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Management strategy of gastrointestinal mucosal injury induced by antiplatelet drugs

Management strategy of gastrointestinal mucosal injury induced by antiplatelet drugs

  • Categories:Stomach healthy
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  • Time of issue:2020-12-01
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(Summary description)

Management strategy of gastrointestinal mucosal injury induced by antiplatelet drugs

(Summary description)

  • Categories:Stomach healthy
  • Author:
  • Origin:
  • Time of issue:2020-12-01
  • Views:0
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  A large number of clinical studies have confirmed that antiplatelet therapy has obvious benefits in the primary and secondary prevention of thromboembolic diseases, but antiplatelet drugs are a "double-edged sword", which inhibits platelet activation and thrombosis on the one hand, and damages on the other. The mucosa of the digestive tract, leading to ulcer formation and bleeding, can cause death in severe cases. Studies have shown that aspirin can increase the risk of damage to the digestive tract by 2-4. At the same time, clopidogrel (75 mg/d) and aspirin (100 mg/d) have similar risks for gastrointestinal bleeding. When aspirin is combined with clopidogrel, the incidence of gastrointestinal bleeding is significantly higher than that of using an antiplatelet drug alone, and the risk increases by 2-3 times. But for patients who have cardiovascular risk factors and need to take antiplatelet drugs for a long time, how to carry out effective drug treatment and management? Reduce the occurrence and extent of their digestive tract mucosal damage. Invite Professor Wang Jiangbin from the Sino-Japanese Friendship Hospital of Jilin University to share with you the importance of antiplatelet drugs in preventing cardiovascular disease and the prevention and treatment concept of inducing mucosal damage.

  One,

  The role of antiplatelet drugs in the prevention of cardiovascular diseases is indispensable

  In recent years, with the continuous improvement and improvement of people’s living standards, although everyone’s awareness of the prevention of cardiovascular and cerebrovascular diseases has increased, the overall incidence of cardiovascular diseases is still on the rise, and the mortality rate of cardiovascular diseases reported in China is still increasing. The reduction is significantly higher than that of malignant tumors and other diseases. Therefore, it is extremely important to evaluate the risk of cardiovascular diseases such as atherosclerosis. Primary prevention of cardiovascular disease requires low-dose (75-100 mg/d) aspirin. Regardless of whether it is cerebrovascular disease, cardiovascular disease, or secondary prevention of peripheral vascular disease, antiplatelet drugs must be taken. Because of its important role in the cardiovascular system, it has been widely clinically verified and the effect is obvious. Therefore, the role of antiplatelet drugs in the treatment of cardiovascular diseases is undisputed.

  二、

  The mechanism of antiplatelet drugs-induced gastric mucosal injury

  Aspirin damages the gastric mucosa. In addition to direct damage, the non-selective inhibitory effect of aspirin on cyclooxygenase is the most important mechanism leading to gastric mucosa. Aspirin inactivates cyclooxygenase, thereby inhibiting the synthesis of the platelet activator thromboxane A2. There are two types of cyclooxygenase in the body, cyclooxygenase-1 and cyclooxygenase-2. There is only cyclooxygenase-1 in platelets. Since platelets are non-nucleated cells, they have no ability to re-synthesize reducing oxygenase. The activity is inhibited, and its effect can continue throughout the life cycle of platelets. However, cyclooxygenase-2 exists in nucleated cells such as endothelium and mediates the synthesis of prostacyclin to play a basic mucosal cell protection. However, aspirin also inhibits this enzyme. Therefore, long-term use of aspirin can cause damage to the gastrointestinal mucosa. Even if you take enteric-coated aspirin, it can only relieve to a certain extent but cannot achieve complete prevention.

