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Thursday, 15 June 2017 20:25

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

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Authors conclude that proton-pump inhibitors should be co-prescribed in this age group to reduce the risk of bleeds.


aspirinqueryIn people aged 75 or over, long-term daily aspirin use is 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 that patients over 75 who take aspirin on a daily basis should be prescribed a proton-pump inhibitor to reduce the risk of bleeding.
Roughly 40-60% of adults aged 75 or older in the USA or Europe take daily aspirin or other antiplatelet drugs to prevent heart attacks or strokes. Lifelong treatment with antiplatelet drugs is recommended for patients who have previously had a heart attack or stroke (so-called secondary prevention).
The advice for lifelong treatment is based on trials mostly done in patients younger than 75, with a follow up of approximately 2-4 years. Previous studies have shown there is a causal link between antiplatelet treatment and upper gastrointestinal bleeding, and although the risk is known to increase with age, estimates on the size of the risk vary widely there are few data on whether severity of bleeding also increases with age.
Professor Peter Rothwell, lead author from University of Oxford, UK, says: “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. However, suddenly stopping medication is definitely not advised, so patients should always talk to their doctors.”
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 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.
For patients under 65 taking daily aspirin, the annual rate of bleeds requiring hospital admission was approximately 1.5%. For patients aged 75-84, the annual rate rose to approximately 3.5% and to 5% for patients aged over 85.
Similarly, the risk of disabling or fatal bleeding increased with age. For patients aged under 65, the annual rate of life-threatening or fatal bleeds was less than 0.5%. For patients aged 75-84, the rate rose to approximately 1.5%, and to nearly 2.5% for patients aged 85 or over.
The outcome of non-fatal bleeds was also worse at older ages. The proportion of survivors for whom a bleed resulted in a new, or sustained increase in disability rose from 3% (4/157) for people aged under 75, to 25% (46/183) for people aged over 75. Overall, the risk of disabling or fatal bleeding over ten years was 10 times higher at ages 75 years or older, compared to younger patients.
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.
Professor Rothwell adds: “While there is some evidence that long-term PPI use might have some small risks, this study shows that the risk of bleeding without them at older ages is high, and the consequences significant. In other words, these new data should provide reassurance that the benefits of PPI use at older ages will outweigh the risks.”
The study was an observational study, rather than a randomised trial, meaning it’s not possible for this study to show that the increased risk is entirely caused by aspirin. However, previous randomised trials have shown that at least half of bleeds occurring on aspirin are due to the medication. The authors note that the majority of patients in the study were taking aspirin (75mg enteric coat) with only a few patients taking clopidogrel, meaning that the findings may not apply to other antiplatelet drugs. Additionally, the findings did not take into account the potential impact of any adverse effects linked to long-term PPI use.

Writing in a linked Comment, Professor Hans-Christoph Diener, University Duisburg-Essen, Germany says: “…the first consequence of (this) study is that the benefit-risk association in long-term antiplatelet therapy should be evaluated every 3-5 years in patients older than 75 years… The second consequence of (the) study is its support for the need to use PPIs in patients on antiplatelet therapy aged 75 years or older or in patients with a history of gastrointestinal bleeds. PPIs are underused in patients on antiplatelet therapy, perhaps because the consequences of upper gastrointestinal bleeds were underestimated in elderly patients who were treated with aspirin.”

Source: The Lancet

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30770-5/fulltext?elsca1=tlpr

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  • Postgrad course on exercise as medicine is being proposed

    Dear prospective applicant,

    A proposal for a postgrad course on physical activity (PA) as a therapy for non-communicable diseases is currently being evaluated. Hereunder, a two-question survey is being forwarded for your attention in order to assess whether the idea sounds appealable or not.

    Proposed award

    M.Sc in Therapeutic Physical Activity (TPA), with postgrad certificate (PgC) and postgrad diploma (PgD) exit routes

    Proposed specialisation titles[1]

    Holders of PgC, TPA can claim the title of: ‘Clinical exercise prescriber’.

    Holders of PgD, TPA can claim the titles of: ‘Advanced exercise prescriber’ or ‘Clinical and public health exercise prescriber’.

