Time-trends in the prescribing of gastroprotective agents to primary care patients initiating low-dose aspirin or non-steroidal anti-inflammatory drugs: a population-based cohort study

Predictive value of gastrointestinal symptoms and patient risk factors for NSAID-associated gastrointestinal ulcers defined by endoscopy? Insights from a pooled analysis of two naproxen clinical trials

OBJECTIVE

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to treat pain and rheumatic conditions. To facilitate patient management, we determined the predictive value of gastrointestinal (GI) symptoms and risk factors for the development of NSAID-associated GI injuries.

METHODS

Post-hoc analysis of pooled data from naproxen treatment arms of two identical, randomized, double-blind, controlled phase 3 trials in arthritis patients at risk of GI adverse events. Endoscopic incidence of GI ulcers at baseline, and 1, 3, and 6 months was employed as a surrogate parameter for GI injury. For GI symptom analysis, Severity of Dyspepsia Assessment questionnaire was used. For GI risk factor analysis, the high risk factors: previous GI injury, concomitant selective serotonin reuptake inhibitors or corticosteroids, ulcer history, concomitant low-dose aspirin, and age >65 years were employed.

RESULTS

Data of 426 naproxen patients were analyzed. Distribution of GI symptoms between patients with and without ulcer was similar; about one third of patients developing an ulcer reported no GI pain symptoms. GI symptoms experienced under naproxen treatment were thus not indicative of GI injury. The proportion of patients developing an ulcer increased with the number of risk factors present, however, about a quarter of patients without any of the analyzed risk factors still developed an ulcer.

CONCLUSION

GI symptoms and the number of risk factors are not reliable predictors of NSAID-induced GI injury to decide which patients need gastroprotection and will lead to a large group of patients with GI injuries. A preventive rather than reactive approach should be taken.

Risk of Post-Myocardial Infarction Pneumonia with Proton Pump Inhibitors, H2 Receptor Antagonists and Mucoprotective Agents: A Retrospective Nationwide Cohort Study

Patients with myocardial infarction (MI) are at high risk of developing pneumonia. Proton pump inhibitors (PPI) and H2-receptor antagonists (H2RA) are commonly used acid-suppressive medications to the patients with MI for gastrointestinal (GI) protection, which may increase the risk for pneumonia. We evaluated whether PPI, H2RA, and mucoprotective agents without anti-acid properties increase the risk of post-MI pneumonia. We performed a retrospective cohort study based on the National Health Insurance Service—National Sample Cohort in Korea. The study included 3701 patients discharged with MI without prior history of pneumonia. During follow-up, treatments with PPI, H2RA, and mucoprotective agents were collected as time-dependent variables based on the prescription records. We performed multivariate time-dependent Cox regression analyses for the development of post-MI pneumonia. During the mean 4.85 ± 3.75 years follow-up, 999 participants developed pneumonia. In the multivariate analyses (adjusted hazard ratio; 95% confidence interval), the risk for pneumonia was significantly increased in treatment with PPI (2.25; 1.57–3.21) and H2RA (1.50; 1.16–1.93). Meanwhile, the risk for pneumonia was not increased in treatment with mucoprotective agents. When we evaluated GI bleeding event according to the medications as a secondary outcome analysis, mucoprotective agents were associated with increased GI bleeding risk, but PPI and H2RA were not. In the use of the GI medications in the treatment of patients with MI, the influence of these drugs on bleeding and pneumonia should be considered.

Proton pump inhibitor use among patients at risk of peptic ulcer bleeding: a nationwide register-based study

BACKGROUND

Proton pump inhibitors reduce the risk of peptic ulcer bleeding in patients at risk. The knowledge about the extent of gastroprotection in patients at increased risk and factors associated with prophylactic treatment is limited.

AIMS

(1) to analyze the extent of gastroprotective undertreatment in patients using aspirin/non-steroidal anti-inflammatory drugs and (2) to analyze which patient characteristics are associated with proton pump inhibitor prophylaxis among those at increased ulcer bleeding risk.

METHODS

A Danish nationwide register-based study. Based on a risk stratification model we identified citizens at increased ulcer bleeding risk and analyzed the proportion concomitantly treated with proton pump inhibitors. Further, we analyzed associations between use of ulcer prophylaxis and comorbidity and socioeconomic characteristics.

