thienopyridine and Gastrointestinal-Hemorrhage

Colonoscopy frequently is performed for patients who are taking aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and other anticoagulants. These colonoscopies often involve polypectomy, which can be complicated by bleeding. The risks of precipitating thromboembolic complications if anticoagulants are stopped must be weighed against the risk of postpolypectomy bleeding if these agents are continued. This article systematically reviews the management of anticoagulation during elective and emergency colonoscopy. For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is <0.5%. Risk factors for postpolypectomy bleeding include large polyp size and anticoagulant use, especially warfarin and thienopyridines. For patients who do not stop aspirin or other nonsteroidal anti-inflammatory drugs prior to colonoscopy, the rate of postpolypectomy bleeding is not significantly different from that for patients who do not take those medications. For patients who continue thienopyridines and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4%. Even for patients who interrupt warfarin, the risk of postpolypectomy bleeding is increased. The direct oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) have a rapid onset and offset of action, and periprocedural bridging generally is not necessary. For the thienopyridines, warfarin, and the direct oral anticoagulants, the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Colonic Polyps; Colonoscopy; Gastrointestinal Hemorrhage; Humans; Platelet Aggregation Inhibitors; Pyridines; Risk Factors; Thromboembolism; Warfarin; Withholding Treatment

For patients undergoing colonoscopy with polypectomy, current guidelines recommend temporary cessation of blood-thinning medications. The data regarding periprocedural management of these medications are sparse.. To perform a systematic review and meta-analysis to determine the risk of post-polypectomy bleeding (PPB) in patients taking anti-platelet, anti-coagulant and/or thienopyridine medications.. We searched Pubmed, Scopus, Web of Science, Biosis and Proceedings First from 1970 to 2015. PPB was defined as overt haemorrhage or drop in haemoglobin of at least 2 g/dL.. Of 1490 articles identified, we included 3 papers and 1 abstract with patients on aspirin and/or NSAIDs, 1 paper on warfarin, 2 abstracts on clopidogrel, and 2 papers on clopidogrel plus aspirin and/or NSAIDs. While the rate of immediate PPB on aspirin and/or NSAIDs was not increased (OR = 1.1, 95% CI 0.7-1.9, P = 0.7), the risk of delayed PPB was increased (OR = 1.7, 95% CI 1.0-2.4, P = 0.0009, I(2)  = 60%) but rendered non-significant with elimination of a small study. There was an elevated risk of delayed PPB on clopidogrel (OR = 9.7, 95% CI 3.1-30.8, P = 0.0, I(2)  = 0). There was an increased risk of delayed PPB in patients on clopidogrel + aspirin and/or NSAIDs (OR = 3.4, 95% CI 1.3-8.8, P = 0.01, I(2)  = 0). Based on a single study on warfarin, the PPB rate was elevated. There were no data regarding PPB and usage of the newer anti-coagulant agents.. Usage of aspirin or NSAIDs does not increase risk of post-polypectomy bleeding. Clopidogrel and warfarin should be discontinued in the periprocedural period to prevent the occurrence of post-polypectomy bleeding.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Blood Coagulation Disorders; Colonic Polyps; Colonoscopy; Gastrointestinal Hemorrhage; Humans; Platelet Aggregation Inhibitors; Pyridines; Risk Factors; Warfarin

