Owing to vascular abnormalities affecting the gastrointestinal (GI) tract, patients with systemic sclerosis (SSc) vs healthy controls are at significantly greater risk of experiencing GI bleeding events, according to study results published in Arthritis Research & Therapy.
Investigators of this retrospective, nationwide database study sought to evaluate the role of SSc in determining the long-term risk for bleeds in the upper and lower GI tracts.
The study included data of 3665 patients diagnosed with SSc and 18,325 healthy controls matched by age, sex, and index date. Researchers used the Catastrophic Illness Patient Database and the National Health Insurance Research Database in Taiwan from 1998 to 2007 to collect data of patients who were followed-up until the diagnosis of GI bleeding, death, withdrawal from the insurance program, or the end of 2008. After adjusting for age, sex, comorbidities, concomitant medication use, and time-dependent covariates, investigators compared the risk for GI bleeding among participants with and without SSc; peptic and nonpeptic ulcer bleeding were also evaluated.
During the 10-year follow-up, 5.21% (n=191) of participants with SSc were diagnosed with GI bleeding vs 3.68% (n=675) of the healthy controls. Among patients with SSc, the incidence rate ratio for overall GI bleeding was 979.37 (95% CI, 847.27-1125.137) per 100,000 person-years, for upper GI bleeding was 591.75 (95% CI, 493.68-709.30) per 100,000 person-years, and for lower GI bleeding was 528. 20 (95% CI, 436.24-639.53) per person-years.
Systemic sclerosis was found to be an independent risk factor for GI bleeding events in the multivariate-adjusted subdistribution hazards model, revealing a hazard ratio of 2.98 (95% CI, 2.21-4.02; P <.001) for overall GI bleeding, 2.80 (95% CI, 1.92-4.08; P <.001) for upper GI bleeding, and 3.93 (95% CI, 2.52-6.13; P <.001) for lower GI bleeding. In terms of upper GI bleeding, patients with SSc had increased risk for peptic ulcer bleeding and nonpeptic ulcer bleeding (adjusted subdistribution hazard ratios 2.52 [95% CI, 1.64-3.88]; P <.001 and 3.57 [95% CI, 2.27-5.61]; P <.001).
The male sex, older age, comorbid diabetes, and hypertension were related to higher overall GI bleeding risk. In addition, nonsteroidal anti-inflammatory drugs were associated with risk for overall GI bleeding, upper GI bleeding, and peptic ulcer bleeding. Antiplatelet therapies and steroids were associated with higher risk for nonpeptic ulcer bleeding and lower GI bleeding.
Study limitations included a lack of data on disease duration and severity and the fact that diagnoses were not based on classification criteria recognizing early or mild SSc symptoms. Only GI bleeding events that warranted hospitalization were included, and patients with obscure GI bleeding who did not undergo endoscopy or enteroscopy may have been misclassified. Demographic and patient characteristics, including smoking status, alcohol use, and nutrition, were not provided. Finally, the investigators were not able to calculate over the counter nonsteroidal anti-inflammatory drug use.
Overall, patients with SSc were found to be at significantly higher risk for GI bleeding events compared with individuals without SSc.
“Gastroenterologists, rheumatologists, and primary health care providers should be aware of GI bleeding risk in [patients with] SSc, and esophagogastroduodenoscopy and monitoring for GI complications should be considered,” the researchers concluded.
Lin YT, Chuang Y-S, Wang J-W, Wu P-H. High risk of gastrointestinal hemorrhage in patients with systemic sclerosis. Arthritis Res Ther. 2019;21(1):301.