Is There a Difference Between Upper Gastrointestinal Tract Bleeding Induced by Nonsteroidal Anti-Inflammatory Drugs and Other Causes in Elderly Patients?

Reading the review by Rollhauser and Fleischerl [1] prompted us to present here our experience with upper gastrointestinal bleeding (UGIB) in the elderly.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in elderly patients to treat fever and pain, both in noninflammatory conditions such as headache and in inflammatory diseases such as rheumatoid arthritis, osteoarthritis, neuromuscular disorders, and musculoskeletal conditions. Gastrointestinal side effects such as ulcers and bleeding are the most prevalent life-threatening problems associated with NSAIDs. Buffum and Buffum have reported that particularly in the elderly, NSAIDs have become a leading cause of hospitalization and may increase the risk of death from ulceration by more than fourfold [2]. Upper gastrointestinal bleeding (UGIB) in elderly individuals is a frequent cause of hospital admission. Comorbidity and polypharmacy in this steadily growing patient group influence the clinical course and adversely affect the outcome [3].

In a study conducted at our institution, we aimed to compare the demographic characteristics, clinical and laboratory presentations, blood transfusion requirements, characteristics of endoscopic lesions, and prognosis in NSAID-induced UGIB versus other causes of bleeding in the elderly.

Records for 92 of 172 patients aged over 65 years who were hospitalized in the intensive-care unit between January 2000 and January 2001 were studied. Patients were grouped as NSAID users (50 patients, 54 %) or non-NSAID users (42 patients, 46 %). NSAID users were defined as patients who had been exposed to NSAIDs during the week before the onset of bleeding; a similar definition was used by Laszlo and co-workers in a study comparing the clinical features of major upper gastrointestinal bleeding in patients exposed to NSAIDs and those not taking these drugs [4]. Patients were also included who had had any type of NSAID usage, with a minimum duration of 24 hours of therapeutic dosage as a criterion. Patients with variceal bleeding were excluded from the study. Hemoglobin levels below 9 g/dl were determined as a criterion for blood transfusion. Statistical significance was calculated using the chi-squared test and Student's t-test.

Demographic, clinical, and laboratory parameters for the NSAID-positive and NSAID-negative groups were as follows: female/male ratio 0.72 and 0.82; average age 76.9 and 76.8; percentage of melena cases 92 % and 88 %; percentage of hematemesis cases 24 % and 29 %; average arterial blood pressure 123/72 mmHg and 125/69 mmHg; pulse rates 88/min and 90/min; Hb 9.84 g/dl and 10.08 g/dl; Hct 29 % and 30 %; urea 77.3 mg/dl and 66.9 mg/dl; blood transfusion requirements 2.5 units and 2.9 units; length of hospital stay 5.8 and 6.9 days; mortality rates 8 % and 11 %. The endoscopic diagnoses in the NSAID-positive and NSAID-negative groups were: gastric ulcers in seven and five patients; gastric erosions in 15 and 12 patients; duodenal ulcers in seven and 29 patients; and duodenal erosions in eight and seven patients. There were no differences between the two groups in relation to these parameters (P > 0.05). Comorbid diseases such as hypertension (34 % and 36 %), diabetes mellitus (24 % and 12 %), ischemic heart disease (26 % and 27 %), congestive heart disease (15 % and 17 %), and malignancy (7 % and 9 %) showed similar distribution ranges in the NSAID-positive and NSAID-negative groups (P > 0.05).

Although low hemoglobin levels, higher blood transfusion requirements, and more gastric lesions were found in the NSAID-positive group than in the NSAID-negative group, the difference between the groups was not statistically significant.

Langman [5] reported that over 40 % of a total of 8528 episodes of ulcer bleeding were seen in patients aged 60 years and over, while over 40 % of the estimated 981 deaths each year appeared to be causally related to the treatments. Substitution of NSAIDs with the lowest level of associated risk could be expected to reduce the frequency of nonaspirin NSAID-associated episodes of ulcer bleeding, and deaths by over 70 %. Using the lowest conventional dose of regular prophylactic aspirin (75mg) could also be expected to reduce the frequency of treatment-related episodes of ulcer bleeding and death by nearly 30 %. The study reported that both strategies employed together could be expected to reduce admissions for NSAID-related and regular aspirin-related ulcer bleeding from 4121 to less than 2184 per year, and deaths from 523 to less than 250 per year [5].

References

• 1 Rollhauser C, Fleischer D E. Nonvariceal upper gastrointestinal bleeding.  Endoscopy. 2002;  34 111-118
• 2 Buffum M, Buffum J C. Nonsteroidal anti-inflammatory drugs in the elderly.  Pain Manag Nurs. 2000;  1 40-50
• 3 Lingenfelser T, Ell C. Gastrointestinal bleeding in the elderly.  Best Pract Res Clin Gastroenterol. 2001;  15 963-982
• 4 Laszlo A, Kelly J P, Kaufman D E. et al . Clinical aspects of upper gastrointestinal bleeding associated with the use of nonsteroidal antiinflammatory drugs.  Am J Gastroenterol. 1998;  93 721-725
• 5 Langman M J. Ulcer complications associated with anti-inflammatory drug use: what is the extent of the disease burden?.  Pharmacoepidemiol Drug Saf. 2001;  10 13-19