We aimed to identify the risk factors of first-time occurrence of non-variceal upper gastrointestinal bleeding (UGIB) among aspirin users after adjusting for confounding factors like age, gender, underlying co-morbidities, and medications.. Using the National Health Insurance Research Database of Taiwan and matching age, gender, underlying co-morbidities and enrollment time by propensity score, 11105 aspirin users and 11105 controls were identified for comparison from a cohort dataset of 1,000,000 randomly sampled subjects. Cox proportional hazard regression models were used to identify independent risk factors for first-time occurrence of non-variceal UGIB in the study cohort and in the aspirin users after adjusting for age, gender, underlying co-morbidities, and medications (e.g., non-steroidal anti-inflammatory drugs [NSAIDs], cyclooxygenase-2 [COX-2] inhibitors, steroids, thienopyridines, selective serotonin reuptake inhibitors, warfarin, and dipyridamole).. By Cox proportional hazard regression analysis, aspirin use increased the risk of first-time occurrence of UGIB (hazard ratio [HR]: 1.48; 95% confidence interval [CI]: 1.28-1.72). Age, male gender, Helicobacter pylori (H. pylori)infection, diabetes, chronic kidney disease (CKD), cirrhosis, history of uncomplicated peptic ulcer disease (PUD), and use of NSAIDs, COX-2 inhibitors, steroids, and thienopyridines were independent risk factors for UGIB among aspirin users.. In addition to age, male gender, H. pylori infection, and concomitant use of NSAIDs, COX-2 inhibitors, steroids, and thienopyridines, underlying co-morbidities including diabetes, CKD, cirrhosis, history of PUD are also important risk factors for first-time occurrence of non-variceal UGIB in aspirin users.

Topics: Aged; Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Cohort Studies; Comorbidity; Cyclooxygenase 2 Inhibitors; Databases, Factual; Female; Gastrointestinal Hemorrhage; Helicobacter Infections; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Proportional Hazards Models; Pyridines; Risk Factors; Steroids; Taiwan

Lower gastrointestinal bleeding (LGIB) is a common complication for patients with coronary artery disease (CAD) due to the use of antithrombotic medications. Limited data exist describing which patients are at increased risk for mortality.. This study aims to (i) determine whether patients on dual antiplatelet therapy (DAPT) or triple therapy are at higher risk of 90-day and 6-month mortality compared with patients on aspirin alone and (ii) evaluate risk factors for mortality in patients with CAD on antithrombotics hospitalized with LGIB.. We conducted a retrospective cohort study of patients hospitalized with LGIB and CAD while on aspirin at a single academic medical center from 2007 to 2015. Patients were identified using a validated, machine-learning algorithm and classified by use of aspirin, DAPT, or triple therapy. Univariate and multivariate Cox proportional hazards were used to determine mortality associated risk factors.. Seven hundred sixteen patients were identified with LGIB and CAD. Four hundred seventy-two (65.9%) patients were on aspirin monotherapy, 179 (25%) on aspirin and thienopyridine (DAPT), and 65 (9.1%) on aspirin, thienopyridine, and systemic anticoagulant (triple therapy). On univariate analysis, triple therapy use was associated with increased risk of 90-day (hazard ratio [HR] 3.12, 95% confidence interval [CI] 1.52-5.92, P = 0.003) and 6-month (HR 2.46, 95%CI 1.29-4.35, P = 0.008) mortality. Holding anticoagulation was associated with higher mortality at 90 days (HR 2.30, 95%CI 1.27-4.07, P = 0.007). On multivariate analysis, after adjusting for confounding variables, the use of triple therapy remained associated with higher 90-day mortality (HR 3.23, 95%CI 1.56-6.16, P = 0.003).. Triple therapy is associated with mortality at 90 days and at 6 months post discharge.

Topics: Aged; Anticoagulants; Aspirin; Cohort Studies; Coronary Artery Disease; Drug Therapy; Female; Fibrinolytic Agents; Gastrointestinal Hemorrhage; Hospitalization; Humans; Male; Middle Aged; Multivariate Analysis; Pyridines; Retrospective Studies; Risk; Risk Factors; Time Factors