RESULTS

Some 44.4% of the high-risk patients were concomitantly treated with proton pump inhibitors. In the crude analyses cohabiting, having a high educational level and a high income were significantly associated with lower odds of being treated with proton pump inhibitors. When adjusting for medication use, age, sex and comorbidity the associations were insignificant.

CONCLUSIONS

There is room for improvement in the extent of ulcer prophylaxis but no clear social gradient in under prescribing of gastroprotection. With the substantial risk-reducing possibility concomitant proton pump inhibitor use could save numerous patients from ulcer bleeding each year. Our study calls for increased awareness of peptic ulcer bleeding risk and dissemination of knowledge to clinicians about risk factors for gastrointestinal hemorrhage and the risk reducing potential of co-prescribing proton pump inhibitors to patients at risk.

Underutilization of gastrointestinal prophylaxis in high-risk chronic nonsteroidal anti-inflammatory drug users in Korea

Background The increasing use of antithrombotic therapies in older patients has led to an increased risk of gastrointestinal (GI) bleeding in chronic nonsteroidal anti-inflammatory drug (NSAID) users. Therefore, there is a pressing need for GI prophylaxis in these high-risk patients. Objective To analyze prescribing patterns and factors associated with the use of gastroprotective agents (GPAs) among high-risk, chronic NSAID users. Setting National claims database including 20% of the total Korean population aged ≥ 65 years. Method In this cross-sectional study, we identified older adults prescribed traditional NSAIDs for > 90 days and classified them into high- and ultra-high-risk groups if they had one or two or more GI risk factors, respectively. Proton pump inhibitors or misoprostol prescribed for more than 80% of traditional NSAID treatment days was regarded as appropriate GI prophylaxis. Main outcome measure Prevalence and associated factors with appropriate GI prophylaxis. Results Among 69,992 chronic traditional NSAID users, 38.8% and 9.4% belonged to the high and ultra-high-risk groups; 13.2% and 19.9% received appropriate GI prophylaxis, respectively. The most frequently used GPA was histamine H₂ antagonists. Multiple NSAID use, concomitant antiplatelets and anticoagulants, and prior GI ulcer history increased the likelihood of receiving appropriate GI prophylaxis. Advanced age (≥ 85 years), indications other than arthritis, and neurology specialists negatively affected appropriate GI prophylaxis use. Conclusion Approximately one in five chronic NSAID users, considered ultra-high risk, are prescribed appropriate GI prophylaxis in Korea. Advanced age, indications, and specialties of the prescriber all need to be considered when selecting target populations for interventions.

Non-steroidal anti-inflammatory drugs and gastroprotection in primary health care users

Objective

The aim of this study is to assess the prevalence of gastroprotection and identify the main factors that influence the taking of protective drugs by the adult population treated with non-steroidal anti-inflammatory drugs (NSAID).

Methods

This study was cross-sectional, conducted by including a contingent of 800 users of primary health care services (n=369, 46% males and n=431, 54% females). Included in the study were individuals of both genders aged 18+ who sought counselling or treatment during the three-month period. The data collection of this study was based on the completion of a structured questionnaire, which included questions related to the use of NSAIDs, the way these drugs were prescribed and administered and the simultaneous taking of gastroprotective drugs.

Results

The prevalence of the gastroprotective drugs use was higher among the elderly, individuals living in urban areas, those with higher education, those with daily use of NSAID, individuals receiving prescriptions from their own doctors, and those suffering from side effects from the use of NSAID, as well as subjects that had a longer duration of NSAID use. Diclofenac was the most prescribed NSAID. Gastric pain and dizziness were the most experienced side effects.

Conclusion

This paper demonstrates the need to improve the quality of primary health care service through informing and educating patients regarding the need to take gastro-protective drugs for those at high risk of adverse effects manifested by the use of NSAIDs.

Predictors of gastrointestinal bleeding in older persons taking nonsteroidal anti-inflammatory drugs: Results from the FDA adverse events reporting system

BACKGROUND AND PURPOSE

Older adults continue to take nonsteroidal anti-inflammatory drugs (NSAIDs) to manage chronic pain. The study's purpose was to identify predictors of gastrointestinal (GI) bleeding in older adults taking NSAIDs.