    Holders of M.Sc, TPA can claim the title of: ‘Physical activity - health specialist’.

    Are you sure you know why physical activity is so important?

    Everyone is aware that physical inactivity is a major health concern but, do you know that through the right type of exercise you can prevent or treat at least 35 chronic conditions? In 2007 the American College of Sports Medicine officially declared an important statement: ‘Exercise is medicine’. Moreover, health-enhancing physical activity (HEPA) is important in today’s world not only in view of improving health and wellbeing but also for its economic values. For example, a lifestyle intervention involving 150 minutes of weekly PA was scientifically shown to be significantly more effective than the administration of metformin.

    Possibilities of further career development in exercise prescription

    Exercise prescription, that is, being qualified to professionally recommend the right type of exercise for health does not stop on a one-to-one basis. Do you think you are qualified to: (a) conduct research on PA interventions, and (b) develop, implement and evaluate community or population programmes involving PA strategies? Unfortunately, many wide-scale programmes that are implemented undergo no evaluation to determine how they have worked or what their effects may be. Have you ever imagined the possibility of attending a tertiary course which would be designed to: (a) give you the ability to design a project for the generation of new knowledge and be able to publish it internationally, or (b) train you on how to evaluate wide-scale interventions and how to apply strategies to sustain their continuities?


    A glimpse of the proposed programme of studies

    Intended for:

    The programme of studies is aimed at a wide and diverse cohort of students wishing to pursue any careers in HEPA sectors mainly: exercise prescription; health promotion (policies and practice); general health and fitness industry; and to further their studies (e.g. PhD). It can also serve as an adjunct to enrich one’s knowledge of his / her established profession or career. Examples include: medical practitioners; pharmacists; nurses; physiotherapists; nutritionists; public health specialists; sport medicine specialists; sport psychologists; teachers of physical education (PE); coaches; gym instructors; and personal trainers. Fitness and sport enthusiasts are also encouraged to apply.

    Duration:

    Three years part-time leading to an M.Sc in PA as an effective therapy, with postgrad certificate and postgrad diploma exit routes after the first and second years respectively.

    Mode of delivery:

    Seventy per cent will be delivered online and the rest of the thought units will be offered on a once weekly two-hour evening basis starting at 18.00hrs.

    Admission criteria:

    You should provide evidence of higher educational qualification(s) - normally, a diploma or a degree related to health and / or PA / sport. An award in PE is also ideal. Mature students without these basic qualifications would be required to present evidence of experience related to PA and health.

    Mode of assessment:

    Units will be assessed through the submission of coursework. These will vary from short assessments to long essays. If you would like to progress at Masters’ level, a traditional dissertation or paper in the format for journal publication and a final presentation (in the form of slides or poster) of your research findings will have to be undertaken.

    Round-up

    Unlike other under- and postgrad courses which only cover a fraction from the whole science of HEPA, this comprehensive programme of studies would lead to a specialization specifically on TPA. For careers in promotion, prescription and research of PA, the proposed programme of studies is a must.

    Important notice

    All the above information is subject to change and would eventually have to be approved by the Programme Validation Committee of the University of Malta. Needless to say, your feedback in the next two questions is extremely important.

    Yours in health & exercise,

    Charles Micallef B.Pharm (Hons), M.Sc PAPH (Staff)                                                8th August 2017

    The two questions hereunder.

    1. In view of the above information, would you be interested in applying for this particular postgrad course leading to a specialisation in physical activity with respect to health, that is, a qualification that gives you the right to prescribe exercise for health, even at population levels?

    Yes or No: 

    1. What would you change from or suggest to what is being proposed?

    Please state your name & surname:

    Your current job / profession:

    Please save your changes and forward your reply to Charles Micallef on: This email address is being protected from spambots. You need JavaScript enabled to view it.

    Your cooperation is greatly appreciated.


    [1] In order to professionally recommend exercise for health, you may need to be registered in the appropriate regulatory board and be in possession of a warrant to operate with the respective titles.

    University of Malta

    Written on August 19, 2017
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