Current guidelines recommend withholding antiplatelets for 5-7 days before high-risk endoscopic procedures. We investigated whether this reduces post-endoscopic submucosal dissection (ESD) bleeding.. Gastric ESD cases with antiplatelets were retorospectively reviewed. Withholding antiplatelets for 5-7 days before ESD was defined as cessation and 0-4 days as continuation. The rate and risk of post-ESD bleeding according to the types and cessation of antiplatelets were assessed.. Among the 215 patients (117 adenoma and 98 early gastric cancer), 161 patients were on single (94 aspirin, 56 thienopyridine, and 11 other agents), 51 on dual, and 3 on triple antiplatelets. Post-ESD bleeding rates were 12.8% in aspirin users, 3.6% in thienopyridine, 27.5% in dual, 33.3% in triple therapy, and 9.7% in the cessation and 15.0% in the continuation group. Multiple antiplatelets (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.01 to 5.76) and specimen size ≥ 5.5 cm (OR, 2.84; 95% CI, 1.04 to 7.73) were the risk of bleeding, while continuation of thienopyridine (OR, 0.23; 95% CI, 0.05 to 1.09) and antiplatelets (OR, 1.83; 95% CI, 0.68 to 4.94) did not increase the risk of bleeding.. Continuing thienopyridine and aspirin did not increase the risk of post-ESD. Multiple antiplatelet therapy and a large specimen size were independent risk factors of post-ESD bleeding.

Topics: Aged; Aged, 80 and over; Aspirin; Drug Administration Schedule; Endoscopic Mucosal Resection; Female; Gastric Mucosa; Gastrointestinal Hemorrhage; Gastroscopy; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Pyridines; Retrospective Studies; Risk Factors; Stomach Neoplasms; Time Factors; Treatment Outcome

Current guidelines recommend suspending thienopyridine therapy 5 to 7 days before therapeutic endoscopy to reduce the risk of bleeding-related complication. However, interruption of antiplatelet therapy may increase the risk of a cardiovascular event. The aim of this study was to evaluate the safety and diagnostic yield of device-assisted enteroscopy (DAE) with endoscopic therapy in patients receiving thienopyridine antiplatelet therapy.. A retrospective chart review was performed for patients treated in the LSU Health Sciences Gastroenterology Clinics between the dates of October 4, 2007 and February 15, 2015. A total of 774 enteroscopy procedures were reviewed to identify patients on active thienopyridine therapy at the time of DAE.. During the study period, a total of 68 patients underwent DAE while on thienopyridine therapy. Confirmed or suspected small bowel bleeding was the most common procedural indication. A total of 143 endoscopic interventions were performed, primarily argon plasma coagulation for ablation of intestinal angioectasias. There were no significant bleeding-related complications associated with these procedures. In addition, the diagnostic yield for these procedures was high (77%) with a significant percentage of patients in the thienopyridine group found to have an active bleeding source at the time of DAE.. The performance of DAE procedures with endoscopic intervention such as argon plasma coagulation may be safe in patients on thienopyridine therapy. Continuing thienopyridines may also increase the diagnostic yield of these procedures by promoting active bleeding from the culprit source.

Topics: Aged; Argon Plasma Coagulation; Endoscopy, Gastrointestinal; Female; Gastrointestinal Hemorrhage; Humans; Intestinal Diseases; Male; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Pyridines; Retrospective Studies; Risk Factors; Treatment Outcome

The incidence of nonsteroidal anti-inflammatory drugs (NSAIDs)-induced enteropathy is currently increasing. However, the predictors of small bowel bleeding (SBB) associated with NSAIDs are unknown. This study aimed to assess the risk factors of SBB in chronic NSAIDs users.. We retrospectively compared the medical records of 147 patients receiving NSAIDs in a tertiary-care setting (31 with SBB and 116 without previous bleeding events) and analyzed the predictors of SBB.. In total, 31 patients underwent video capsule endoscopy to detect SBB, 74.2% of whom showed the evidence of SBB. Non-invasive treatment was performed in 90.3% of the patients. Multivariate logistic regression analysis revealed that the presence of coronary artery disease [adjusted odds ratio (aOR) 12.43, 95% confidence interval (CI) 1.19-130.34, P = 0.04], use of thienopyridine (aOR 16.93, 95% CI 3.78-75.72, P < 0.001) and prior use of rebamipide (aOR 0.31, 95% CI 0.12-0.82, P = 0.02) were independently associated with SBB in NSAIDs users.. Coronary artery disease and co-use of thienopyridine were associated with SBB in NSAIDs users. The patients with coronary artery disease co-using thienopyridine need to be monitored for the occurrence of SBB when they were prescribed with NSAIDs.