METHODS

A secondary analysis of the 2016 Food and Drug Administration's Adverse Events Reporting System data was conducted with 1,347 cases aged 65 years and older with an NSAID as the primary suspect for an adverse drug event (ADE). Data included age, sex, NSAID, multiple NSAID use, rivaroxaban, warfarin, clopidogrel, cardiovascular drug (proxy for cardiovascular disease), diabetes drug (proxy for diabetes mellitus), and primary adverse drug response.

CONCLUSIONS

Aspirin was the primary suspect NSAID in 72.5% of cases. Rivaroxaban was taken in 67.9% of cases. Logistic regression was conducted to predict GI bleed versus other NSAID-related ADEs with age, sex, cardiovascular medication, diabetes medication, warfarin, clopidogrel, concurrent NSAID use, aspirin, and rivaroxaban as predictors. Aspirin, rivaroxaban, and concurrent NSAID were significant predictors of GI bleed. Gastrointestinal bleed risk versus other ADE risk increased by 39.77 times when taking aspirin, rivaroxaban, and another NSAIDs concurrently.

IMPLICATIONS FOR PRACTICE

Results support reduced NSAID use by older adults, especially aspirin, and avoidance of rivaroxaban in older persons taking NSAIDs.

Co-prescription patterns of cardiovascular preventive treatments: a cross-sectional study in the Aragon worker' health study (Spain)

OBJECTIVES

To identify cardiovascular disease (CVD) preventive treatments combinations, among them and with other drugs, and to determine their prevalence in a cohort of Spanish workers.

DESIGN

Cross-sectional study.

SETTING

Aragon Workers' Health Study (AWHS) cohort in Spain.

PARTICIPANTS

5577 workers belonging to AWHS cohort. From these subjects, we selected those that had, at least, three prescriptions of the same therapeutic subgroup in 2014 (n=4605).

PRIMARY AND SECONDARY OUTCOME MEASURES

Drug consumption was obtained from the Aragon Pharmaceutical Consumption Registry (Farmasalud). In order to know treatment utilisation, prevalence analyses were conducted. Frequent item set mining techniques were applied to identify drugs co-prescription patterns. All the results were stratified by sex and age.

RESULTS

42.3% of men and 18.8% of women in the cohort received, at least, three prescriptions of a CVD preventive treatment in 2014. The most prescribed CVD treatment were antihypertensives (men: 28.2%, women 9.2%). The most frequent association observed among CVD preventive treatment was agents acting on the renin-angiotensin system and lipid-lowering drugs (5.1% of treated subjects). Co-prescription increased with age, especially after 50 years old, both in frequency and number of associations, and was higher in men. Regarding the association between CVD preventive treatments and other drugs, the most frequent pattern observed was lipid-lowering drugs and drugs used for acid related disorders (4.2% of treated subjects).

CONCLUSIONS

There is an important number of co-prescription patterns that involve CVD preventive treatments. These patterns increase with age and are more frequent in men. Mining techniques are a useful tool to identify pharmacological patterns that are not evident in the individual clinical practice, in order to improve drug prescription appropriateness.

Use of Non-Steroidal Anti-Inflammatory Drugs and Associated Gastroprotection in a Cohort of Workers

BACKGROUND

This study describes the prevalence of non-steroidal anti-inflammatory drug (NSAID) use, and analyses prescribing patterns of NSAIDs and associated gastroprotection.

METHODS

The study population consisted of 5650 workers at the General Motors automobile assembly plant in Zaragoza, Spain. NSAID prescription data for 2014 were obtained from the prescription database of Aragon (Spain). NSAID consumption was determined based on the number of defined daily doses purchased per year. Heavy NSAIDs users were identified using Lorenz curves.

RESULTS

NSAID use in the cohort was high (40.7% of workers, 95% CI 39.4⁻41.9). The prescription of proton pump inhibitors increased with age. Gastrointestinal protection was lacking in some participants who were being treated with drugs associated with a high risk of gastrointestinal bleeding. Heavy NSAID users (defined as those above the 95th percentile of consumption), accounted for 26% of total DDDs, and consumed a greater proportion of coxibs than non-heavy users.

CONCLUSIONS

The rate of NSAID consumption in the cohort was high. To reduce the risk of gastrointestinal complications, monitoring and adequate gastroprotection are essential in patients who are prescribed NSAIDs for long periods of time or who are treated concomitantly with drugs that increase the risk of gastrointestinal bleeding.

