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aspirin and gastrointestinal bleeding

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1. Acetylsalicylic acid (ASA)

Acetylsalicylic acid (ASA) © 2020 Thrombosis Canada Page 1 of 6 ACETYLSALICYLIC ACID (ASA) OBJECTIVE: To provide information on the use of acetylsalicylic acid in the prevention of vascular thromboembolic events. BACKGROUND: Acetylsalicylic acid (ASA) is well-established in the management of acute myocardial infarction and in the secondary prevention of cardiovascular disease among both men and women, based on large randomized trials. ASA may also be considered in selected patients (...) of ASA • Dyspepsia © 2020 Thrombosis Canada Page 3 of 6 • The most common serious adverse effect of ASA is bleeding into the gastrointestinal tract (which is dose-related) • Allergic reactions, aspirin-induced asthma (may be severe) PERI-PROCEDURAL MANAGEMENT FOR PATIENTS TAKING ASA: Patients receiving ASA and: 1) undergoing an invasive diagnostic test, i. associated with a low risk of bleeding, should continue ASA without interruption. ii. associated with a high risk of bleeding, should discontinue

2020 Thrombosis Interest Group of Canada

2. Canadian Stroke Best Practice recommendations, seventh edition: acetylsalicylic acid for prevention of vascular events

% more people die of heart conditions, stroke or vascular cognitive impairment than die from all cancers combined. 1 The benefits of acetylsalicylic acid (ASA) for secondary pre- vention of atherosclerotic cardiovascular disease are well estab- lished. In contrast, although low-dose ASA therapy for primary prevention of atherosclerotic cardiovascular disease was once commonly recommended, this practice is now being recon- sidered in light of recent evidence. Three large randomized con- trolled trials (...) -dose ASA reduces the risk of vascular events including myocardial infarction, stroke and vascular death in patients who have had a previous vascular event. The Antithrombotic Trialists’ Collaboration (2002) has meta-analyzed data from many large trials showing consistent effects of ASA on preventing recurrent cardiovascular events. 11 For example, treatment with ASA instead Box 1: Recommendations for the use of acetylsalicylic acid (ASA) in the prevention of vascular events* Secondary prevention

2020 CPG Infobase

3. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Digestive PPI proton pump inhibitor PUB peptic ulcer bleeding RBC red blood cell RCT randomized controlled trial RD riskdifference RR relative riskor risk ratio TAE transcatheter angiographicembolization TTS through-the-scope TXA tranexamic acid UGIH upper gastrointestinal hemorrhage VKA vitamin K antagonist Guidelines Gralnek Ian M et al. Endoscopic diagnosis and … Endoscopy 2021; 53 | © 2021. European Society of Gastrointestinal Endoscopy. All rights reserved.?Table1 (...) antiplatelet agent/s (APA/s) Upper GI endoscopy demonstrates nonvariceal source of hemorrhage, e.g. peptic ulcer High risk endoscopic stigmata diagnosed (FIa, FIb, FIIa, FIIb – active spurting/oozing bleeding, nonbleeding visible ulcer, adherent clot) Low dose aspirin used for primary prophylaxis (a) Continue to withhold low dose aspirin (b) Resume low dose aspirin after careful re-evaluation of its clinical indication Low dose aspirin used for primary prophylaxis (a) Continue to withhold low dose aspirin

2021 European Society of Gastrointestinal Endoscopy

4. Rivaroxaban (Xarelto) - Co-administered with acetylsalicylic acid for the prevention of atherothrombotic events in adult patients

acid) reduced the incidence of a composite outcome that included stroke, cardiovascular death and myocardial infarction, mainly due to reductions in stroke and cardiovascular death. It also increased the incidence of major bleeding. Chairman Scottish Medicines Consortium www.scottishmedicines.org.uk 2 Indication Co-administered with acetylsalicylic acid (aspirin) for the prevention of atherothrombotic events in adult patients with: - coronary artery disease, or - symptomatic peripheral artery (...) submission rivaroxaban (Xarelto ® ) is accepted for restricted use within NHSScotland. Indication under review: Co-administered with acetylsalicylic acid for the prevention of atherothrombotic events in adult patients with: - coronary artery disease, or - symptomatic peripheral artery disease at high risk of ischaemic events. SMC restriction: use in patients with stable coronary artery disease that does not require dual antiplatelet therapy. Addition of rivaroxaban to low-dose aspirin (acetylsalicylic

