Antithrombotic therapy in the etiology of an acute posthaemorrhagic anaemia

Czech version

Authors: I. Krč ¹; V. Krčová ²
Authors‘ workplace: II. interní klinika Lékařské fakulty UP a FN, Olomouc, přednosta prof. MUDr. Jiří Ehrmann, CSc. ¹; Hemato-onkologická klinika Lékařské fakulty UP a FN, Olomouc, přednosta prof. MUDr. Karel Indrák, DrSc. ²
Published in: Vnitř Lék 2005; 91(7 a 8): 873-877
Category: 128th Internal Medicine Day - 21rd Vanysek's Day Brno 2005

Overview

In patients, undergoing for various reasons an antithrombotic therapy, severe, life-threatening bleeding can occur, mostly originating in upper parts of the gastrointestinal tract. From the viewpoint of internal medicine, this type of bleeding represents the most important cause of an acute posthaemorrhagic anaemia. Crucial factors influencing the fate of the patient appear to be both the magnitude of blood loss and the time interval from the outset of bleeding to the beginning of effective treatment. Although in approximately 80% of cases a spontaneous improvement of haemorrhagic manifestations can occur in 48 hours, this brings about a high lethality (10% according to the literature) irrespective of the use of modern therapeutic approaches, particularly in older patients. The aim of our prospective study was to evaluate a group of patients treated for acute massive gastrointestinal bleeding at the Intensive care unit of the II Medical Department of the Palacky University during a six-year period (1999-2005). Our cohort included a total of 1081 subjects (619 males and 462 females). Their past history confirmed a long term medication of different types of both antithrombotics and anticoagulants (34.0%), as well as a direct relationship to the bleeding episode. The most important inducing agent of haemorrhage was aspirin (17.9%), whilst warfarin caused bleeding in 9.5%. Important associated factors of the above complication were advanced age, alcohol abuse and polymedication, in particular simultaneous therapy of non-steroid antiinflammatory drugs. The most frequent sources of the haemorrhagic lesions were endoscopically confirmed peptic ulcers. A significant blood loss with heavy anaemia and values of haemoglobin below 100 gm/L was found in 49.2% of the patients in the examined group. Nevertheless, the four-week lethality was relatively low and equalled only 6.7%. Our survey has confirmed previous conclusions found in the literature, about an increased frequency of the acute massive gastrointestinal tract bleeding, caused by anticoagulation treatment. To prevent this complication it appears fundamental to monitor consistently all types of antithrombotic or anticoagulatory treatment, particularly in elderly subjects, alcohol abusers and polymedicated patients. Before prescription of long-term aspirin or other anticoagulants we should always consider and judge individually benefits of the chosen therapy against its possible side-effects.

Key words:
gastrointestinal tract bleeding - side-effects of antithrombotic therapy - acute posthaemorrhagic anaemia

Sources

1. White RH, Beyth RJ, Zhon H et al. Major bleeding after hospitalization for deep venous thrombosis. Hepato-Gastroenterol 2000; 47: 596-560.

2. Vazquez A, Del Monte M, Lozano C et al. Haemorrhagic complications from anticoagulant treatment. Sangre 1999; 44: 216-221.

3. Gallus AS, Baker RI, Chong BH et al. Consensus guidelines for warfarin therapy. Med J Australia 2000; 172: 600-605.

4. Lee GR. Acute posthemorrhagic anemia. In Lee GR, Foerster J, Lukens J et al. Wintrobe´s Clinical hematology. Baltimore: Williams & Wilkins 1998: 1485-1488.

5. Campbell NRC, Hull RD, Brant R et al. Aging and heparin-related bleeding. Arch Int Med 1996; 156: 857-860.

6. Gullov AL, Koefoed BG, Petersen P. Bleeding during warfarin and aspirin therapy in patients with atrial fibrillation. The AFASAK 2 study. Arch Int Med 1999; 159: 1322-1328.

7. Sachs RA, Smith JH, Kuney M et al. Does anticoagulation do more harm than good? A comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty. J Arthroplasty 2003; 18: 389-395.

8. Smith NL, Psaty BM, Furberg CD et al. Temporal trends in the use of anticoagulants among older adults with atrial fibrillation. Arch Int Med 1999; 159: 1574-1578.

9. Hylek EM. Complications of oral anticoagulant therapy: bleeding and nonbleeding, rates and risk factors. Semin Vasc Med 2003; 3: 271-278.

10. Krč I, Ehrmann J. Hemolytic anemia in alcohol-induced liver damage. Blut 1985; 51: 184.

11. Beyth RJ, Quinn L, Landefeld CS. A multicomponent intervention to prevent major bleeding complications in older patients receiving warfarin. Ann Intern Med 2000; 133: 687-695.

12. McCall KL, MacLaughlin EJ. Warfarin-associated bleeding complication saved life. Pharmacotherapy 2002; 22: 97-101.

13. Harker LA, Boissel LP, Pilgrim AJ et al. Comparative safety and tolerability of clopidogrel and aspirin [CAPRIE]. Drug Saf 1999; 21: 325-335.

14. Kaufman DW, Kelly JP, Wiholm BE et al. The risk of acute major upper gastrointestinal bleeding among users of aspirin and ibuprofen at various levels of alcohol consumption. Am J Gastroenterol 1999; 94: 3189-3196.

15. Pirmohamed M, James S, Meakin S et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 2004; 329: 15-19.

16. Farell JL, Friedman LS. Gastrointestinal bleeding in the elderly. Gastroenterol Clin N Amer 2001; 30: 377-407.

17. Bloch A, Ben-Chetrit E, Muszkat M et al. Major bleeding caused by warfarin in a genetically susceptible patient. Pharmacotherapy 2002; 22: 97-101.

18. Derry S, Loke KL. Risk of gastrointestinal haemorrhage with long term use of aspirin: Meta-analysis. BMJ 2000; 321: 1183-1187.

19. De Abajo FJ, Rodriguez LA, Montero D et al. Association between selective serotonin uptake receptor inhibition and upper gastrointestinal bleeding: population based case-control study. BMJ 1999; 319: 1081-1082.

20. Nelva A, Guy C, Tardy-Poncet B et al. Syndromes hémorrhagiques sous antidepresseurs inhibiteurs sélectifs de la récapture de la serotonine (ISRS). A propos de sept cas et revue de la littérature. Rev Méd Interne (France) 2000; 21: 152-160.

21. Udvardy M, Telek B, Mezey G et al. Successful control of massive coumarol-induced acute upper gastrointestinal bleeding and correction of prothrombin time by recombinant active factor VII (Eptacog-alpha, NovoSeven) in a patient with a prosthetic aortic valve and two malignancies (chronic lymphoid leukaemia and lung cancer). Blood Coagulation & Fibrinolysis 2004; 15: 265-267.

22. Blich M, Fruchter O, Edelstein S et al. Somatostatin therapy ameliorates chronic and refractory gastrointestinal bleeding caused by diffuse angiodysplasia in a patient on anticoagulation therapy. Scand J Gastroenterol 2003; 38: 801-803.