, stressed the importance of “proactive assessment” of individual risk, and of the need for improved communication among cardiologists, gastroenterologists and primary care physicians to improve patient safety. Likewise, patients must be informed of the importance of disclosing all medication information to ensure that appropriate measures can be taken to reduce risk.

The organizations made recommendations for these clinical scenarios:

• GI complications of aspirin and of combined aspirin and nonaspirin NSAIDs. Gastroprotective therapy should be prescribed for at-risk patients who use low-dose aspirin. And for those using any NSAIDs in conjunction with cardiac-dose aspirin. Because the risk of upper-gastrointestinal events increases with aspirin dose escalation, doses greater than 81 mg should not be routinely prescribed for chronic phase therapy.

• GI effects of combined aspirin and anticoagulate therapy. There is a “clinically meaningful and significantly increased risk of major extracranial bleeding events, a large proportion from the upper GI tract in those on this combination, which has an “established vascular”, arrhythmic, or valvular indication. Concomitant proton pump inhibitor (PPI) therapy is advised.

• GI effects of clopidogrel plus anticoagulant therapy. Clopidogrel should not be substitutes for aspirin as a strategy to reduce recurrent ulcer bleeding in high risk patients because it is inferior to the combination of aspirin plus PPIs. Also, the combination of clopidogrel and warfarin therapy is associated with an increased incidence of major bleeding, compared with monotherapy; this combination should be considered only when the benefits are likely to outweigh the risk. An international normalized ratio of 2.0-2.5 is recommended when warfarin is added to aspirin or to aspirin and clopidogrel.

• Treatment and prevention of aspirin and NSAID-related gastroduodenal injury. PPIs should be used for both the prevention and the treatment of NSAID and aspirin associated GI injury.

• H. pylori testing and eradication. Before initiating chronic antiplatelet therapy in patients with a history of ulcer disease, test for and eradicate H. Pylori.

• Discontinuation of antiplatelet therapy because of bleeding. The decision to discontinue aspirin therapy in the setting of acute ulcer bleeding should be individualized based on cardiac risk and GI risk assessments to discern potential thrombotic and hemorrhagic complications.

• Endoscopy in patients on mono or dual antiplatelet therapy. High-risk cardiovascular patients on dual therapy may benefit from endoscopic therapy. Collaboration between the cardiologist and endoscopist is important to assess the risk of bleeding against the risk of thrombosis in regard to the timing of antiplatelet therapy cessation.

The consensus document is considered to be part of “an ongoing dialogue” and will be updated “as more definitive data are accrued”, according to the ACC statement.