Gastrointestinal risk factors and prescribing pattern of antiulcer agents in patients taking low-dose aspirin in Japan

Objectives

To identify prescribing patterns of antiulcer agents in patients on low-dose aspirin (LDA) and to evaluate the number of gastrointestinal (GI) risk factors of the patients.

Methods

A retrospective chart review of patients taking LDA was conducted at the National Cerebral and Cardiovascular Center in Japan. The rate of concomitant use of antiulcer agents and the risk of each patient to develop GI complications were evaluated.

Results

Of the 314 patients, 64 were not on antiulcer agents and 55 of them had >1 risk factor. More patients not on antiulcer agents had started LDA before hospitalization.

Conclusion

The rate of coprescribing antiulcer agents with LDA was high. However, the timing of initiating LDA therapy affected the prescribing pattern of antiulcer agents.

International Consensus on Guiding Recommendations for Management of Patients with Nonsteroidal Antiinflammatory Drugs Induced Gastropathy-ICON-G

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs), one of the most commonly used medications worldwide, are frequently associated with gastrointestinal adverse events. Primary care physicians often face the challenge of achieving adequate pain relief with NSAIDs, while keeping their adverse events to a minimum. This is especially true when long-term use of NSAIDs is required such as in patients with osteoarthritis and rheumatoid arthritis. To help primary care physicians deal with such challenges more effectively, a panel of expert gastroenterologists came together with the aim of developing practice recommendations.

METHODS

A modified 'Delphi' process was used to reach consensus and develop practice recommendations. Twelve gastroenterologists from nine countries provided their expert inputs to formulate the recommendations. These recommendations were carefully developed taking into account existing literature, current practices, and expert opinion of the panelists.

RESULTS

The expert panel developed a total of fifteen practice recommendations. Following are the key recommendations: NSAIDs should be prescribed only when necessary; before prescribing NSAIDs, associated modifiable and non-modifiable risk factors should be considered; H. pylori infection should be considered and treated before initiating NSAIDs; patients should be properly educated regarding NSAIDs use; patients who need to be on long-term NSAIDs should be prescribed a gastroprotective agent, preferably a proton pump inhibitor and these patients should be closely monitored for any untoward adverse events.

CONCLUSION/CLINICAL SIGNIFICANCE

These practice recommendations will serve as an important tool for primary care physicians and will guide them in making appropriate therapeutic choices for their patients.How to cite this article: Hunt R, Lazebnik LB, Marakhouski YC, Manuc M, Ramesh GN, Aye KS, Bordin DS, Bakulina NV, Iskakov BS, Khamraev AA, Stepanov YM, Ally R, Garg A. International Consensus on Guiding Recommendations for Management of Patients with Nonsteroidal Anti-inflammatory Drugs Induced Gastropathy-ICON-G. Euroasian J Hepatogastroenterol, 2018;8(2):148-160.

Cost Effectiveness of Gastroprotection with Proton Pump Inhibitors in Older Low-Dose Acetylsalicylic Acid Users in the Netherlands

Purpose

The present study aimed to assess the cost effectiveness of concomitant proton pump inhibitor (PPI) treatment in low-dose acetylsalicylic acid (LDASA) users at risk of upper gastrointestinal (UGI) adverse effects as compared with no PPI co-medication with attention to the age-dependent influence of PPI-induced adverse effects.

Methods

We used a Markov model to compare the strategy of PPI co-medication with no PPI co-medication in older LDASA users at risk of UGI adverse effects. As PPIs reduce the risk of UGI bleeding and dyspepsia, these risk factors were modelled together with PPI adverse effects for LDASA users 60–69, 70–79 (base case) and 80 years and older. Incremental cost-utility ratios (ICURs) were calculated as cost per quality-adjusted life-year (QALY) gained per age category. Furthermore, a budget impact analysis assessed the expected changes in expenditure of the Dutch healthcare system following the adoption of PPI co-treatment in all LDASA users potentially at risk of UGI adverse effects.

Results

PPI co-treatment of 70- to 79-year-old LDASA users, as compared with no PPI, resulted in incremental costs of €100.51 at incremental effects of 0.007 QALYs with an ICUR of €14,671/QALY. ICURs for 60- to 69-year-old LDASA users were €13,264/QALY and €64,121/QALY for patients 80 years and older. Initiation of PPI co-treatment for all Dutch LDASA users of 60 years and older at risk of UGI adverse effects but not prescribed a PPI (19%) would have cost €1,280,478 in the first year (year 2013 values).