2019 Scottish Medicines Consortium

5. Misoprostol Heals Small Bowel Ulcers in Aspirin Users With Small Bowel Bleeding Full Text available with Trip Pro

Misoprostol Heals Small Bowel Ulcers in Aspirin Users With Small Bowel Bleeding There is no effective treatment for aspirin-induced small bowel ulcer bleeding. We performed a double-blind, randomized, placebo-controlled trial to determine whether misoprostol can heal small bowel ulcers in patients with small bowel bleeding who require continuous aspirin therapy.We performed a prospective study of 84 aspirin users with small bowel bleeding who required continued aspirin therapy in Hong Kong (...) [range, 0-25]) than in the placebo group (from 7 [range, 1-29] to 4 [range, 0-19] (P = .005).In a double-blind, randomized, placebo-controlled trial, we found misoprostol to be superior to placebo in promoting healing of small bowel ulcers among aspirin users complicated by small bowel ulcer bleeding who require continuous aspirin therapy. However, use of misoprostol alone would provide only limited protection against aspirin on the small bowel. ClinicalTrials.gov ID NCT01998776.Copyright © 2018 AGA

2018 EvidenceUpdates

6. Major GI bleeding in older persons using aspirin: incidence and risk factors in the ASPREE randomised controlled trial

people using aspirin. We calculated the incidence, risk factors and absolute risk using data from a large randomised, controlled trial. Design: Data were extracted from an aspirin versus placebo primary prevention trial conducted throughout 2010-2017 ('ASPirin in Reducing Events in the Elderly (ASPREE)', n=19 114) in community-dwelling persons aged ≥70 years. Clinical characteristics were collected at baseline and annually. The endpoint was major GI bleeding that resulted in transfusion (...) Major GI bleeding in older persons using aspirin: incidence and risk factors in the ASPREE randomised controlled trial Major GI bleeding in older persons using aspirin: incidence and risk factors in the ASPREE randomised controlled trial - PubMed This site needs JavaScript to work properly. Please enable it to take advantage of the complete set of features! Clipboard, Search History, and several other advanced features are temporarily unavailable. COVID-19 is an emerging, rapidly evolving

2020 EvidenceUpdates

7. The Risk of Gastrointestinal Hemorrhage in Low-Dose Aspirin Users with Diabetes Mellitus: Systematic Review and Meta-Analysis Full Text available with Trip Pro

of aspirin in all patients with coronary artery disease [ – ]. The definition of “low-dose aspirin” is based on the North American formulation of single analgesic-strength tablets [ ]. Most clinicians recommend a 100 mg tablet or less as the maximum daily dosage for treatment. Nonetheless, long-term therapy with aspirin is reported to carry a risk of gastrointestinal (GI) adverse effects, including ulceration and bleeding [ – ]. Derry’s research of a meta-analysis suggests that GI hemorrhage occurred (...) was not significant ( , ; ). Figure 2 Forest plot of researches comparing GI hemorrhage in aspirin users with or without DM. The summary odds ratio and its 95% confidence interval were conducted in a Fixed Effect model by the Mantel-Haenszel method. Case, gastrointestinal bleeding patients. Control, no gastrointestinal bleeding patients. Events, diabetics. Figure 3 Funnel plot of heterogeneity of studies. 3.4. Sensitivity Analysis We recalculated the pooled effected size for the analysis in which only high

2020 Gastroenterology research and practice

8. Misoprostol for small bowel ulcers in patients with obscure bleeding taking aspirin and non-steroidal anti-inflammatory drugs (MASTERS): a randomised, double-blind, placebo-controlled, phase 3 trial. Full Text available with Trip Pro

Misoprostol for small bowel ulcers in patients with obscure bleeding taking aspirin and non-steroidal anti-inflammatory drugs (MASTERS): a randomised, double-blind, placebo-controlled, phase 3 trial. The incidence of obscure gastrointestinal bleeding, which originates from the small bowel and is mainly associated with the use of aspirin and non-steroidal anti-inflammatory drugs (NSAIDs), is rising. We assessed the efficacy and safety of misoprostol for the treatment of small bowel ulcers (...) and erosions in patients taking low-dose aspirin or NSAIDs with obscure gastrointestinal bleeding.In this randomised, double-blind, placebo-controlled, phase 3 trial, we recruited patients (aged ≥18 years) with small bowel ulcers who were taking low-dose aspirin, NSAIDs, or both for a minimum of 4 weeks, at University Hospital Crosshouse (Kilmarnock, UK). Eligible patients had evidence of obscure gastrointestinal bleeding (iron deficiency anaemia, a decrease in haemoglobin concentration of ≥20 × 103 mg/L

