What about patients that actually do need to take multiple blood thinners, such as warfarin and clopidogrel? Researchers cite a decade-old expert consensus that recommends something just a minority of clinicians are doing: adding a proton pump inhibitor such as omeprazole also known as Prilosec to help suppress acid production in the stomach.
Bleeding is a common cause of GI hospitalization that is often quite predictable beforehand. Some recent and ongoing studies are currently trying to address the specific question of whether prescribing a PPI reduces the risk of bleeding in those patients on multiple blood thinners, he adds. In the meantime, Barnes and Kurlander say anticoagulation clinics, which provided the data for this study, might be the right place to examine the underuse of PPIs among patients who take blood thinners. The anticoagulation clinics, he says, might be able to identify patients who could be candidates to reduce the number of blood thinner medications or prescribe PPIs, and then reach out to the prescribing doctors to see if one of those actions is appropriate.
His research team is currently testing this within the Michigan Anticoagulation Quality Improvement Initiative. Anticoagulant drugs such as warfarin and apixaban slow down blood clotting, while antiplatelets such as aspirin and clopidogrel prevent platelets from clumping. Both types of blood thinners are commonly used to prevent strokes in patients with heart conditions.
The Mayo team of researchers and physicians analyzed , patients receiving blood-thinning medication between Oct. After one year, patients being treated for both atrial fibrillation and coronary artery disease , for example, had a similar risk of bleeding 4 percent when getting just an anticoagulant or just an antiplatelet, but a 7. Only 29 patients with atrial fibrillation and coronary artery disease would need to be treated with an anticoagulant and antiplatelet in combination to cause one additional bleeding event, according to the study.
The study also found that patients 75 and older were twice as likely as younger patients to have gastrointestinal bleeding when on two blood thinners. Patients were at a similar risk for bleeding when using just an anticoagulant or just an antiplatelet drug, the researchers say.
Abraham says. Study co-investigators are Nilay Shah, Ph. Her labs show a new anemia at hemoglobin level 6. She is transfused several units of packed red blood cells and fresh frozen plasma without further bleeding. She undergoes an esophagogastroduodenoscopy EGD and colonoscopy, which are notable only for extensive diverticulosis. An year-old male with coronary artery disease status post-percutaneous coronary intervention, with placement of a drug-eluting stent several years prior, is admitted with multiple weeks of epigastric discomfort and acute onset of hematemesis.
His laboratory tests are notable for a new anemia at hemoglobin level 6. Urgent EGD demonstrates a bleeding ulcer, which is cauterized.
He is started on a proton-pump inhibitor PPI. He inquires as to when he can restart his home medications, including aspirin. Gastrointestinal GI bleeding is a serious complication of anticoagulant and antiplatelet therapy.
Risks for GI bleeding include older age, history of peptic ulcer disease, NSAID or steroid use, and the use of antiplatelet or anticoagulation therapy. Although there is consensus on ceasing anticoagulant and antiplatelet agents during an acute GI bleed, debate remains over the appropriate approach to restarting these agents.
A recent study published in Archives of Internal Medicine supports a quick resumption of anticoagulation following a GI bleed. After adjusting for various clinical indicators e.
Of note, in those patients restarted on warfarin, the mean time to medication initiation was four days following the initial GI bleed. In those not restarted on warfarin, the earliest incidence of thrombosis was documented at eight days following cessation of anticoagulation. Though its clinical implications are limited by the retrospective design, this study is helpful in guiding management decisions. Randomized control trials and society recommendations on this topic are lacking, so the decision to resume anticoagulants rests on patient-specific estimates of the risk of recurrent bleeding and the benefits of resuming anticoagulants.
Among patients using oral anticoagulants alone, the risk of hospitalization for upper GI tract bleeding is highest with rivaroxaban Xarelto and lowest with apixaban Eliquis.
Cotherapy with a PPI reduces the risk among patients using any oral anticoagulant. The risk of serious upper GI tract bleeding associated with individual anticoagulant drug choice with or without PPI cotherapy is uncertain. These investigators analyzed the U. Medicare beneficiary files of patients 30 years or older who initiated oral anticoagulation treatment with apixaban, dabigatran Pradaxa , rivaroxaban, or warfarin Coumadin.
The primary outcome of interest was hospitalization for upper GI tract bleeding that is potentially preventable by PPI cotherapy, including esophagitis, peptic ulcer disease, and gastritis. Multiple analyses occurred to control for covariates, including cardiovascular disease, low-dose aspirin prophylaxis, frailty, alcohol abuse, liver disease, history of previous upper GI tract bleeding, current use of other medications that affect bleeding risk e.
A total of 1,, patients had 1,, new episodes of oral anticoagulant treatment from January 1, , through September 30, The mean age of the patients was In patients receiving anticoagulant treatment without PPI cotherapy, the adjusted incidence of hospitalization for upper GI tract bleeding was significantly higher in those who received rivaroxaban compared with those who received dabigatran, warfarin, or apixaban per 10, person-years vs.
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