Long-term daily aspirin use linked to higher bleeding risk in adults aged 75 or over

In people aged 75 or over, long-term daily aspirin use has been linked to a higher than expected risk of disabling or fatal bleeding, according to a new study in The Lancet. While short-term aspirin use after a stroke or heart attack has clear benefits, the authors say patients over 75 who take aspirin on a daily basis should be prescribed a proton-pump inhibitor (heartburn drugs) to reduce the risk of bleeding.

Professor Peter Rothwell, lead author from University of Oxford, UK, said: “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.”

The Oxford Vascular Study followed 3166 patients who had previously had a stroke or heart attack and were prescribed antiplatelet drugs (mostly aspirin). Half the patients were aged 75 or over at the start of the study. Over the 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.

Although the risk of heart attacks and strokes also increases with age, the authors 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.

PPIs could reduce upper gastrointestinal bleeding by 70–90% in patients receiving long-term antiplatelet treatment. However, prescription is not routine and only about a third of patients in the study were taking them. While there are some known risks associated with long-term PPI use, the authors conclude that the benefits of PPI use at older ages outweigh the risks, and guidelines should recommend the co-prescription of PPIs in this age group.

“However, suddenly stopping medication is definitely not advised, so patients should always talk to their doctors,” Professor Rothwell advised.

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