The following are 12 points to remember about this expert consensus document:
- Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin (ASA), are the most widely used class of medications in the United States.
- As the use of any NSAID—including COX-2-;selective agents and over-the-counter doses of traditional NSAIDs, in conjunction with cardiac-dose ASA—substantially increases the risk of ulcer complications, a gastroprotective therapy should be prescribed for at-risk patients.
- The use of low-dose ASA for cardioprophylaxis is associated with a two- to fourfold increase in upper gastrointestinal event (UGIE) risk. Enteric-coated or buffered preparations do not reduce the risk of bleeding. For patients at risk of adverse events, gastroprotection should be prescribed. The risk of UGIE increases with ASA dose escalation; thus, for the chronic phase of therapy, doses greater than 81 mg should not be routinely prescribed.
- The combination of aspirin and anticoagulant therapy (including unfractionated heparin, low molecular weight heparin, and warfarin) is associated with a clinically meaningful and significantly increased risk of major extracranial bleeding events, a large proportion from the upper GI tract. This combination should be used with established vascular, arrhythmic, or valvular indication; patients should receive concomitant proton pump inhibitors (PPIs) as well. When warfarin is added to aspirin plus clopidogrel, an international normalized ratio (INR) of 2.0-2.5 is recommended.
- Substitution of clopidogrel for ASA is not a recommended strategy to reduce the risk of recurrent ulcer bleeding in high-risk patients and is inferior to the combination of ASA + PPI.
- The combination of clopidogrel and warfarin therapy is associated with an increased incidence of major bleeding when compared with monotherapy alone. Use of combination antiplatelet and anticoagulant therapy should be considered only in cases in which the benefits are likely to outweigh the risks. When warfarin is added to aspirin plus clopidogrel, an INR of 2.0-2.5 is recommended.
- PPIs are the preferred agents for the therapy and prophylaxis of NSAID- and ASA-associated GI injury.
- Testing for and eradicating H. pylori in patients with a history of ulcer disease is recommended before starting chronic antiplatelet therapy.
- Decision for discontinuation of ASA in the setting of acute ulcer bleeding must be made on an individual basis, based on cardiac risk and GI risk assessments, to discern potential thrombotic and hemorrhagic complication
- Endoscopic therapy may be performed in high-risk cardiovascular patients on dual antiplatelet therapy, and collaboration between the cardiologist and endoscopist should balance the risks of bleeding with thrombosis with regard to the timing of cessation of antiplatelet therapy.
- Overall, in appropriate patients, oral antiplatelet therapy decreases ischemic risks, but this therapy may increase bleeding complications
- Communication between cardiologists, gastroenterologists, and primary care physicians is important to weigh the ischemic and bleeding risks in an individual patient who needs antiplatelet therapy, but who is also at risk for or develops significant GI bleeding. Debabrata Mukherjee, M.D., F.A.C.C.
