New program helps mitigate GI bleeding in patients on anti-thrombotic therapy

One in 7 patients over age 65 will develop ulcers with bleeding, perforation or obstruction related to the use of nonsteroidal anti-inflammatory drugs. Gastrointestinal (GI) bleeding is the most common reason for acute gastrointestinal hospital admission and a significant cause of morbidity and mortality. The risk is greatest for cardiac patients on complex anti-thrombotic therapy (CAT).

"As baby boomers age, they're developing multiple cardiac comorbidities that are treated not just with aspirin monotherapy but also with aspirin in dual and triple combination with anti-platelets and anticoagulants. The increased use of these combination therapies is a major risk factor for gastrointestinal bleeding," says Neena S. Abraham, M.D., who heads Mayo Clinic's cardiogastroenterology program in Scottsdale, Arizona.

In a study that appeared in the Oct. 22, 2013, issue of Circulation, Dr. Abraham and colleagues found that the risk of upper and lower GI bleeding was 40 to 60 percent higher in older men undergoing CAT therapy compared with controls. The risks of hospitalization and blood transfusion were also significantly increased.

Dr. Abraham notes that although the benefits of anti-thrombotic treatments are well-established, the risks, especially GI bleeding, are downplayed or not understood, making it crucial that cardiologists and gastroenterologists work together to decide the best approach for patients.

To that end, in 2008, the American College of Cardiology (ACC), American College of Gastroenterology (ACG) and American Heart Association (AHA) published consensus recommendations to help physicians minimize anti-platelet-related bleeding risks. A primary recommendation was the concomitant use of proton pump inhibitors (PPIs) in high-risk patients — those with a prior history of GI bleeding, older age, Helicobacter pylori infection, or concurrent use of aspirin, anticoagulants or steroids.

The recommendation proved controversial when observational studies questioned the safety of co-prescribing a PPI and clopidogrel based on a mutual cytochrome P-450-dependent metabolism. But subsequent randomized controlled trial data have demonstrated that the observed increase in cardiac events among PPI users was due to genetic differences in the ability to metabolize the anti-platelet medication, not a drug-drug interaction.

Because these later studies demonstrate that PPI gastroprotection can reduce the risk of GI bleeding as much as 66 percent in patients prescribed aspirin plus anti-platelet agents, Dr. Abraham recommends PPI gastroprotection for patients at high risk — a recommendation endorsed in the updated 2010 ACC, ACG, AHA guidelines. Furthermore, the collaborative process involved in developing the recommendations significantly influenced the clinical treatment of cardiac patients.

"I think before that time, gastroenterologists and cardiologists were in their own silos, each telling their side of the risk-benefit equation but not really engaging patients or each other in a collaborative fashion," Dr. Abraham says. That led her to the idea of a multidisciplinary clinic for cardiac patients at risk of upper and lower GI bleeding and, in 2013, to the establishment of Mayo Clinic's cardiogastroenterology program in Arizona, the only one of its kind in the United States.

What the cardiogastroenterology program offers

The program specializes in GI bleeding management and periendoscopic management of patients with significant cardiac issues. Services include:

  • Colorectal cancer screening for patients with more than three Framingham criteria
  • Endoscopic management of patients unable to withdraw from anti-thrombotic regimens
  • Risk modification for patients who take novel anticoagulants or have multiple cardiac stents

Patients referred to the program are assessed for GI risk factors, and those risks are minimized immediately. Careful endoscopic evaluations also are performed to map the GI tract before GI bleeding occurs to identify potential mucosal defects and anatomic alterations, so "if a patient does bleed, we can address that in the most specific fashion instead of (as) a shot in the dark," Dr. Abraham says.

She stresses the individualized care each patient receives. "One size does not fit all. Each patient is different. It really does require thought, care and full engagement with patients," she explains. "My objective is to individualize care, and I practice shared decision-making with every patient at every single visit. We use an iterative process of negotiation, with full involvement of cardiologists, to help patients make the right decision regarding anti-thrombotic regimens."

Dr. Abraham points out that shared decision-making is the foundation of patient-centered health care and that physicians need to become comfortable with it. "It's incredibly important to learn how to engage patients because when they're trying to decide which is the lesser of two evils, you can't impose your impressions on them. You can help frame the information, but then you engage in conversation and pull out what is important to them and negotiate a regimen that works for them.

"These techniques are not taught in medical school, but they need to be as patients live longer and develop more comorbid complications. We need to start working with patients instead of prescribing things in isolation. The right care is the right care for that particular patient."

For more information

Abraham N, et al. Risk of lower and upper gastrointestinal bleeding, transfusions and hospitalizations with complex antithrombotic therapy in elderly patients. Circulation. 2013;128:1869.

Bhatt D. AACF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2008;118:1894.

Abraham N, et al. ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: A focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: A report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation. 2010;122:2619.