Peter Rothwell (University of Oxford, Oxford, UK) and colleagues report in The Lancet that long-term use of aspirin in people aged 75 or older is associated with a higher than expected risk of disabling or fatal bleeding. They add that, to counter this risk, patients over 75 who take aspirin on a daily basis should be prescribed a proton-pump inhibitor to reduce the risk of bleeding.
The Oxford Vascular Study followed 3,166 patients who had previously had a stroke or a myocardial infarction and were prescribed antiplatelet drugs (mostly aspirin). Half the patients were aged 75 or older at the start of the study. Over 10 years of the study, a total of 314 patients were admitted to hospital for bleeding. The risk of bleeding, in particular the risk of fatal or disabling bleeding, increased with age.
For patients under 65 taking daily aspirin, the annual rate of bleeds requiring hospital admission was approximately 1.5%. However for patients aged 75–84, the annual rate rose to approximately 3.5% and to 5% for patients aged over 85. Similarly, the annual rate of life-threatening or fatal bleeds was less than 0.5% for patients aged younger than 65 years whereas but rose to approximately 1.5% for patients aged 75–84 and to nearly 2.5% for patients aged 85 or over.
The outcome of non-fatal bleeds was also worse at older ages. The proportion of survivors for whom a bleed resulted in a new, or sustained increase in disability, rose from 3% (4/157) for people aged younger than 75 to 25% (46/183) for people aged over 75. Overall, the risk of disabling or fatal bleeding over 10 years was 10 times higher at ages 75 years or older, compared with younger patients.
Rothwell says: “We have known for some time that aspirin increases the risk of bleeding for elderly patients. But our new study gives us a much clearer understanding of the size of the increased risk and of the severity and consequences of bleeds. Previous studies have shown there is a clear benefit of short term antiplatelet treatment following a heart attack or stroke. But our findings raise questions about the balance of risk and benefit of long-term daily aspirin use in people aged 75 or over if a proton-pump inhibitor is not co-prescribed. However, suddenly stopping medication is definitely not advised, so patients should always talk to their doctors.”
However, Rothwell et al note that use of a proton pump inhibitor could help to reduce the risk of bleeding associated with aspirin. They conclude that for patients aged 75 or older, major upper gastrointestinal bleeding as a result of antiplatelet therapy was at least as likely to be disabling or fatal as recurrent ischaemic stroke if a proton pump inhibitor (PPI) is not co-prescribed. Acknowledging that there are potential risks with prescribing PPIs long-term, the authors state that the benefits of PPIs outweigh these risks and that guidelines should recommend the co-prescription of PPIs in this age group.
“While there is some evidence that long-term PPI use might have some small risks, this study shows that the risk of bleeding without them at older ages is high, and the consequences significant. In other words, these new data should provide reassurance that the benefits of PPI use at older ages will outweigh the risks,” Rothwell comments.