Topics: Aged; Alanine; Anti-Inflammatory Agents, Non-Steroidal; Anti-Ulcer Agents; Capsule Endoscopy; Coronary Artery Disease; Female; Gastrointestinal Hemorrhage; Humans; Incidence; Intestine, Small; Male; Middle Aged; Platelet Aggregation Inhibitors; Pyridines; Quinolones; Retrospective Studies; Risk Factors

It is not clear whether the cardiovascular risk of discontinuing treatment with antiplatelet agents, specifically the thienopyridines, before elective colonoscopy outweighs the risks of postpolypectomy bleeding (PPB). We studied the rate of PPB in patients who continue thienopyridine therapy during colonoscopy.. We performed a prospective study of 516 patients not taking warfarin who received polypectomies during elective colonoscopies; 219 were receiving thienopyridines, and 297 were not (controls). The occurrence of immediate PPB and delayed PPB was recorded. Delayed PPB was categorized as clinically important if it resulted in repeat colonoscopy, hospitalization, or blood transfusion.. Patients receiving thienopyridines were older and had significantly more comorbid diseases than controls; the mean number of polyps removed per patient was significantly higher (3.9 vs 2.9) in the thienopyridine group. Immediate PPB developed in 16 patients in the thienopyridine group (7.3%) and in 14 in the control group (4.7%, P = .25). Among patients who completed a 30-day follow-up analysis (96% of patients enrolled), clinically important, delayed bleeding occurred in 2.4% of patients receiving thienopyridines and in none of the controls (P = .01). All PPB events in both groups were resolved without surgery, angiography, or death.. Although a significantly higher percentage of patients who continue thienopyridine therapy during colonoscopy and polypectomy develop clinically important delayed PPB than patients who discontinue therapy, the rate of PPB events is low (2.4%), and all are resolved without sequelae. The risk for catastrophic cardiovascular risks among patients who discontinue thienopyridine therapy before elective colonoscopies could therefore exceed the risks of PPB. ClinicalTrials.gov, Number NCT01647568.

Topics: Aged; Colonoscopy; Endoscopy; Female; Gastrointestinal Hemorrhage; Humans; Intestinal Polyps; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Prevalence; Prospective Studies; Pyridines

Topics: Colonoscopy; Endoscopy; Female; Gastrointestinal Hemorrhage; Humans; Intestinal Polyps; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Pyridines

Delayed bleeding after lower endoscopy and polypectomy can cause significant morbidity. One strategy to reduce bleeding is to place an endoscopic clip on the polypectomy site. We used decision analysis to investigate the cost-effectiveness of routine clip placement after colon polypectomy.. Probabilities and plausible ranges were obtained from the literature, and a decision analysis was conducted by using TreeAge Pro 2011 Software. Our cost-effectiveness threshold was an incremental cost-effectiveness ratio of $100,000 per quality-adjusted life year. The reference case was a 50-year-old patient who had a single 1.0- to 1.5-cm polyp removed during colonoscopy. We estimated postpolypectomy bleeding rates for patients receiving no medications, those with planned resumption of antiplatelet therapy (nonaspirin), or those receiving anticoagulation therapy after polypectomy. We performed several sensitivity analyses, varying the cost of a clip and hospitalization, number of clips placed, clip effectiveness in reducing postpolypectomy bleeding, reduction in patient utility days related to gastrointestinal bleeding, and probability of harm from clip placement.. On the basis of the reference case, when patients did not receive anticoagulation therapy, clip placement was not cost-effective. However, for patients who did receive anticoagulation and antiplatelet therapies, prophylactic clip placement was a cost-effective strategy. The cost-effectiveness of a prophylactic clip strategy was sensitive to the costs of clips and hospitalization, number of clips placed, and clip effectiveness.. Placement of a prophylactic endoscopic clip after polypectomy appears to be a cost-effective strategy for patients who receive antiplatelet or anticoagulation therapy. This approach should be studied in a controlled trial.

