Underutilization of Peptic Ulcer Disease Prophylaxis among Elderly Users of Antiplatelets and Anticoagulants

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The authors investigated physician adherence with recommending peptic ulcer disease (PUD) prophylaxis for elderly patients who were receiving dual antiplatelet therapy or anticoagulation or who were at risk of bleeding PUD, as per expert consensus guidelines from the American College of Gastroenterology (ACG), the American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA). Most patients in the study were receiving dual antiplatelet therapy (45.5%), direct oral anticoagulants (23%), or warfarin (12%). Only 40% of patients who met criteria for PUD prophylaxis received a proton pump inhibitor.
Most patients over the age of 64 with an indication for PUD prophylaxis were not receiving guideline-recommended proton pump inhibitors. This finding may explain the stable or increasing rates of hospitalizations for complicated PUD in the older population.
Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.

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Abstract

INTRODUCTION

An expert consensus document published jointly in 2008 by the American College of Gastroenterology (ACG), the American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA) provided recommendations on prevention of PUD among users of antiplatelets and anticoagulants. This work aimed to evaluate physicians' compliance with these guidelines in a tertiary academic setting.

METHODS

The authors examined our medical record database for the 9 month period extending from April 2018 until December 2018. Using this database, we identified elderly patients (> 64 years old) who were chronic (> 3 months) users of low dose aspirin (81 mg once daily) and had an indication for PUD prophylaxis as per the ACG-ACCF-AHA guideline document. The authors performed a retrospective chart review of patients included in this study.

RESULTS

A total of 852 patients were included in this study. The mean age was 75 years old, and 43% of patients were females. In addition to aspirin, patients were prescribed P2Y12 inhibitors (45.5%), direct oral anticoagulants (DOACs) (23%), warfarin (12%), steroids (9%) or enoxaparin (1%). Users of DOACs were most commonly prescribed apixaban (16%), followed by rivaroxaban (6%) and dabigatran (1%). Overall, only 40% of patients with an indication for PUD prophylaxis received a proton pump inhibitor.

CONCLUSION

PUD prophylaxis may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and an aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.