From the Guidelines
Aspirin can cause gastrointestinal (GI) bleeds, even at low doses, by inhibiting the enzyme cyclooxygenase (COX) and reducing the production of protective prostaglandins in the stomach lining. This makes the stomach more vulnerable to acid damage and can lead to erosions, ulcers, and bleeding. The risk is dose-dependent, with higher doses causing greater risk, and is increased in older adults, those with a history of GI bleeding or ulcers, people taking other NSAIDs, anticoagulants, or corticosteroids, and those who consume alcohol regularly 1.
To reduce this risk while taking aspirin, patients should:
- Take it with food
- Consider enteric-coated formulations, although enteric-coated or buffered preparations do not clearly reduce the adverse gastrointestinal effects of aspirin 1
- Use the lowest effective dose, as a dosage of approximately 75 mg/d seems as effective as higher dosages 1
- Avoid combining with other NSAIDs, as nonsteroidal anti-inflammatory drug therapy combined with aspirin approximately quadruples the risk for serious gastrointestinal bleeding compared with the risk with aspirin alone 1
- Limit alcohol consumption
- Discuss with their doctor about adding a proton pump inhibitor (like omeprazole) for protection if they're at high risk, as omeprazole healed and prevented ulcers more effectively than did ranitidine in patients who required continuous treatment with NSAIDs and who had ulcers or erosions in their stomach or duodenum 1
Anyone experiencing symptoms of GI bleeding such as black tarry stools, vomiting blood, or severe abdominal pain while taking aspirin should seek immediate medical attention. The net benefit of aspirin use in persons older than 80 years is probably best in those without risk factors for gastrointestinal bleeding (other than older age) and in those who could tolerate a gastrointestinal bleeding episode 1.
From the FDA Drug Label
Stomach bleeding warning: This product contains an NSAID, which may cause severe stomach bleeding The chance is higher if you are age 60 or olderHave had stomach ulcers or bleeding problemsTake a blood thinning (Anticogulant) or steroid drugTake other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others)have 3 or more alcoholic drinks every day using this product Yes, aspirin can cause GI bleeds. The risk is increased in certain individuals, including:
- Those age 60 or older
- Those with a history of stomach ulcers or bleeding problems
- Those taking blood thinning or steroid drugs
- Those taking other NSAIDs
- Those who consume 3 or more alcoholic drinks per day 2
From the Research
Aspirin and GI Bleeds
- Aspirin can cause gastrointestinal (GI) bleeds, with the risk increasing with old age, male sex, ulcer history, and concomitant medication with NSAIDs, cyclooxygenase 2 selective inhibitors, corticosteroids, or other antithrombotic agents 3.
- Even low doses of aspirin (75-325 mg daily) may cause GI bleeding, and the risk does not differ between conventional and enteric-coated aspirin use 4.
- The use of proton pump inhibitors (PPIs) can help reduce the risk of GI bleeding in patients taking aspirin, and PPIs are more effective than histamine-2 receptor antagonists (H2RAs) in preventing aspirin-induced GI bleeding 5.
Risk Factors for GI Bleeds
- Anticoagulants, low-dose aspirin, and other non-aspirin antiplatelet agents are associated with an increased risk of upper and lower GI bleeding, with anticoagulants being the strongest risk factor 6.
- Low-dose aspirin users have a higher incidence of lower GI bleeding (LGIB) than non-users, and aspirin is an independent risk factor for LGIB 7.
- Other risk factors for LGIB include NSAIDs, steroids, selective serotonin reuptake inhibitors (SSRIs), PPIs, and H2RAs 7.