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Update of TARGET ( T reatment a nd R elief of G astroint e s t inal disorder)

Update of TARGET ( T reatment a nd R elief of G astroint e s t inal disorder). Dr Norita Yasmin Morning read 19/9/13. Journal of Digestive Diseases 2013 ; 14; 1–10 The Use Of Antiplatelet Therapy And Proton Pump Inhibitors In The Prevention Of Gastrointestinal Bleeding.

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Update of TARGET ( T reatment a nd R elief of G astroint e s t inal disorder)

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  1. Update of TARGET(Treatment and Relief of Gastrointestinal disorder) Dr Norita Yasmin Morning read 19/9/13

  2. Journal of Digestive Diseases 2013; 14; 1–10 The Use Of Antiplatelet Therapy And Proton Pump Inhibitors In The Prevention Of Gastrointestinal Bleeding Statements of the Malaysian Society of Gastroenterology & Hepatology (MSGH) and the National Heart Association of Malaysia (NHAM) task force 2012 working party

  3. 1. Antiplatelet drugs increase the risk of GI bleeding 2. PPIs are superior to H2-receptor antagonists (H2RAs) in primary and secondary prevention of aspirin induced ulcer 3. Helicobacter pylori (H. pylori) detection and eradication is recommended for high GI risk patients before commencing long-term aspirin 4. Continuing PPIs after H. pylori eradication is superior to H. pylori eradication alone in preventing recurrent ulcer bleeding in patients on aspirin 5. In patients with previous upper GI bleeding, PPIs should be added to antiplatelet therapy to prevent recurrent ulcer bleeding 6. Patients with a high risk for GI bleeding requiring antiplatelet therapy should be on long-term PPIs Outline Journal of Digestive Diseases 2013; 14; 1–10

  4. 1. Antiplatelet drugs increase the risk of GI bleeding

  5. A meta-analysis of 18 trials involving 129 314 patients evaluated the bleeding risk of antiplatelet therapy. Not surprisingly, patients on dual antiplatelet therapy were associated with an increased risk of major (RR 1.47, 95% CI 1.36–1.60) and minor bleeding (RR 1.56, 95% CI 1.47–1.66). These patients have a 40–50% increase in risk of major and minor bleeding. 1. Antiplatelet drugs increase the risk of GI bleeding Serebruary et al, 2008

  6. Anti platelet and risk of GI bleeding Journal of Digestive Diseases 2013; 14; 1–10

  7. Prior history of GI bleeding Concomitant NSAIDs Concomitant COX-2 inhibitors Concomitant anticoagulants Concomitant clopidogrel Concomitant corticosteroids Helicobacter pylori infection Age >65 years Short-term NSAIDs Risks of GIT bleeding Journal of Digestive Diseases 2013; 14; 1–10

  8. 2. PPIs are superior to H2-receptor antagonists (H2RAs) in primary and secondary prevention of aspirin induced ulcer

  9. Patients who has no previous peptic ulcer at baseline H2RAs have been shown to be effective as primary prevention for aspirin-induced peptic ulcer disease in average-risk patients PPIs have also been shown to be effective as primary prevention for aspirin-induced ulcer. Primary prevention Journal of Digestive Diseases 2013; 14; 1–10

  10. Primary prevention of aspirin-induced ulcer Journal of Digestive Diseases 2013; 14; 1–10

  11. PPIs were found to be superior to H2RAs in the primary prevention of peptic ulcer disease, especially in those treated with multiple antiplatelet therapies Ng et alconducted an RCT comparing the efficacy of famotidine and esomeprazole in preventing GI complications in patients with ACS or ST-elevation MI receiving aspirin, clopidogrel and enoxaparin or thrombolysis. Primary prevention of PUD in multiple anti platelet therapies Journal of Digestive Diseases 2013; 14; 1–10

  12. Primary prevention for multiple anti platelet therapies More effective Journal of Digestive Diseases 2013; 14; 1–10

  13. For secondary prevention of aspirin-induced peptic ulcer disease, PPIs again have been shown to be superior to H2RAs Secondary ulcer prevention Journal of Digestive Diseases 2013; 14; 1–10

  14. Prevention aspirin-related PUD More effective Ng et al Medi Journal of Digestive Diseases 2013; 14; 1–10

  15. Prevent recurrent aspirin-related PUD/dyspepsia More effective Journal of Digestive Diseases 2013; 14; 1–10

  16. 3. Helicobacter pylori (H. pylori) detection and eradication is recommended for high GI risk patients before commencing long-term aspirin 4. Continuing PPIs after H. pylori eradication is superior to H. pylori eradication alone in preventing recurrent ulcer bleeding in patients on aspirin

