Joseph J.Y. Sung, MD, PhD; James Y.W. Lau, MD; Jessica Y.L. Ching, MPH; Justin C.Y. Wu, MD; Yuk T. Lee, MD; Philip W.Y. Chiu, MD; Vincent K.S. Leung, MD; Vincent W.S. Wong, MD; Francis K.L. Chan, MD
It is uncertain whether aspirin therapy should be continued after endoscopic hemostatic therapy in patients who develop peptic ulcer bleeding while receiving low-dose aspirin.
To test that continuing aspirin therapy with proton-pump inhibitors after endoscopic control of ulcer bleeding was not inferior to stopping aspirin therapy, in terms of recurrent ulcer bleeding in adults with cardiovascular or cerebrovascular diseases.
A parallel randomized, placebo-controlled noninferiority trial, in which both patients and clinicians were blinded to treatment assignment, was conducted from 2003 to 2006 by using computer-generated numbers in concealed envelopes. (ClinicalTrials.gov registration number: NCT00153725)
A tertiary endoscopy center.
Low-dose aspirin recipients with peptic ulcer bleeding.
78 patients received aspirin, 80 mg/d, and 78 received placebo for 8 weeks immediately after endoscopic therapy. All patients received a 72-hour infusion of pantoprazole followed by oral pantoprazole. All patients completed follow-up.
The primary end point was recurrent ulcer bleeding within 30 days confirmed by endoscopy. Secondary end points were all-cause and specific-cause mortality in 8 weeks.
156 patients were included in an intention-to-treat analysis. Three patients withdrew from the trial before finishing follow-up. Recurrent ulcer bleeding within 30 days was 10.3% in the aspirin group and 5.4% in the placebo group (difference, 4.9 percentage points [95% CI, âˆ’3.6 to 13.4 percentage points]). Patients who received aspirin had lower all-cause mortality rates than patients who received placebo (1.3% vs. 12.9%; difference, 11.6 percentage points [CI, 3.7 to 19.5 percentage points]). Patients in the aspirin group had lower mortality rates attributable to cardiovascular, cerebrovascular, or gastrointestinal complications than patients in the placebo group (1.3% vs. 10.3%; difference, 9 percentage points [CI, 1.7 to 16.3 percentage points]).
The sample size is relatively small, and only low-dose aspirin, 80 mg, was used. Two patients with recurrent bleeding in the placebo group did not have further endoscopy.
Among low-dose aspirin recipients who had peptic ulcer bleeding, continuous aspirin therapy may increase the risk for recurrent bleeding but potentially reduces mortality rates. Larger trials are needed to confirm these findings.
Institute of Digestive Disease, Chinese University of Hong Kong.
What happens if patients who take aspirin to prevent cardiovascular disease continue to take it after an acute gastrointestinal bleeding event?
This trial included 156 adults with cardiovascular disease, history of aspirin use, and acute peptic ulcer bleeding. Immediately after successful endoscopic treatment, they were randomly assigned to receive low-dose aspirin (80 mg/d) or placebo for 8 weeks. All patients also received pantoprazole. More aspirin recipients than placebo recipients (10% vs. 5%) had recurrent ulcer bleeding within 30 days, although fewer aspirin recipients died (1% vs. 13%).
The study was small. Some deaths in the placebo group were from causes not normally prevented by aspirin.
NSAID = nonsteroidal anti-inflammatory drug; OTC = over the counter.
* High-risk stigmata of hemorrhage included active spurting or oozing ulcer or ulcer showing protuberant vessel or adherent blood clot.
Solid circles indicate censoring. GI = gastrointestinal.
Solid circles indicate censoring. CVA = cerebrovascular; CVS = cardiovascular; GI = gastrointestinal.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Sung JJ, Lau JY, Ching JY, Wu JC, Lee YT, Chiu PW, et al. Continuation of Low-Dose Aspirin Therapy in Peptic Ulcer Bleeding: A Randomized Trial. Ann Intern Med. 2010;152:1–9. doi: 10.7326/0003-4819-152-1-201001050-00179
Download citation file:
Published: Ann Intern Med. 2010;152(1):1-9.
Gastroenterology/Hepatology, Peptic Disease, Peptic Ulcer.
Copyright © 2018 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use