New Guidelines Released for Heart Patients using common anti-inflammatory medications In order to reduce the risk of ulcers and gastrointestinal (GI) bleeding, the American College of Cardiology in collaboration with the American College of Gastroenterology and the American Heart Association has developed guidelines outlining a stepwise approach for patients using nonsteroidal anti-inflammatory drugs (NSAIDs, such as naproxen and ibuprofen) along with antiplatelet agents (such as aspirin and Plavix).

Antiplatelet drug treatment, which reduces the blood’s ability to clot, is considered a cornerstone in the care of heart patients – helping prevent heart attacks and strokes.  Combinations of antiplatelet agents (usually aspirin plus Plavix) are also recommended after patients receive coronary artery stents to prevent dangerous clotting at the site of implantation.

NSAIDs – the most widely used class of medications in the United States – can reduce fever, pain, and inflammation (swelling and redness). Some are available over the counter, while others require a prescription. The best-known NSAID is aspirin (which also acts as an antiplatelet agent). Other common NSAIDs are ibuprofen, ketoprofen and naproxen.  Celebrex is an example of a prescription NSAID.

Many Americans who survive and live with heart disease have conditions (such as arthritis and muscular pain) that also require them to take NSAIDs.  Gastrointestinal bleeding is a major and potentially life-threatening complication for patients taking antiplatelet and NSAID therapy together. Patients taking low-dose aspirin plus NSAIDs have a two- to four-fold increased risk of gastrointestinal bleeding compared with those not taking these medications

Managing GI risk, therefore, is becoming an increasingly important part of cardiovascular care.

“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,” said Deepak L. Bhatt, M.D., document co-chair and chief of cardiology, VA Boston Healthcare System. “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.”

Here are some highlights from the guidelines:

1. Because the use of any NSAID (whether prescription or over-the-counter) in conjunction with aspirin substantially increases the risk of ulcer complications, medications to reduce the risk of GI bleeding should be prescribed for at-risk patients.

2. Proton pump inhibitors (such as Prilosec, Prevacid, Nexium, etc.) are considered the preferred medications for treating and reducing the risk of NSAID and aspirin-associated gastrointestinal injury.

3. Even the use of low-dose aspirin alone is associated with an increased risk of GI bleeding. Enteric-coated or buffered preparations do not reduce the risk of bleeding. For patients at risk of adverse events, proton pump inhibitors should be prescribed. The risk of GI bleeding increases with higher aspirin dose; therefore, for long term use doses greater than 81 mg should be avoided.

4. The combination of aspirin and Coumandin (warfarin) is associated with a significantly increased risk of bleeding events, especially from the upper GI tract. Patients who require this combination therapy should always receive concomitant proton pump inhibitors.

5. Substitution of Plavix for aspirin is not a recommended strategy to reduce the risk of recurrent ulcer bleeding in high-risk patients, and is inferior to the combination of aspirin with proton pump inhibitors.

6. In patients with history of stomach ulcer disease, testing for and eradicating H. pylori (a bacteria commonly present in the lining of the stomach in patients with ulcers) is recommended before starting long term antiplatelet therapy.

7. The risk of bleeding from antiplatelet medications needs to be weighed against the potential significant benefit of mild blood thinning in individual patients.  Good communication between cardiologists, gastroenterologists, and primary care physicians is important, especially in patients with a prior history of GI bleeding.

These recommendations are part of an ongoing dialogue between the three collaborating organizations and, according to the authors, will be updated as more definitive data are accrued. 

It should be noted that according to a recent survey, 18 percent of patients fail to report recent use of non-prescription NSAIDs, and this can greatly complicate attempts to manage risk. It is always in a patient’s best interest to be forthcoming and complete when reporting all of the medications they use (including any over-the-counter preparations and any supplements). 

Sources:

American College of Cardiology Press Release, 2008