2019 The lancet. Gastroenterology & hepatology Controlled trial quality: predicted high

9. The effect of low-dose aspirin on colorectal cancer prevention and gastrointestinal bleeding according to bodyweight and body mass index: Analysis of UK primary care data. Full Text available with Trip Pro

The effect of low-dose aspirin on colorectal cancer prevention and gastrointestinal bleeding according to bodyweight and body mass index: Analysis of UK primary care data. Meta-analysis of trial data suggests that in primary cardiovascular disease (CVD) prevention bodyweight modifies low-dose aspirin's effects on colorectal cancer (CRC) and major bleeding risk. We sought to investigate whether these effects are seen in patients with or without CVD in routine clinical practice by undertaking sub (...) -analyses of data from two cohort studies with nested-case-control analyses.We followed ~200,000 new users of low-dose aspirin (75-300 mg/day) and a matched cohort of non-users to identify incident cases of CRC/upper gastrointestinal bleeding (UGIB). Adjusted relative risks (RRs) with 95% confidence intervals (CIs) were calculated for current vs. non-use of low-dose aspirin using logistic regression stratified by bodyweight/body mass index (BMI) strata.RRs (95% CIs) for CRC by bodyweight were: 0.60

2019 International journal of cardiology

10. Low-dose aspirin and risk of upper/lower gastrointestinal bleeding by bleed severity: a cohort study with nested case-control analysis using primary care electronic health records from the United Kingdom. Full Text available with Trip Pro

Low-dose aspirin and risk of upper/lower gastrointestinal bleeding by bleed severity: a cohort study with nested case-control analysis using primary care electronic health records from the United Kingdom. Risks of low-dose aspirin-associated upper and lower gastrointestinal bleeds (UGIB/LGIB) may vary by severity and presence of cardiovascular disease (CVD). No study has quantified these risks for UGIB and LGIB in the same real-world study population.Using UK primary care data, 199,049 new (...) users of low-dose aspirin (75-300 mg/day) and 1:1 matched non-users were followed to identify incident UGIB (N = 1843)/LGIB (N = 2763) cases. Nested case-control analyses compared current low-dose aspirin vs. non-use on UGIB/LGIB risk.Adjusted incidence rate ratios (ORs; 95% CIs) were 1.62 (1.42-1.86) for non-fatal UGIB, 1.63 (1.47-1.81) for non-fatal LGIB, 0.77 (0.51-1.16) for fatal UGIB, 1.29 (0.50-3.36) for fatal LGIB. For hospitalizations, adjusted ORs (95% CIs) were 1.55 (1.32-1.81) for UGIB

2019 Annals of Medicine

11. Low doses of acetylsalicylic acid increase risk of gastrointestinal bleeding in a meta-analysis

Low doses of acetylsalicylic acid increase risk of gastrointestinal bleeding in a meta-analysis Untitled Document The CRD Databases will not be available from 08:00 BST on Friday 4th October until 08:00 BST on Monday 7th October for essential maintenance. We apologise for any inconvenience.

2011 DARE.

12. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group

pylori eradication and required con- tinued antiplatelet therapy (acetylsalicylic acid [ASA]) (88). A meta-analysis of 2 trials showed that PPIs plus ASA reduced rebleeding rates versus clopidogrel alone (RR, 0.07 [CI, 0.01 to 0.34]) in patients with pre- vious ASA-associated ulcer bleeding who did not have H pylori infection or who had it successfully eradicated (90, 91). In patients with previous ASA-associated ulcer bleeding, trials found no difference between PPIs and eradication treatment (...) resuscitation to increase blood pressure to normal values may exacerbate blood loss, disrupt coagulation, andincreasemortality(23,24).Thealternativeisrestric- tive or hypotensive resuscitation, in which ?uid is given but the target end point is less than normotension. A Cochrane systematic review included 6 randomized tri- als that examined timing and volume of ?uid adminis- tration in 2128 patients with bleeding. Trials were het- erogeneous regarding patient types, clinical settings, types of ?uids

