Investigation of ulcer and bleeding sings in patients with non-steroidal anti-inflammatory drugs and low-dose aspirin consumption: a case-

control study Coordinator: Dr. Anca Negovan

Author: Andreea Bianca StoicaCo-authors: Drd. Monica Pantea

Adrian Stoica

Roxana Spac

Gavriela Radoiu

INTRODUCTIONNon-steroidal anti-inflammatory drugs

(NSAID) and low-dose aspirin (LDA) are well known to cause gastrointestinal mucosal injury.

The gastrointestinal side effects of NSAIDs and antiplatelet therapy are important causes of patients’ addressability to the gastroenterologist in a population with a high prevalence of Helicobacter pylori infection.

BackgroundLow-dose aspirin (ASA) is frequently used in

primary and secondary prevention of cardio-vascular and cerebro-vascular events due to the clinical evidence of benefits in decreasing mortality.

Long term treatment has some benefits such as reducing myocardial infarction, cerebro-vascular events and death caused by vascular disease, but it also has disadvantages: it can cause a higher prevalence of endoscopic upper gastrointestinal lesions.Kim C, et al. Am J Prev Med 2004

Pirmohamed M, BMJ 2004, 329:15-19

THE AIM

To determine the prevalence and severity of endoscopic upper gastrointestinal lesions in patients taking low-dose aspirin and non-aspirin non-steroidal anti-inflammatory drugs in a population with a high prevalence of H. pylori infection

METHODS (1)We perform a longitudinal descriptive study

of upper gastrointestinal endoscopy and medical records (including medication) in patients referred for endoscopy in III-rd Medical Clinic Targu-Mures during a period of three years (2011-2013).

We matched patients who were taking NSAIDs (n=111), aspirin (226) with control patients (n=750) who were reportedly not taking any of these medications

METHODS (2)Including criteria were: patients referred for

UDE presenting dyspeptic symptoms (heartburn, abdominal pain, vomiting), melaena, haematemesis, unexplained anemia or patients evaluated for unexplained weight loss, or evaluated before cardiac surgery.

Excluding criteria were: portal hypertension, Mallory-Weiss tears, neoplastic lesions, therapeutic maneuver, alcohol intake more than 20U weekly.

METHODS (3)We recorded details of

patients demography, digestive complaints, clinical observations, drug intake

The UDE database was reviewed to ascertain endoscopic findings which were categorized as ulcers (gastric or duodenal), gastritis (erosive or non-erosive);

RESULTSA total number of 1421 patients, 740 men and

681 women (mean age 60,6 years) were referred for UDE because symptoms (heartburn, pain), bleeding signs, unexplained anemia or weight loss and pre-surgery clinical evaluation during 3 years.

The patients were classified into three groups based on current exposure to medications of interest: ASA=aspirin, NSAIDs=non-steroidal anti-inflammatory drugs and control group.

RESULTS The most frequent NSAIDs used were

diclofenac and ketoprofen.Low-dose aspirin represented 75 or 100

or 125 mg daily.We excluded patients taking combinations

of these.

Demographical characteristics of studied group

681; 47.92%740; 52.08%

Feminin

Masculin

< 20 years 21 - 40 years

41 - 60 years

61 - 80 years

> 80 years0

100

200

300

400

500

600

700

2

312

649

428

30

Demographical characteristics of studied group

NSAID ASA Control0

50

100

150

200

250

300

350

400

MaleFemale

SYMPTOMS NSAIDs groupN=111

p ASA groupN=226

p Control groupN=750

Epigastric pain

65,7% 0,02 45,1% 0,020 54%

Heartburn 37,8% 0,05 21,2% 0,03 28,5%

Nausea/vomiting

23,4% 0,07 14,6% 0,6 16%

Melaena 8,1% 0,06 4,4% 0,7 3,7 %

Anemia 35,1% <0,0001

16,3% 0,2 13,3%

Epigastric pain Heartburn Nausea/vomiting Melena Anemia0

50

100

150

200

250

300

350

400

450

7342 26 9

39

102

48 3310

37

405

214

120

28

100

NSAIDs group N=111ASA group N=226Control group N=750

Endoscopic findingsNSAIDs group N=111

p ASA group N=226

p Control group N=750

Gastric and/or duodenal ulcers

17,1% 0,02 12,3% 0,2 9,4%

Bleeding signs 18,% 0,008 8,8% 0,6 7,7%

Erosive gastritis 24,3% <0,0001

23,4% <0,0001

10,2%

NSAIDs group N=111 ASA group N=226 Control group N=7500

10

20

30

40

50

60

70

80

19

28

71

20 20

58

27

53

77Gastric and/or duodenal ulcersBleeding signsErosive gastritis

Histological aspectsNSAIDs groupN=111

ASA groupN=226

Control groupN=750

H. pylori infection 44,1%; p=0,01

34%; p=0,6 32,2%

Chronic gastritis 23,4% 21,6% 22,6%

Gastric atrophy/intestinal metaplasia

9,9%; p=0,02

20,3%; p=0,7

19%

H. pylori infection Chronic gastritis Gastric atrophy/intestinal metaplasia

0

50

100

150

200

250

4926

11

7749 46

242

170143

NSAIDs group N=111

ASA group N=226

CONCLUSION Long-term therapy with aspirin is very frequent in patients

referred for endoscopic evaluation, but the patients have less frequent digestive symptoms.

Patients treated with NSAID therapy have more frequent digestive symptoms and anemia comparative with patients not taking gastrotoxic medication.

Gastrointestinal toxicity was higher in patients taking NSAID who presented more frequent ulcer and bleeding signs on endoscopy, possibly correlated with high prevalence of H. pylori infection in this group.

The aspirin consumers do not have in our population more severe endoscopic lesions than control group, may due to selection criteria (patients screened before surgery without symptoms)

Thank you for your attention!