Topics: Colonoscopy; Endoscopy; Female; Gastrointestinal Hemorrhage; Humans; Intestinal Polyps; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Pyridines

Antithrombotics is increasingly being used for cardiovascular prevention. In more recent studies, small bowel injury and enteropathy associated with low-dose aspirin are increasingly being recognized. Aim of this study was to evaluate small bowel injury using video capsule endoscopy (VCE) in obscure gastrointestinal bleeding (OGIB) patients taking low-dose aspirin including other antithrombotics.. This is a retrospective review of chronic users of antithrombotics who underwent VCE for suspected small bowel bleeding. Small bowel mucosal injury was evaluated using VCE findings.. Fifty-four OGIB patients (36 men and 18 women, mean age 72.4 years) underwent VCE from January 2007 to May 2009. Twenty-two patients were taking 100 mg of enteric-coated aspirin (aspirin group), 8 taking thienopyridine, (ticlopidine or clopidogrel, thienopyridine group), 13 taking aspirin combined with thienopyridine (combined group), and 11 taking warfarin (warfarin group). The mucosal injury, especially ulcers were most frequently detected in the combined group (46.2%, p = 0.01) among the four groups. The median number of redness lesions in the combined group was the highest among the four groups and was significantly higher than that in the warfarin group. The lesions of redness or small erosions in the aspirin and the combined groups tended to exist in the proximal part of small bowel.. Combination of low-dose aspirin therapy and thienopyridine may exacerbate small bowel injury, and the preventive strategies should be established.

Topics: Aged; Aged, 80 and over; Aspirin; Capsule Endoscopy; Clopidogrel; Drug Therapy, Combination; Female; Fibrinolytic Agents; Gastrointestinal Hemorrhage; Humans; Intestinal Mucosa; Intestine, Small; Male; Middle Aged; Pyridines; Retrospective Studies; Ticlopidine; Ulcer; Warfarin

Topics: Acute Coronary Syndrome; Aspirin; Clopidogrel; Drug Therapy, Combination; Drug-Eluting Stents; Electrocardiography; Follow-Up Studies; Gastrointestinal Hemorrhage; Humans; Myocardial Infarction; Myocardial Revascularization; Odds Ratio; Peptic Ulcer; Platelet Aggregation Inhibitors; Prognosis; Proton Pump Inhibitors; Pyridines; Randomized Controlled Trials as Topic; Ticlopidine; Time Factors

The aim of this study was to examine the effects of gastric medicines on gastroduodenal injury during antiplatelet therapy after coronary intervention.. A total of 501 patients were enrolled and as dual antiplatelet therapy, aspirin and thienopyridine were administered. Patients were divided into four groups: histamine H2-receptor antagonists (H2RA); proton pump inhibitors (PPI); other gastromucosal protective agents (GMP); or nothing (None), and follow-up lasted 8-20 months.. H2RA were prescribed in 212 cases (42%), PPI in 150 (30%), GMP in 56 (11%), and None in 83 (17%). Significant findings by endoscopy were recognized in 18 cases and upper gastrointestinal bleeding requiring hospitalization occurred in 7 patients (1.4%; H2RA in 4, GMP in 2, and None in 1). There were no gastrointestinal injuries in the PPI group. To minimize the effect of selection bias on gastroduodenal lesions, the propensity score analysis for clinical characteristics was used. The results of propensity score matching showed that administration of PPI reduced the incidence of gastrointestinal lesions compared with that of the non-PPI group.. Administration of PPI reduced the incidence of gastrointestinal lesions compared with that of the non-PPI group.

Topics: Aged; Angina Pectoris; Angioplasty, Balloon, Coronary; Aspirin; Female; Follow-Up Studies; Gastric Mucosa; Gastrointestinal Hemorrhage; Histamine H2 Antagonists; Humans; Male; Peptic Ulcer; Platelet Aggregation Inhibitors; Propensity Score; Proton Pump Inhibitors; Pyridines; Stents

Topics: Acute Coronary Syndrome; Angioplasty, Balloon, Coronary; Clopidogrel; Drug Interactions; Gastrointestinal Hemorrhage; Humans; Piperazines; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Proton Pump Inhibitors; Pyridines; Randomized Controlled Trials as Topic; Thiophenes; Ticlopidine