From the Guidelines
For a 94-year-old female with gastrointestinal bleeding who is on aspirin, diclofenac, and famotidine, immediate discontinuation of both aspirin and diclofenac is recommended as these medications significantly increase bleeding risk. The patient should be hospitalized for close monitoring, fluid resuscitation, and blood transfusion if hemodynamically unstable or if hemoglobin levels are critically low. A proton pump inhibitor (PPI) such as pantoprazole 40mg IV twice daily should be initiated, replacing famotidine, as PPIs are more effective at reducing gastric acid and promoting healing of gastrointestinal lesions 1. Urgent endoscopy should be performed within 24 hours to identify the bleeding source and potentially provide therapeutic intervention. After stabilization, if antiplatelet therapy is essential (such as for cardiovascular protection), consultation with cardiology is needed to determine the safest approach, which might include restarting aspirin alone at the lowest effective dose with PPI coverage 1. For pain management, acetaminophen should be used instead of NSAIDs. The bleeding is likely due to the combined effects of aspirin and diclofenac, which inhibit prostaglandin production, reducing the protective mucus layer in the GI tract and increasing acid-induced damage, while age-related factors further increase this risk in elderly patients 1.
Some key points to consider in the management of this patient include:
- The risk of gastrointestinal complications with NSAIDs is increased in elderly patients, and the use of aspirin and diclofenac together further increases this risk 1.
- The use of PPIs can reduce the risk of gastrointestinal complications in patients taking NSAIDs, and they are more effective than H2-receptor antagonists such as famotidine 1.
- Urgent endoscopy is recommended to identify the source of bleeding and provide therapeutic intervention if necessary.
- The use of acetaminophen for pain management instead of NSAIDs can help reduce the risk of gastrointestinal complications.
- Consultation with cardiology is necessary to determine the safest approach for antiplatelet therapy, if needed, after stabilization of the patient.
From the FDA Drug Label
WARNINGS ... Gastrointestinal Bleeding, Ulceration, and Perforation ... NSAIDs, including diclofenac, cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of the esophagus, stomach, small intestine, or large intestine, which can be fatal.
Risk Factors for GI Bleeding, Ulceration, and Perforation ... Patients with a prior history of peptic ulcer disease and/or GI bleeding who use NSAIDs had a greater than 10-fold increased risk for developing a GI bleed compared to patients without these risk factors ... concomitant use of oral corticosteroids, aspirin, anticoagulants, or selective serotonin reuptake inhibitors (SSRIs); smoking, use of alcohol, older age, and poor general health status ... Most postmarketing reports of fatal GI events occurred in elderly or debilitated patients.
Strategies to Minimize the GI Risks in NSAID-treated Patients ... Use the lowest effective dosage for the shortest possible duration. Avoid administration of more than one NSAID at a time ... If a serious GI adverse event is suspected, promptly initiate evaluation and treatment, and discontinue diclofenac potassium tablets until a serious GI adverse event is ruled out.
The patient is experiencing gastrointestinal bleeding, which is a known risk of NSAID use, particularly in elderly patients. Given the patient's age and the fact that she is taking aspirin and diclofenac, both of which increase the risk of GI bleeding, the following steps should be taken:
- Discontinue the use of diclofenac and aspirin to minimize further risk of GI bleeding.
- Monitor the patient closely for signs and symptoms of GI ulceration and bleeding.
- Consider alternate therapies for pain management that do not increase the risk of GI bleeding.
- Promptly initiate evaluation and treatment for the GI bleeding, as the patient's condition warrants immediate attention 2.
From the Research
Management of Gastrointestinal Bleeding
The patient's medication regimen includes aspirin, diclofenac (a nonsteroidal anti-inflammatory drug (NSAID)), and famotidine (an H2 receptor antagonist), which can contribute to gastrointestinal bleeding 3, 4.
- Discontinue or modify medications: Consider discontinuing or modifying the patient's medications that may be contributing to the gastrointestinal bleeding, such as aspirin and diclofenac 3, 4.
- Helicobacter pylori eradication: Consider testing for and eradicating Helicobacter pylori, as this can help prevent gastrointestinal bleeding 3.
- Co-medication with a proton pump inhibitor (PPI): Consider adding a PPI to the patient's medication regimen to help reduce the risk of gastrointestinal bleeding 3, 4.
- Endoscopy: Perform an endoscopy to diagnose and potentially treat the source of the gastrointestinal bleeding 5, 6.
- Hemodynamic stabilization: Ensure the patient is hemodynamically stable before proceeding with any diagnostic or therapeutic interventions 5, 6.
Diagnostic Approach
- Thorough history taking and physical examination: Perform a thorough history taking and physical examination to assess the patient's condition and identify potential causes of the gastrointestinal bleeding 5.
- Imaging diagnostic techniques: Consider using imaging diagnostic techniques, such as CT angiography, scintigraphy with labeled erythrocytes, or arteriography, to help diagnose the source of the bleeding 6.