Conclusions

PPI co-medication in LDASA users at risk of UGI adverse effects is generally cost effective. However, this strategy becomes less cost effective with higher age, particularly in patients aged 80 years and older, mainly due to the increased risks of PPI-induced adverse effects.

Long-Term Safety of a Coordinated Delivery Tablet of Enteric-Coated Aspirin 325 mg and Immediate-Release Omeprazole 40 mg for Secondary Cardiovascular Disease Prevention in Patients at GI Risk

Introduction

In two, 6‐month, randomized, double‐blind Phase 3 trials, PA32540 (enteric‐coated aspirin 325 mg and immediate‐release omeprazole 40 mg) compared to aspirin alone was associated with fewer endoscopic gastric and duodenal ulcers in patients requiring aspirin therapy for secondary cardiovascular disease (CVD) prevention who were at risk for upper gastrointestinal (UGI) events.

Aims

In this 12‐month, open‐label, multicenter Phase 3 study, we evaluated the long‐term cardiovascular and gastrointestinal safety of PA32540 in subjects who were taking aspirin 325 mg daily for ≥3 months for secondary CVD prevention and were at risk for aspirin‐associated UGI events. Enrolled subjects received PA32540 once daily for up to 12 months and were assessed at baseline, month 1, month 6, and month 12.

Results

The overall safety population consisted of 379 subjects, and 290 subjects (76%) were on PA32540 for ≥348 days (12‐month completers). Adverse events (AEs) caused study withdrawal in 13.5% of subjects, most commonly gastroesophageal reflux disease (1.1%). Treatment‐emergent AEs occurred in 76% of the safety population (11% treatment‐related) and 73% of 12‐month completers (8% treatment‐related). The most common treatment‐related AE was dyspepsia (2%). One subject had a gastric ulcer observed on for‐cause endoscopy. There were five cases of adjudicated nonfatal myocardial infarction, one nonfatal stroke, and one cardiovascular death, but none considered treatment‐related.

Conclusions

Long‐term treatment with PA32540 once daily for up to 12 months in subjects at risk for aspirin‐associated UGI events is not associated with any new or unexpected safety events.

Characterizing Potentially Inappropriate Prescribing of Proton Pump Inhibitors in Older People in Primary Care in Ireland from 1997 to 2012

OBJECTIVES

To characterize prescribing of proton pump inhibitors (PPIs) and medicines that increase gastrointestinal bleeding risk (ulcerogenic) in older people from 1997 to 2012 and assess factors associated with maximal-dose prescribing in long-term PPI users.

DESIGN

Repeated cross-sectional study of pharmacy claims data.

SETTING

Eastern Health Board region of Ireland.

PARTICIPANTS

Individuals aged 65 and older from a means-tested health plan in 1997, 2002, 2007, and 2012 (range 78,489-133,884 individuals).

MEASUREMENTS

PPI prescribing prevalence was determined per study year, categorized according to duration (≤8 or >8 weeks), dosage (maximal or maintenance), and co-prescribed drugs. Logistic regression in long-term PPI users was used to determine whether age, sex, polypharmacy, and ulcerogenic medicine use were associated with being prescribed a maximal dose rather than a maintenance dose. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) are presented.

RESULTS

Half of this older population received a PPI in 2007 and 2012. Long-term use (>8 weeks) of maximal doses rose from 0.8% of individuals in 1997 to 23.6% in 2012. Although some ulcerogenic medicines and polypharmacy were significantly associated with maximal PPI doses, any nonsteroidal anti-inflammatory drug use was significantly associated with lower odds of maximal PPI dose (adjusted OR = 0.87, 95% CI = 0.85-0.89), as were aspirin use and older age. Adjusting for medication and demographic factors, odds of being prescribed a maximal PPI dose were significantly higher in 2012 than in 1997 (adjusted OR = 6.30, 95% CI = 5.76-6.88).

CONCLUSIONS

Long-term maximal-dose PPI prescribing is highly prevalent in older adults and is not consistently associated with gastrointestinal bleeding risk factors. Interventions involving prescribers and patients may promote appropriate PPI use, reducing costs and adverse effects of PPI overprescribing.