2020 Canadian Association of Gastroenterology

13. Clopidogrel/Acetylsalicylic acid Teva

demand in the presence of a high-grade fixed coronary obstruction, due to increased myocardial oxygen and nutrition requirements, such as those resulting from exertion, emotional stress, or physiologic stress (e.g., from dehydration, blood loss, hypotension, infection, thyrotoxicosis, or surgery). This Marketing Authorisation Application concerns clopidogrel/acetylsalicylic acid tablets containing clopidogrel (75 mg) and acetylsalicylic acid (ASA) (75 mg or 100 mg). Clopidogrel / Acetylsalicylic acid (...) of the extensive data available on the use of combined individual medicinal products at the dosage now being applied for in the Clopidogrel/ASA application. Safety pharmacology Safety pharmacology studies with clopidogrel did not reveal any relevant effect to the central nervous, cardiovascular, respiratory, gastrointestinal and renal systems. The targets for toxicity of acetylsalicylic acid have been identified in nonclinical studies and clinical experience has put these findings into context. Medicinal

2014 European Medicines Agency - EPARs

14. Risk for Major Hemorrhages in Patients Receiving Clopidogrel and Aspirin Compared With Aspirin Alone After Transient Ischemic Attack or Minor Ischemic Stroke: A Secondary Analysis of the POINT Randomized Clinical Trial. Full Text available with Trip Pro

in the clopidogrel plus aspirin group and 1 in the aspirin alone group); 3 of the 4 were intracranial. There were 7 intracranial hemorrhages (0.1%); 5 were in the clopidogrel plus aspirin group and 2 in the aspirin plus placebo group. The most common location of major hemorrhages was in the gastrointestinal tract.The risk for major hemorrhages in patients receiving either clopidogrel plus aspirin or aspirin alone after TIA or minor AIS was low. Nevertheless, treatment with clopidogrel plus aspirin increased (...) Risk for Major Hemorrhages in Patients Receiving Clopidogrel and Aspirin Compared With Aspirin Alone After Transient Ischemic Attack or Minor Ischemic Stroke: A Secondary Analysis of the POINT Randomized Clinical Trial. Results show the short-term risk of hemorrhage in treating patients with acute transient ischemic attack (TIA) or minor acute ischemic stroke (AIS) with clopidogrel plus aspirin or aspirin alone.To characterize the frequency and kinds of major hemorrhages in the Platelet

2019 JAMA neurology Controlled trial quality: predicted high

15. Diagnosis and management of acute lower gastrointestinal bleeding

and has no requirement for bowel preparation. As bright or dark red blood per rectum or blood mixed in with stool and haemodynamic instability may be a presentation of UGIB, senior clinical discussion should consider the appropriate- ness of upper GI endoscopy before proceeding directly to CTA in unstable patients. Bright red rectal bleeding may be indicative of an anorectal source of haemorrhage. Patients with this pres- entation should undergo direct anorectal inspection. If anoscopy and CTA do (...) endoscopy (VCE) is a non-invasive investigation that permits examination of the entire length of the small bowel in 79–90% of patients. 60 This modality is increasingly used in patients presenting with overt-obscure GI bleeding who have had negative adequate upper and lower GI endoscopy. Three RCTs support the use of VCE in patients with overt-obscure GI bleeding (documented blood loss, no cause found) and no source identified on upper and lower GI endoscopy, reporting a higher diagnostic yield than

2019 British Society of Gastroenterology

16. Risk of Gastrointestinal Bleeding and Benefit from Colorectal Cancer Reduction from Long-term Use of Low Dose Aspirin. A Retrospective Study of 612,509 Patients. (Abstract)

Risk of Gastrointestinal Bleeding and Benefit from Colorectal Cancer Reduction from Long-term Use of Low Dose Aspirin. A Retrospective Study of 612,509 Patients. Aspirin, commonly used for prevention of cardiovascular and cerebrovascular diseases, is well known to protect against development of colorectal cancer (CRC) but increases risk of gastrointestinal bleeding (GIB). This cohort study aims to evaluate the benefit of low-dose aspirin to prevent CRC and its associated risk of GIB.A (...) hazard ratio = 1.09; 95% confidence interval = 1.00 to 1.19). Subgroup analyses showed the use of acid-secreting agents significantly reduced aspirin-induced mortality.The long-term use of aspirin reduces both incidence and mortality of CRC and at the same time increases incidence and mortality risk of GIB. With combination use of acid-secreting agents, the bleeding risk can be reduced.© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

