Underutilization of Gastroprotective Strategies in Aspirin Users at Increased Risk of Upper Gastrointestinal Complications

L. E. Targownik; C. J. Metge; S. Leung

Disclosures

Aliment Pharmacol Ther. 2008;28(1):88-96. 

In This Article

Results

We identified a total of 7826 subjects who met our initial entry criteria, including 7189 with no history of admission for complications of PUD and 637 with a history of hospital admission for complications of PUD. Of the total 4137 (3500 without a history of PUD, 637 with PUD) surveys distributed, 1436 surveys were returned with analysable data, for an overall response rate of 35%. The response rate was slightly lower among subjects with a known history of hospital admissions presumed caused by PUD than for subjects with no history of PUD. (198/637, 31% vs. 1238/3500, 35%). Respondents were slightly more likely to be male and to live in an urban centre than were nonrespondents ( Table 1 ).

A flow sheet describing the characteristics of respondents is shown in Figure 1. Aspirin use was frequent among both our survey cohorts, although use among subjects with a history of hospital admission for PUD and its complications was significantly lower than in subjects with no history of similar hospital admissions (78% vs. 89%, P < 0.001). Most aspirin use in both cohorts was low-dose (81 mg or less) aspirin, though the proportion of low-dose aspirin users was higher in the subjects with a prior history of admission for complications of PUD (79% vs. 67%, P = 0.004). Ninety-six per cent of aspirin users reported taking aspirin on a daily basis.

Flow sheet for survey subjects.

Demographic and clinical characteristics of responders with and without a prior history of PUD are shown in Table 2 . Among all aspirin users, 71% had at least one other risk factor in addition to underlying cardiac disease for the development of aspirin-related UGI complications, with the distribution of risk factors being shown in Figure 2. Thirty-one per cent of subjects had two or more risk factors, and 10% had three or more risk factors. Overall, 23% of aspirin users who had at least one risk factor for aspirin-related UGI complications had been prescribed a PPI in the previous 90 days. Among aspirin users with a history of hospital admission for PUD, only 56% had been prescribed a PPI in the previous 90 days, vs. 20% of subjects with no history of hospital admission for PUD (P = 0.001) Among subjects with no history of PUD, there was a trend towards increasing likelihood of a recent dispensation for PPIs with an increasing number of risk factors for gastrointestinal complications (Figure 3). Seventy-five per cent of subjects were aware that aspirin could cause severe gastrointestinal side effects. However, only 19% of these subjects who had additional risk factors besides previous PUD believed that they were at high risk of developing gastrointestinal complications, and only 39% of subjects with a prior history of PUD recognized their being at increased risk of ASA-related UGI events.

Logistic regression analyses reveal that a history of PUD is most strongly associated with the likelihood of being prescribed a PPI among aspirin users (OR 4.51, 95% CI 2.96-6.87). Other variables predictive of being prescribed a PPI include oral corticosteroid use (OR 2.13, 95% CI 1.04-4.34), self-reported very poor or poor health (OR 2.09, 95% CI 1.31-3.34), clopidogrel use (OR 1.66, 95% CI 1.09-2.52), female gender (OR 1.39, 95% CI 1.02-1.89) and age over 70 (OR 1.35, 95% CI 1.01-1.82). Reporting active gastro-oesophageal reflux disease symptoms (OR 1.25, 95% CI 0.88-1.79), dyspepsia which had been ascribed to aspirin therapy (OR 1.14, 95% CI 0.68-1.93), or use of aspirin at doses of ≤81 mg per day (OR 0.96, 95% CI 0.74-1.26) was predictive of PPI use.

Distribution of risk factors among aspirin users both with and without a prior history of hospital admission for peptic ulcer disease.* *For patients with PUD, the number of risk factors is in addition to a history of PUD. Risk factors include chronic use of NSAIDs (including COX-2 inhibitors), warfarin, systemic corticosteroids, clopidogrel, age ≥70, and major chronic medical comorbidities in addition to cardiac disease (including respiratory, renal, hepatic, autoimmune diseases and/or active malignancy).

The likelihood of being prescribed a proton pump inhibitor in the previous 90 days according to the number of additional risk factors* for aspirin-related upper gastrointestinal complications. *For patients with PUD, the number of risk factors is in addition to a history of PUD. Risk factors include chronic use of NSAIDs (including COX-2 inhibitors), warfarin, systemic corticosteroids, clopidogrel, age ≥70, and major chronic medical comorbidities in addition to cardiac disease (including respiratory, renal, hepatic, autoimmune diseases and/or active malignancy).

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