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Identifying and treating the potentially life-threatening problem of gastrointestinal complications in patients who use the combination 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, which was published online on Oct. 6.

Ulcerations 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, according to Dr. Deepak L. Bhatt, document cochair, and his colleagues on the consensus document writing committee (J. Am. Coll. Cardiol. 2008 [doi:10.1016/j.jacc.2008.08.002]).

"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," Dr. Bhatt, chief of cardiology at VA Boston Healthcare System, noted in the statement. "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, Dr. David Johnson, 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 between cardiologists, gastroenterologists, and primary care physicians to improve patient safety. Likewise, patients must be informed of the importance of disclosing all medication information.

The organizations made recommendations for the following scenarios:

• GI complications of aspirin and of combined aspirin and nonaspirin NSAIDs.
  Gastroprotective therapy should be prescribed for at-risk patients on low-dose aspirin, and those using any NSAIDs along 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.
• 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, and the combination should be used with an "established vascular, arrhythmic, or valvular indication." Concomitant proton pump inhibitor (PPI) therapy is advised.
• GI effects of clopidogrel and clopidogrel plus anticoagulant therapy.
  Clopidogrel should not be substituted 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 risks. 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 asses the risk of bleeding against the risk of thrombosis in regard to the timing of antiplatelet therapy cessation.

When asked to comment on this article, Dr. Ali F. AbuRahma, chief of vascular and endovascular surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, stated: "This is an extremely important contribution to the clinical practice of every vascular specialist. Many of our patients are on antiplatelet therapy, and a significant number take a combination of aspirin and Plavix. Some are also on warfarin for cardiac reasons. A combination of both antiplatelet agents, aspirin, and Plavix adds to the risk of GI side effects, and when warfarin is added, the risk increases significantly. I am certain that the side effects of this combination therapy are being underestimated by both the public and physicians.