  17. Prior history of GI bleeding Concomitant NSAIDs Concomitant COX-2 inhibitors Concomitant anticoagulants Concomitant clopidogrel Concomitant corticosteroids Helicobacter pylori infection Age >65 years Short-term NSAIDs Risks of GIT bleeding Journal of Digestive Diseases 2013; 14; 1–10

  18. H. Pylori eradication Journal of Digestive Diseases 2013; 14; 1–10

  19. Obviously, > risk factors a patient  higher the risk of upper GI bleeding. By identifying and eliminating the risk factors the risk of GI bleeding could be minimized. Journal of Digestive Diseases 2013; 14; 1–10

  20. H. Pylori eradication Chan et al: effectiveness of eradication = maintenance PPI in patients with history of upper GI bleeding who were taking aspirin. Journal of Digestive Diseases 2013; 14; 1–10

  21. Meta analysis vs Journal of Digestive Diseases 2013; 14; 1–10 Anti secretory: PPI, H2RA, antacid

  22. Treatment of H. pylori infection is more effective than antisecretory non-eradicating therapy (with or without long-term maintenance antisecretory therapy) in preventing recurrent bleeding from peptic ulcer. Consequently, all patients with peptic ulcer bleeding should be tested for H. pylori infection, and eradication therapy should be prescribed to H. pylori-positive patients. Conclusion from meta analysis Cochrane Database Syst Rev. 2004;(2):CD004062

  23. In patients with aspirin-induced ulcer, treatment with PPIs following successful H. pylori eradication significantly reduces the risk of recurrent ulcer complications. H.Pylori eradication + maintenance PPI Journal of Digestive Diseases 2013; 14; 1–10

  24. Worth detecting and eradicating H. pylori infection in patients followed by PPIs maintenance in high GI bleeding risk patients who require long-term Aspirin, although long term data is lacking Conclusion Journal of Digestive Diseases 2013; 14; 1–10

  25. Sequential therapy is superior to seven day triple therapy and similar to regimens of longer duration or including more than two antimicrobial agents. BMJ 2013: Global eradication rates for Helicobacter pylori infection: systematic review and meta-analysis BMJ 2013

  26. UKM guideline: sequential therapy for 10 days

  27. 5. In patients with previous upper GI bleeding, PPIs should be added to antiplatelet therapy to prevent recurrent ulcer bleeding

  28. Patients who have previous upper GI bleeding from any cause are at a higher risk of recurrence. • For patients with aspirin-induced peptic ulcer bleeding and who need to continue with antiplatelet therapy, the initial recommendation was to prescribe clopidogrel to replace aspirin for the prevention of recurrent peptic ulcer. Previous vsrecent anti platelet recommendation Journal of Digestive Diseases 2013; 14; 1–10

  29. However, subsequent studies have confirmed that adding PPIs to aspirin was a better approach than replacing aspirin with clopidogrelto prevent recurrent peptic ulcer complications. multiple ulcer complications Study Journal of Digestive Diseases 2013; 14; 1–10

  30. 6. Patients with a high risk for GI bleeding requiring antiplatelet therapy should be on long-term PPIs

  31. Prior history of GI bleeding Concomitant NSAIDs Concomitant COX-2 inhibitors Concomitant anticoagulants Concomitant clopidogrel Concomitant corticosteroids Helicobacter pylori infection Age >65 years Short-term NSAIDs Risks of GIT bleeding Journal of Digestive Diseases 2013; 14; 1–10

  32. Primary prophylaxis for GI bleeding is not necessary for patients with average GI bleeding risk commencing aspirin. In average risk patients starting aspirin therapy, the risk of major upper GI bleeding is increased 1.5 to 3.2 fold and the absolute rate is increased by 0.12% per year. The number needed to harm (NNH) at one year was 833. Primary prophylaxis for average risk Journal of Digestive Diseases 2013; 14; 1–10

  33. In patients at high risk of GI bleeding but who have not bled in the past, PPI should be added if they require antiplatelet therapy RCT on dual antiplatelet and risk of GI event Primary prevention for high risk Journal of Digestive Diseases 2013; 14; 1–10

  34. 1. Antiplatelet drugs increase the risk of GI bleeding 2. PPIs are superior to H2-receptor antagonists (H2RAs) in primary and secondary prevention of aspirin induced ulcer 3. Helicobacter pylori (H. pylori) detection and eradication is recommended for high GI risk patients before commencing long-term aspirin 4. Continuing PPIs after H. pylori eradication is superior to H. pylori eradication alone in preventing recurrent ulcer bleeding in patients on aspirin 5. In patients with previous upper GI bleeding, PPIs should be added to antiplatelet therapy to prevent recurrent ulcer bleeding 6. Patients with a high risk for GI bleeding requiring antiplatelet therapy should be on long-term PPIs Take home message Journal of Digestive Diseases 2013; 14; 1–10

  35. Thank you for your kind attention

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