Journal Reading

Nonsteroidal Anti-
Inflmmatory Drug-
Related
Gastrointestinal
Bleeding In The
Elderly

Presented by:
-Mirantika Audina-
 INTRODUCTION
Have number of • Increased incidence of
diseases such as spontaneous bleeding and
cardiovascular perforation of peptic ulcer
disorders and arthritis • Higher expenses for the
that are treated with prescription of
antiplatelet agents or gastroprotective drugs and
nonsteroidal for hospitalization for
anti-inflammatory gastrointestinal (GI)
drugs (NSAIDs) hemorrhage.

Suspect occupy
20% of the
population in 2030 Health care professionals must thus be conversant
with the problem of NSAID-related GI bleeding in the
elderly, as they will likely see more and more older
patients with this complication
 AGE RELATED PHYSIOLOGIC CHANGES
IN THE GI TRACT
The esophageal sphincter
pressure decrease

Increase the risk of Atrophy of

type B chronic mucosa and
gastritis, gastric achlorhydia are
atrophy, peptic ulcer not unsual
disease and neoplasm

Source May induce gastritis,

of hypergastrinemia,
obscure decreased gastric
Diverticulae are more Increasing prevalence
GI emptying and
common oh Helicobacter pylori
bleeding bacterial overgrowth
 PATHOGENESIS OF NSAID-RELATED
PEPTIC ULCER DISEASE

NSAIDs has Indirect

acid properties mechanism
Topical
IInjury
Decreaseasing the Duodenogastric reflux of
hydrophobic properties active NSAID metabolites or
Systemic of gastric mucus bile
Effects

Allowing endogenous gastric

acid and pepsin to injure the
surface epithelium
 PATHOGENESIS OF NSAID-RELATED
PEPTIC ULCER DISEASE
GI tract, platelet,
Prostaglandins are derived Cox -1 endothelial, ect
from arachidonic acid
Topical which is catalyze by: Cox -2 Brain and kidney
IInjury cells

Decreased synthesis
Systemic of mucosal Suppresion Nonselective
Effects prostaglandins inhibitors

Defend the gastric and Gastroduodenal NSAIDs

duodenal mucosa against ulceration
injury and ulceration
 NSAID-RELATED GI BLEEDING IN
EDERLY

76 patients with NSAID-related disease were older

More likely to have cardio-respiratory disease
than the 112 patients with non-NSAID-related
ulcer
Those with NSAID-related diease were
hospitalized for significantly longer, most likely
Choudari et al
because of thier other condition

991 patients with coronary heart disease on low-

dose aspirin found relatively low incidence of GI
bleeding 1,5% per year in 2 years
Morbidity associated with bleeding was significant
 NSAID-RELATED GI BLEEDING
IN EDERLY

Incidence of clinically apparent upper GI event

3-4,5% patients taking NSAIDs

1,5% Develop serious complication Increase

the risk of
The mortality among patients who are hospitalize
5-10% for NSAIDs-induced upper GI bleeding
diverticular
bleeding in
the elderly
The risk of GI bleeding, gastric ulcer and duodenal
5,5-fold ulcer for those in 65 years and above who take
NSAIDs
 DIAGNOSIS OF NSAID-RELATED GI
BLEEDING
GI bleeding >> fecal occult blood testing
But utility is limited because insufficiency sensitivity and spesifity
Esophagogastroduodenosopy (EGD) or colonosopy
Often difficult, Most reliable tool for diagnose of ulceration of upper GI tract
Pain may be
masked for a Push-enteroscopy, capsule endoscopy or double-balloon enterosopy
number of To demonstrate an obvious lession in small bowel but uncomfortable by
reason elderly
Sucrose Permeability Test
Suggested test for NSAID-induced GI damage, but only of limited
usefulness since cannot define the location .
 TREATMENT AND PREVENTION

Avoiding unnecessary use of NSAIDs,

there are several stategies to manage
elderly patients who must take the drugs
but who are prone to or hae already
experienced GI bleeding
 TREATMENT AND PREVENTION

Specifically designed to provide pain relief Switch to COX-2

comparable to that of traditional NSAIDs while selective inhibitor
reducing the incidence of adverse GI events in
the elderly

Less likely to surpress mucosal prostaglandin

secretion than the traditional nonselective
NSAIDs

e.g rofecoxib and valdecoxib 1

 TREATMENT AND PREVENTION

Misoprostol
Prostaglandin analog

Although effective, its utility frequently limited by

side effects

Has no significant protective effet against the risk

of bleeding in patients with a history of peptic
ulcer
2
 TREATMENT AND PREVENTION

Mucosal
e.g sucralfat, a basic aluminium salt of sucrose Protective Agents
octasulfate

Effective in the treatment of both NSAID and non-

NSAID-related duodenal ulcer

As effective as H2 receptor antagonist in the

healing of non-NSAID-related gastric ulcer
3
 TREATMENT AND PREVENTION

Treatment of peptic ulcer disease with

conventional doses of H2 receptor antagonist for Histamine H2-
6-12 weeks results in the healing of Receptor
approximately 75% of gastric and 87% of
duodenal ulcer, despite the conntinued use of Antagonist
NSAIDs
Dosages of the renally cleared H2 receptor
antagonist should, therefore be adjusted
accordingly

4
 TREATMENT AND PREVENTION

Protont Pump
Inhibitors (PPIs)
Much more effective than H2-receptor blockers

Significantly better risk reduction for peptic ulcers

in both acute and chronic NSAID users than were
H2-receptor blockers

5
 TREATMENT AND PREVENTION

Eradication of H.
pylori
Necessary to prevent GI bleeding in patients on
low dose aspirin or NSAIDs
Have not recommende for patients at no or low
risk of peptic ulcer disease
Reduces the ulcer risk for patients who are being
started on NSAIDs but not for those already on
long-term NSAID therapy 6
Conclusion
Aging is inevitable, and the elderly are often subject to
chronic diseases. In these patients, NSAIDs are a 2-
edged sword.
They may well be
useful for treatment or Proper patient When they must be given,
secondary prevention selection is important. however, the use of
of the diseases to A history of peptic gastroprotective agents
which these patients ulcer should be will probably reduce the
are susceptible. regarded as a relative incidence of bleeding
However, they also contraindication to the associated
clearly pose a risk of use of NSAIDs with them
bleeding, to which the
elderly are more
prone.
Thank You