2018 Journal of gastroenterology and hepatology

17. Impact of perioperative aspirin continuation on bleeding complications in laparoscopic colorectal cancer surgery: a propensity score-matched analysis. (Abstract)

Impact of perioperative aspirin continuation on bleeding complications in laparoscopic colorectal cancer surgery: a propensity score-matched analysis. In laparoscopic surgery for colorectal cancer (CRC) for patients who receive antiplatelet therapy (APT), it remains unclear whether APT should be continued or temporarily withdrawn. We investigated the safety of perioperative aspirin continuation, specifically focused on bleeding complications.We performed retrospective analysis utilizing (...) based on our institutional committee-approved guidelines for antithrombotic management.In PSM cohorts, all patient demographics were comparable between the groups. Regarding intraoperative outcomes, we found no significant difference in operation duration (p = 0.969), blood loss (p = 0.068), and blood transfusion (p = 0.517). Postoperative overall morbidity was 20.0% and 13.3% in the cAPT and non-cAPT groups, respectively (p = 0.195). The incidence of bleeding complications was also comparable

2020 Surgical endoscopy

18. Conditioning on future exposure to define study cohorts can induce bias: the case of low-dose acetylsalicylic acid and risk of major bleeding Full Text available with Trip Pro

example seeking to emulate a "per-protocol" association between continuous versus never use of low-dose acetylsalicylic acid (ASA) and major bleeding (e.g., cerebral hemorrhage or gastrointestinal bleeding).Danish medical registry data from 2004 to 2011 were used to construct two analytic cohorts. In Cohort 1, we used information about future redemption of low-dose ASA prescriptions to identify cohorts of continuous and never-ASA users. In Cohort 2, we identified ASA initiators and non-initiators (...) Conditioning on future exposure to define study cohorts can induce bias: the case of low-dose acetylsalicylic acid and risk of major bleeding A principle of cohort studies is that cohort membership is defined by current rather than future exposure information. Pharmacoepidemiologic studies using existing databases are vulnerable to violation of this principle. We evaluated the impact of using data on future redemption of prescriptions to determine cohort membership, motivated by a published

2017 Clinical epidemiology

19. Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding

. Adolescents in whom a bleeding disorder has been diagnosed should be reminded that products that prevent platelet adhesion, such as aspirin or nonsteroidal antiinflammatory drugs, should be used only with the recommendation of a hematologist. In adolescents with known bleeding disorders, preoperative surgical evaluation, choice of hemostatic agents for control of intraoperative blood loss, and need for blood products should be determined in conjunction with a hematologist and an anesthesiologist (...) be reminded that products that prevent platelet adhesion, such as aspirin or nonsteroidal antiinflammatory drugs, should be used only with the recommendation of a hematologist ( ). Future Gynecologic and Reproductive Health Concerns In adolescents with known bleeding disorders, preoperative surgical evaluation, choice of hemostatic agents for control of intraoperative blood loss, and need for blood products should be determined in conjunction with a hematologist and an anesthesiologist. Vulvovaginal

2019 American College of Obstetricians and Gynecologists

20. Incidences, temporal trends and risks of hospitalisation for gastrointestinal bleeding in new or chronic low-dose aspirin users after treatment for <i>Helicobacter pylori</i>: a territory-wide cohort study. Full Text available with Trip Pro

Incidences, temporal trends and risks of hospitalisation for gastrointestinal bleeding in new or chronic low-dose aspirin users after treatment for Helicobacter pylori: a territory-wide cohort study. The risk of GI bleeding (GIB) in aspirin users after Helicobacter pylori (HP) eradication remains poorly defined. We characterised the incidences and temporal trends of hospitalisations for all GIB in aspirin users after HP eradication therapy.Based on a territory-wide health database, we (...) of hospitalisation for all GIB in new, chronic and non-users was 10.4, 7.2 and 4.6 per 1000 person-years, respectively. Upper and lower GIB accounted for 34.7% and 45.3% of all bleeding, respectively. Compared with chronic users, new users had a higher risk of GIB (HR with propensity score matching: 1.89; 95% CI 1.29 to 2.70). Landmark analysis showed that the increased risk in new aspirin users was only observed in the first 6 months for all GIB (HR 2.10, 95% CI 1.41 to 3.13) and upper GIB (HR 2.52, 95% CI 1.38

2019 Gut

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