Effect of Antithrombotic (AT) Medication on Blood Transfusions in Gastrointestinal Bleed (GIB) Patients in a Community Hospital Setting (CHS)

Abstract

Purpose: Blood transfusions are often required in patients who present with GI bleeding while concomitantly taking daily AT medications. The aim of this study was to illustrate, in the setting of an active GIB, which ATs among Acetylsalicylic Acid (ASA), Clopidogrel, Warfarin, Dabigatran and Non-ASA NSAIDs resulted in the greatest percentage of massive GI blood loss (defined as requiring ≥4 units of blood) in a CHS. Methods: A retrospective chart review was performed for all GI bleed patients on daily AT medication who received a blood transfusion at a single medical center between June 1, 2011, and December 31, 2011. Subjects were eligible if they received ≥1 unit of packed RBC. GI bleeding was defined as hematemesis, hematochezia, or occult blood in the stool accompanying a decrease in hemoglobin confirmed by a gastroenterologist, who identified the site of bleeding by endoscopy. Medications were reviewed and recorded in a database. The data was assessed by determining the total number of cases requiring transfusion while on these medications, and then by calculating the frequency of massive GI bleeds among those cases and converting that frequency to a percentage. Results: 10,843 patients were admitted to a CHS, of which 221 (2.04%), aged 67±16 years, had a GIB requiring transfusion. The source of the bleeding was found to be upper (57%), proximal to the ligament of Treitz, lower (30%), and obscure (12%), with 0.45% of cases having both an upper and lower bleed. Of the 221 patients, 68 on AT medication experienced massive GI bleeding. ASA had the greatest number of massive GIB. However, 71.4% of patients requiring transfusion while taking Clopidogrel experienced massive GI blood loss. The combination of ASA + Clopidogrel produced the largest single transfusion requirement (13 units). Conclusion: In a CHS, although ASA produced the greatest total number of GIB requiring transfusion, a greater percentage of patients who required transfusion while taking Clopidogrel resulted in massive GI blood loss. These results suggest that certain AT medications, like Clopidogrel, are more likely to require large blood transfusions than others when a GI bleed occurs; however, a limitation of this study was the small sample size for each medication. Further studies with a larger number of cases may provide a more adequate comparison of AT medications effect on blood transfusion requirements when an active GIB is present.