Risk of upper gastrointestinal bleeding with oral bisphosphonates and non steroidal anti-inflammatory drugs: a case-control study.
BACKGROUND
Gastrointestinal injuries including gastric ulcers have been reported with oral bisphosphonate therapy. However, the risk of the more serious upper gastrointestinal bleeding (UGB) especially in the community setting with these drugs remains unknown. Similarly, the risk of UGB among users of both bisphosphonates and non steroidal anti-inflammatory drugs (NSAIDs) in the community is also unknown.


OBJECTIVE
To explore the risk of more serious UGB among users of bisphosphonates and the risk of UGB among users of both bisphosphonates and NSAIDs in the community.


METHODS
We conducted a case-control study within a cohort of Quebec residents who had received a revascularization procedure from 1995 to 2004. Cohort members were followed up from the date of their first procedure until the earliest of: (1) study outcome, (2) date of death or (3) end of health care coverage. Cases were defined as those with the first diagnosis of a UGB. For each case, 20 controls were selected and matched to the cases by index date, age and cohort entry. Adjusted odds ratios for current use of bisphosphonates, NSAIDs and co-therapy of both drugs were computed.


RESULTS
Within the initial cohort, 3253 incident cases of UGBs and corresponding 65 060 matched controls were identified. The adjusted odds ratio (OR) for UGB by current users of bisphosphonates was 1.01 (95% CI, 0.72-1.43). Current NSAID use was associated with an increased risk of UGB OR = 1.75; 95% CI, 1.53-1.99. The OR for use of bisphosphonates and NSAIDs was elevated OR = 2.00; 95% CI, 1.12-3.57. This risk was still elevated for users of bisphosphonates and COX-2 inhibitors [OR = 2.38 (95% CI, 1.26-4.50)].


CONCLUSIONS
We found no evidence of an increase in the risk of UGB among current users of bisphosphonates. The risk of combined NSAID and bisphosphonate therapy was increased, but this risk was not higher than the risk for NSAID users alone.
Etminan
M
M
Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Department of Medicine, University of British Columbia, Vancouver, BC, Canada. mahyar.etminan@vch.ca
Lévesque
L
L
Fitzgerald
J M
JM
Brophy
J M
JM
D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects* / Q000627:therapeutic use; D016022:Case-Control Studies; D052246:Cyclooxygenase 2 Inhibitors / Q000009:adverse effects* / Q000627:therapeutic use; D004164:Diphosphonates / Q000009:adverse effects* / Q000627:therapeutic use; D004347:Drug Interactions; D004359:Drug Therapy, Combination; D005260:Female; D005765:Gastrointestinal Agents / Q000627:therapeutic use; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced* / Q000453:epidemiology; D006801:Humans; D008297:Male; D016017:Odds Ratio; D011792:Quebec / Q000453:epidemiology; D012307:Risk Factors; D016896:Treatment Outcome
D000894:Anti-Inflammatory Agents, Non-Steroidal; D052246:Cyclooxygenase 2 Inhibitors; D004164:Diphosphonates; D005765:Gastrointestinal Agents