Meta-analysis of major bleeding events on aspirin versus vitamin K antagonists in randomized trials

Effects of antiplatelet therapy on menstrual blood loss in reproductive-aged women: a systematic review

Background

The effects of antiplatelet therapy on menstrual bleeding have not been well characterized.

Objectives

To systematically review the effects of antiplatelet therapy on menstrual bleeding.

Methods

A literature search was performed for studies of reproductive-aged women who received antiplatelet therapy. Characteristics of menstrual bleeding both before and after initiation of antiplatelet therapy and from comparison groups were collected. Two reviewers independently assessed the risk of bias in individual studies.

Results

Thirteen studies with a total of 611 women who received antiplatelet therapy were included. Types of antiplatelet drugs used were aspirin (n = 8), aspirin and/or clopidogrel (n = 2), prasugrel (n = 1), and not specified (n = 2). Risk of bias was assessed at moderate (n = 1), serious (n = 8), critical (n = 2), and no information (n = 2). Three studies reported changes in menstrual blood loss volume. One of these showed no increase during antiplatelet therapy; the other 2 studies suggested that aspirin may increase menstrual blood loss volume. In 3 studies that assessed the duration of menstrual bleeding, up to 13% of women reported an increased duration of menstruation. In 5 studies that reported the intensity of menstrual flow, 13% to 38% of women experienced an increase in the intensity of flow. Five studies reported the prevalence of heavy menstrual bleeding in women who received antiplatelet therapy, with estimates ranging from 7% to 38%.

Conclusion

There is lack of high-quality data on the effects of antiplatelet therapy on menstrual bleeding. Aspirin may increase menstrual blood loss, at least in a minority of women, whereas the effects of P2Y12 inhibitors are unknown.

Predictors of hemorrhagic stroke in older persons taking nonsteroidal anti-inflammatory drugs: Results from the Food and Drug Administration Adverse Event Reporting System

BACKGROUND

Hemorrhagic strokes have not declined in the United States despite a decline worldwide.

PURPOSE

To identify hemorrhagic stroke risk associated with nonsteroidal anti-inflammatory drugs (NSAIDs), other medications associated with increased risk for hemorrhagic stroke, and diabetes, cardiovascular disease, gender, and age.

METHODS

A post hoc design was used to examine predictors of hemorrhagic stroke for adults of age 65 years and older from the Food and Drug Administration Adverse Events Reporting System database. The initial sample consisted of all cases reported during the third quarter of 2016 and the second quarter of 2018 with an NSAID as the primary suspect for the adverse drug event (ADE). An additional 397 cases with warfarin as the primary suspect were included in the final sample (N = 3,784) to test for bias from including only NSAID as the primary ADE suspect cases. Extracted data included the primary ADE (hemorrhagic stroke or other ADE), age, gender, primary suspect drug (NSAID or warfarin), and presence of a second NSAID, rivaroxaban, warfarin, clopidogrel, antidepressants (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants), inhaled corticosteroids, diabetes, or cardiovascular medications. Logistic regression was used to predict hemorrhagic stroke.

RESULTS

Aspirin and warfarin increased the risk for hemorrhagic stroke by 3.458 and 3.059, respectively. Presence of an additional NSAIDs reduced the risk by 48%.

IMPLICATIONS FOR PRACTICE

Hemorrhagic stroke risk specific to older adults may provide helpful estimates for practitioners as they weigh the risk benefit of prescribing aspirin as an antiplatelet therapy for older adults.

Bleeding risk with dabigatran, rivaroxaban, warfarin, and antiplatelet agent in Asians with non-valvular atrial fibrillation

It is not understood if dabigatran or rivaroxaban are superior to antiplatelet agents (AA) for safety outcomes in Asians with non-valvular atrial fibrillation (NVAF). In this study we evaluated the bleeding risk of dabigatran, rivaroxaban, warfarin and AA in Asians with NVAF. This national retrospective cohort study analyzed 6,600, 3,167, 5,338 and 8,238 consecutive NVAF patients taking dabigatran, rivaroxaban, warfarin or AAs (including aspirin, clopidogrel or ticlopidine), respectively, from June 1, 2012 to December 31, 2013. Propensity-score weighting was used to balance covariates across study groups. Patients were followed until the first occurrence of any bleeding outcome or the end of the study. The CHA₂DS₂-VASc scores were 4.1±1.6, 4.1±1.6, 3.3±1.8 and 2.4±1.6 for the dabigatran, rivaroxaban, warfarin, and AA groups, respectively. There were 5,822 (88.2%) and 164 (5.2%) patients taking low dose dabigatran and rivaroxaban, respectively. Hazard ratios (95% confidence intervals) for dabigatran, rivaroxaban, or warfarin versus AA were: intracranial hemorrhage, 0.36 (0.23-0.57;PP=0.0037) and 1.34 (0.89-2.02;P=0.1664); gastrointestinal bleeding, 0.44 (0.32-0.59;PP=0.0189); and all hospitalized major bleeding, 0.41 (0.32-0.53;PP=0.0644) and 0.90 (0.70-1.16;P=0.4130) after adjustment. The risk reduction of all major bleeding for dabigatran versus AA persisted on subgroup analysis. In conclusion, we observed that dabiagtran was associated with a lower risk of all major bleeding in Asians with NVAF, whereas rivaroxaban had a similar risk of all major bleeding compared with antiplatelet agents after adjustment of comorbidities.