Noncompliance with guidelines on proton pump inhibitor prescription as gastroprotection in hospitalized surgical patients who are prescribed NSAIDs

BACKGROUND AND AIMS

As NSAIDs can cause serious upper gastrointestinal harm, guidelines have been established for the prescribing of proton pump inhibitors (PPIs) in high-risk patients using NSAIDs. Studies examining guideline compliance in surgical patients are scarce. Therefore, a retrospective cross-sectional database study was carried out aimed at determining the proportion of noncompliance with the Dutch guideline and determining the association of several factors with this noncompliance.

MATERIALS AND METHODS

Hospital admissions of patients on surgical wards of Erasmus University Medical Center between 1 January 2013 and 1 August 2014 were included in which an NSAID was newly prescribed. Preadmission PPI use was excluded. The main outcome was the proportion of noncompliance with the guideline. As a secondary outcome, the association of several potential risk factors with noncompliance was assessed. The proportion of guideline noncompliance was calculated as the percentage of all included surgical ward admissions. For the secondary analysis, univariate and multivariable logistic regression analyses were carried out.

RESULTS

A total of 409 admissions were included. The proportion of admissions in which guideline noncompliance was present was 46.6%, mostly because of incorrectly added PPIs. Coxib use [adjusted odds ratio 0.22 (95% confidence interval 0.12-0.44)], polypharmacy (the use of five or more drugs) [2.18 (1.27-3.76)], and the surgical wards orthopedics [22.32 (5.38-92.55)], plastic surgery [10.82 (2.51-46.59)], trauma surgery [5.78 (1.47-22.70)], and transplant/vascular surgery [4.45 (1.10-18.00)] were statistically significantly associated with noncompliance.

CONCLUSION

Noncompliance with the guideline on NSAID use and gastroprotection is present in almost half of surgical hospital admissions and mainly involves overprescribing.

Assessing prescribing of NSAIDs, antiplatelets, and anticoagulants in Canadian family medicine using chart review

Background Drug-related problems have been identified as a major contributor to emergency room visits, hospitalizations, and death. The most commonly implicated medications are nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelets, and anticoagulants. Considering a significant proportion of these harms are preventable, indicators to identify risky prescribing before they lead to harm have been developed. Objective To examine the prevalence and patterns of potentially inappropriate prescriptions (PIPs) in a primary care population who are using high-risk medications. Setting This study was performed within two multi-disciplinary family medicine teaching clinics in Winnipeg, Canada. Method A cross-sectional electronic/paper chart audit was conducted within two multi-disciplinary family medicine teaching clinics to evaluate the prevalence of 13 evidence-based high-risk prescriptions. Patients were included if they were prescribed an oral NSAID, antiplatelet, or an anticoagulant within the 12 month period between June 2012 and June 2013. Main outcome measure The proportion of PIPs associated with an increased bleeding risk for NSAIDs, antiplatelets, and anticoagulants. Results Of the 567 patients included in the review, 198 (35 %) patients had received at least 1 PIP in the past year. The most common PIP was the use of an oral NSAID with one or more GI risk factors without adequate gastro-protection. Only 34 (6 %) of these patients received a full medication review performed by a pharmacist. Although not statistically significant, patients who received a medication review had fewer inappropriate prescriptions (27 % with review, 35 % without). Conclusion Over one-third of the patients who were using high-risk medications were using them potentially inappropriately. Although pharmacists have been shown to reduce the amount of inappropriate prescribing, very few patients using these medications were referred to the pharmacist for a full medication review. These data suggest that there is opportunity for the identification and assessment of these patients when prescribing or dispensing these high-risk medications.

Current Strategies to Reduce Gastrointestinal Bleeding Risk Associated with Antiplatelet Agents

Antiplatelet agents remain the cornerstone in the primary and secondary therapeutic intervention for cardiovascular disease. Some patients may be subjected to a year or more of dual antiplatelet therapy to reduce the risk of subsequent cardiovascular events. Patients on antiplatelet therapy have an increased risk of gastrointestinal bleeding; however, not all patients benefit from concomitant acid suppressive therapy. This review will provide an overview of the pharmacology of antiplatelet agents and outline patient risk profiles that ought to be considered when considering prophylactic therapy to reduce gastrointestinal toxicity. In addition, we discuss the current risk-reduction strategies intended to mitigate against the potential for related gastroduodenal injury.