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Should older adults on long-term aspirin get PPIs?

Should older adults on long-term aspirin get PPIs?

Publication date: Saturday, 09 September 2017
Contributor(s): Jeremy Bray

A new study shows that long-term daily aspirin use in people aged ≥75 years, is linked to a higher than expected risk of disabling or fatal bleeding.  While short-term aspirin use after a stroke or heart attack has clear benefits, the study authors say that older patients who take aspirin on a daily basis should also be prescribed a proton-pump inhibitor (PPI) to reduce the risk of bleeding.

The Oxford Vascular Study followed 3166 patients who had previously had a stroke or heart attack and were prescribed antiplatelet drugs (mostly aspirin). Over 10 years of the study, a total of 314 patients were admitted to hospital for bleeding. The risk of bleeding, in particular the risk of fatal or disabling bleeding, increased with age.  For patients 85 years. Similarly, the risk of disabling or fatal bleeding increased with age (Table).


Patients aged <65

Patients aged 75-84

Patients aged ≥85

Annual rate of life-threatening or fatal bleeds




Table: Relationship between age and rate of life-threatening/fatal bleeds in patients on long-term aspirin.

The outcome of non-fatal bleeds was also worse at older ages and overall, the risk of disabling or fatal bleeding over ten years was 10 times higher at ages 75 years or older, compared to younger patients.

The authors concluded that the benefits of PPI use at older ages outweigh the risks, and guidelines should recommend the co-prescription of PPIs in this age group.

Approximately 40-60% of adults aged 75 or older in the USA or Europe take daily aspirin or other antiplatelet drugs to prevent heart attacks or strokes. Lifelong treatment with antiplatelet drugs is recommended for patients who have previously had a heart attack or stroke.


These results suggest that clinicians should evaluate risk-benefit in their older patients on long-term antiplatelet therapy, and perhaps consider using PPIs in appropriate patients. However this was an observational study rather than a randomised trial, and included some patients taking clopidogrel rather than aspirin, so further focused studies are required to clarify the findings.

Li L, Geraghty O, Mehta Z, et al. Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: a population-based cohort study. Lancet 2017, published online

Topics covered:
Category: Evidence in Practice
Edition: Volume 2 Number 7 PCCJ Online 2017
Contributor(s): Jeremy Bray

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