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Proton Pump Inhibitor (PPI) co-therapy and gastrointestinal bleeding with antithrombotic drugs: a step forward but not enough

Published:January 21, 2021DOI:https://doi.org/10.1016/j.ejim.2021.01.014
      Nonvariceal gastrointestinal (GI) bleeding is common and one of the most frequent medical events which determine hospitalizations worldwide. Death rates (5-12%) in patients with GI bleeding are resistant to decrease despite the new advances in diagnosis and therapy, which is probably linked to a higher proportion of elderly patients with significant comorbidities who suffer from this complication [
      • Sung JJ
      • Tsoi KK
      • Ma TK
      • Yung MY
      • Lau JY
      • Chiu PW.
      Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases.
      ]. However, the number of hospitalizations due to GI bleeding is decreasing over time in many countries with a sharp reduction of upper GI bleeding events, which is not compensated by the observed increase in the number of hospitalizations due to lower GI bleeding events [
      • Lanas A
      • García-Rodríguez LA
      • Polo-Tomás M
      • Ponce M
      • Alonso-Abreu I
      • Perez-Aisa MA
      • et al.
      Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice.
      ]. Another aspect that deserved to be outlined here is that the characteristics of patients who develop GI bleeding have also changed in the last decades. In the past, most GI bleeding cases were due to peptic ulcers associated to either H. pylori infection or NSAID use. In contrast, nowadays, the most common patient admitted to our hospitals with GI bleeding is an elderly man or woman with various comorbidities taking antiplatelet agents, anticoagulants or both [
      • Lanas Á
      • Carrera-Lasfuentes P
      • Arguedas Y
      • García S
      • Bujanda L
      • Calvet X
      • Ponce J
      • et al.
      Risk of upper and lower gastrointestinal bleeding in patients taking nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants.
      ]. There must be several reasons for the observed changes, but it seems obvious that the worldwide decrease in the prevalence of H. pylori infection in western countries, and the widespread use of proton pump inhibitors (PPIs) in patients taking NSAIDs are two important factors. Both therapies have shown to decrease the incidence of peptic ulcers and their complications [
      • Lanas A
      • Dumonceau JM
      • Hunt RH
      • Fujishiro M
      • Scheiman JM
      • Gralnek IM
      • et al.
      Non-variceal upper gastrointestinal bleeding.
      ].
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