Aspirin doubles risk for upper GI bleeding events in older adults
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Aspirin almost doubles the risk for serious upper gastrointestinal bleeding in older people and can further increase with age, smoking, chronic kidney disease and NSAIDs, according to data from Digestive Disease Week.
“This study confirms that among older adults, low dose aspirin is associated with an increased risk of gastrointestinal bleeding with the risk highest among those who smoke and have high blood pressure or kidney disease,” Andrew T. Chan, MD, chief, clinical and translational epidemiology unit director of cancer epidemiology at Massachusetts General Cancer Center, told Healio Gastroenterology.
Chan and colleagues assessed data on 19,114 patients from Aspree, an aspirin primary prevention trial. In the trial, 9,525 patients were randomly assigned to receive aspirin while 9,589 received placebo. Annually, investigators collected baseline clinical characteristics and a physician panel standardized and adjudicated GI bleeding events. The incidence of upper and lower GI bleeding was calculated. Then, predictors were identified with Cox regression analyses and the absolute risk for bleeding based on age and risk factors was modeled.
Of the 264 reported serious GI bleeding events, 137 were upper GI events (aspirin group n = 89, placebo group n = 48; HR = 1.87; 95% CI, 1.32-2.66) and 127 were lower GI events (aspirin group n = 73, placebo group n = 54; HR = 1.36; 95% CI, 0.96-1.94). Age, smoking, chronic kidney disease and NSAID use were risk factors for upper GI bleeding while age, smoking and hypertension were risk factors for lower GI bleeding, according to multivariate analyses. Proton pump inhibitor use was not linked to reduced bleeding events.
Chan and colleagues reported that the absolute, 5-year serious bleeding risk was 0.2% for 70-year-olds and 0.4% if patients were on aspirin, and up to 5.5% for 80-year-olds on aspirin with significant risk factors.
“Because this study was a rigorously performed randomized controlled trial, it provides more accurate estimates of the absolute risk of bleeding among individuals who initiate aspirin at an older age,” Chan said. “This will be useful for further studies to appropriately weigh the risks and benefits of low dose aspirin treatment."
Reference:
Mahady SE, et al. Abstract 337. Presented at: Digestive Disease Week; May 2-5, 2020; Chicago (meeting canceled).
Perspective
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Carole Macaron, MD
While aspirin’s efficacy in preventing recurrent cardiovascular events has been established, its role for primary cardiovascular prevention, especially in the elderly, is not well defined. The Aspree trial in 2018 shed the light on the risk of clinically significant gastrointestinal bleed, defined as bleeding that required transfusions, hospitalizations, or lead to death, among the healthy older adults who received low dose aspirin for primary prevention. GI bleeding accounted for nearly half of the major bleeding events in the trial. The study also did not demonstrate a significant protective cardiovascular effect of aspirin in the healthy elderly. The new analysis from the Aspree trial presented at Digestive Disease Week this year quantified the risk for major gastrointestinal bleeding to be twice as high in the healthy older participants who received low dose aspirin compared with placebo. Particularly, older adults who smoke, have high blood pressure, chronic kidney disease, and those who concomitantly use anti-inflammatory agents were at the highest risk for major upper or lower GI bleed. Proton pump inhibitors use did not decrease the risk for bleeding events.
The bottom line is that even low dose aspirin can cause major bleed in the healthy elderly. Focusing on smoking cessation, controlling high blood pressure, and lifestyle modification would be a more prudent approach to help prevent heart attacks and stroke particularly in the group of older adults at the highest risk for bleeding.
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