  Clopidogrel antiplatelet mechanism: On the one hand, it inhibits the production of vascular endothelial growth factor by platelets, thereby inhibiting the proliferation of gastric mucosal epithelial cells; on the other hand, it induces apoptosis of gastric mucosal cells and reduces the expression of tight junction proteins between cells, thereby affecting the stomach The repair ability of the mucosa. Therefore, clopidogrel also has a damaging effect on the gastric mucosa to some extent, and it increases with the increase of the dose.

  In contrast, the damage of aspirin to the gastric mucosa has a much higher chance of inducing gastrointestinal bleeding than clopidogrel. The risk of gastric mucosal damage caused by the combination of the two is higher than that of the single use. Therefore, when patients need dual antiplatelet therapy in clinical practice, they must be more cautious about the damage of their digestive tract mucosa.

  three,

  Prevention and treatment strategies for gastric mucosal injury induced by antiplatelet drugs

  1. Helicobacter pylori (Hp) eradication treatment

  Hp infection is an independent risk factor for gastrointestinal bleeding. Hp eradication can reduce the recurrence of ulcers and bleeding. Although eradication of Hp is not sufficient to completely prevent gastric mucosal damage induced by antiplatelet drugs, domestic and foreign guidelines suggest that before planning to take antiplatelet drugs, Hp eradication needs to be tested and treated. Currently, we recommend a quadruple eradication program of proton pump inhibitor (PPI) + antibiotics (2 types) + mucosal protective agent, and the course of treatment is 14 days. Investigations in five studies at home and abroad have shown that Hp eradication can effectively improve antiplatelet drugs-induced peptic ulcers. Another study showed that eradication of Hp can reduce 8.5% of gastric mucosal injury events induced by antiplatelet drugs. Therefore, Hp eradication should be given to patients who take low-dose aspirin for a long time.

  2. Application of proton pump inhibitor (PPI)

  The acid suppression effect of PPI will cause the pH of the stomach to rise, which will cause two results. On the one hand, the damage effect of aspirin on the mucous membrane is reduced, and on the other hand, its absorption will be reduced, and its effect on cardiovascular protection will be reduced. A study compared the adverse cardiovascular events of a group of patients taking aspirin and PPI and a group of patients taking H2 receptor antagonist (H2RA). The results showed that the adverse cardiovascular events induced by the combination of H2RA were lower than those of the combination of different types of PPI. group. Studies have also shown that PPI and H2RA can reduce the secretion of gastric acid. However, the acidity of gastric juice is one of the main bactericidal barriers. Considering its biological principles, the bactericidal barrier of gastric acid and the anti-acid properties of PPI and H2RA, the use of acid inhibitors can increase The risk of pneumonia in patients, especially stroke patients with dysphagia. In addition, in recent years, a small number of studies have shown that PPI can also inhibit NO synthase, resulting in a decrease in the production of NO. NO is an essential substance for maintaining coronary vasodilation. Therefore, the reduction of NO leads to a decrease in vasodilation tension, thereby reducing the blood supply of coronary blood vessels. Then the incidence of cardiovascular disease will increase.

  3. Application of mucosal protective agent

  Mucosal protective agents have been widely used in the protective treatment of gastroduodenal mucosa. For example, polyprezinc can increase gastric blood flow, inhibit the production of inflammatory factors, and reduce free oxygen free radicals without affecting gastric acid. Play a variety of mucosal protection mechanisms, treat symptoms related to gastrointestinal mucosal damage caused by antiplatelet drugs, and prevent the occurrence of ulcers. At the same time, in vitro studies have confirmed that polyprezinc, a gastrointestinal mucosal protective agent, on the one hand can inhibit inflammation and oxidative stress, on the other hand, promote the proliferation of epithelial cells and advance the repair mechanism independent of prostaglandin E, and at the same time can improve Hp eradication The effect of the effect. Another study of patients who have been taking low-dose aspirin for more than three months and have had upper small intestinal mucosal injury showed that the mucosal protectant-polyprezinc can effectively promote ulcer healing and improve the histological score of gastric mucosa and upper small intestine Mucosal histology score.

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