Balancing Heart and Gut Risks of NSAIDs and Antiplatelets

Size: px
Start display at page:

Download "Balancing Heart and Gut Risks of NSAIDs and Antiplatelets"

Transcription

1 Balancing Heart and Gut Risks of NSAIDs and Antiplatelets Dato Dr Tan Huck Joo Senior Consultant Gastroenterologist and Hepatologist Sunway Medical Centre, Petaling Jaya Selangor

2 Contents NSAID and risk of PUD Prevention NSAID/COX2i and CV risks Choosing the right NSAIDs Antiplatelet and PUD Prevention strategy Antiplatelet and PPI

3 PPI is protective against NSAID induced GI toxicity Odds ratio after adjusted for age, gender, H pylori Acute users Chronic users NSAID NSAID +PPI Pilotto A et al. Aliment Pharmacol Ther 2004

4 A 70 year old lady with rheumatoid arthritis and history of NSAID induced ulcer bleed. She also has dyspepsia. You would 1. Prescribe coxib 2. Add PPI to NSAID 3. Use non NSAID analgesia 4. Prescribe PPI and coxib

5 Coxibs vs diclofenac plus omeprazole 6-month cumulative incidence of ulcers Celecoxib Diclofenac + Omeprazole 0 Bleeding ulcers Endoscopic ulcers All ulcers Chan FK et al. N Engl J Med 2002 Chan FK et al. Gastroenterology 2004

6 Celecoxib vs lansoprazole and naproxen Recurrent ulcer complications at 6 months Celecoxib Naproxen + Lansoprazole 2 0 Recurrent ulcer Dyspepsia Lai KC et al. Am J Med 2005

7 Coxib+PPI in Very High Risk 13 month cumulative incidence of recurrent ulcer bleeding Coxib+PPI P= Coxib+placebo Chan FK et al. Lancet 2007

8 Helicobacter pylori eradication in patients starting NSAID 6-month probability of ulcers and complicated ulcers HP erad Placebo Peptic ulcer Complicated ulcers Chan FK et al. Lancet 2002

9 PPI vs HP Eradication in Preventing Recurrent Bleeding Probability of recurrent bleeding at 6 months N=400 P=0.05 P=NS Aspirin NSAID Erad group PPI Chan FK. NEJM 2001

10 PPI prevent ulcer complications after HP eradication in pts on aspirin Ulcer recurrence at 12 months 16 n-= Lansaprazole Placebo Lai KC et al. NEJM 2002

11 NSAID AND CV RISKS

12 Is cardiovascular toxicity a class effect Rofecoxib (VIGOR, APPROVe trials) Celecoxib (APC trial) Paracoxib + Valdecoxib (post-coronary bypass) Lumiracoxib (TARGET trial) YES

13 Is cardiovascular toxicity dose dependent? (APC trial) Adenoma Prevention with Celecoxib trial N= 2035 patients Celecoxib 200mg or 400md bid vs placebo Follow up 2.8 to 3.1 years End point cardiovascular and noncardiovascular events Soloman SD et al. N Engl J Med 2005;352(11):

14 CV toxicity is dose dependent Soloman SD et al. N Engl J Med 2005;352(11):

15 Cardiovascular toxicity is related to treatment duration Bresalier et al. N Engl J Med 2005

16 IS CONVENTIONAL NSAID SAFER THAN COXIBS?

17 NSAID is no safer than coxib in cardiovascular toxicity celecoxib rofecoxib NSAID Adjusted rate ratio Mamdani M et al. Lancet 2004;363:1751-6

18 The risk of CCF was higher in patients prescribed rofecoxib or NSAID than celecoxib The risk of death and recurrent CCF were similar between patients prescribed NSAID and rofecoxib Hudson M. BMJ 2005 The incidence of serious cardiovascular events were similar between celecoxib and NSAID White WB. Am J Cardiol 2002

19 A 70 year old gentleman with IHD presented with acute gout. You would prescribe 1. Ibuprofen 2. Naproxen 3. Coxib

20 Naproxen is protective? Juni P et al. Arch Intern Med 2002

21 Juni et al. Lancet 2004

22 CAN CONCOMITANT ASPIRIN REDUCE CARDIOVASCULAR RISK OF COXIBS AND NSAIDS?

23 Aspirin does not reverse CV risk of high dose rofecoxib RR of MI ASA+rofecoxib 25mg ASA+rofecoxib >25mg od Levesque LE et al. Ann Intern Med 2005

24 Aspirin negates GI toxicity sparing effect of coxibs Cumulative incidence of ulcers Placebo Aspirin ASA+ rofecoxib Ibuprofen Laine L et al Gastroenterology 2004;127(2):

25 Aspirin negates GI toxicity sparing effects of coxibs Annual incidence % celecoxib NSAID ulcer complications Symptomatic ulcer Patients not taking aspirin Silverstein et al JAMA 2000

26 6 Annual incidence % P= P=0.92 Celecoxib NSAID 1 0 Ulcer complications Symptomatic ulcer Patients taking aspirin Silverstein et al JAMA 2000

27 Aspirin Increases GI risk of NSAIDs Relative risk of UGIB A75 A150 A300 NSAID Combined Weil et al. BMJ 1995

28 Ibuprofen negates CV protective effect of aspirin MacDonald TM et al. Lancet 2003

29 Ibuprofen abrogates the benefits of aspirin for prevention of MI Hazard ratio for recurrent AMI ASA+ibuprofen Trend towards lower rate of AMI ASA+naproxen 30 days > 60 days > Hudson M et al. J Rheumatol 2005

30 NSAID & CV toxicity Coxibs increase cardiovascular risk (class effect) Different coxibs have different CV toxicities NSAID is no safer naproxen is safer choice CV toxicity is dose dependent CV toxicity is related to treatment duration Aspirin does not reverse CV toxicity of NSAID/Coxib Aspirin plus NSAID increase risk of UGI bleed Ibuprofen negates CV protective effect of aspirin

31 Long term NSAID use: Risk vs Benefit Low GI Risk High GI Risk Low CV Risk NSAIDs COX2i + PPI High CV Risk Naproxen GI risk concern: COX2i + PPI CV risk concern: Naproxen + PPI

32 A 75 year old lady with IHD presented with aspirin induced gastric ulcer bleeding. You would 1. Switch aspirin to clopidogrel 2. Add PPI to aspirin long term 3. prescribe PPI + clopidogrel 4. Stop aspirin

33 ASPIRIN PLUS PPI VS CLOPIDOGREL

34 Aspirin plus esomeprazole vs clopidogrel in recurrent ulcer prevention Clopidogrel ASA + esomeprazole Clopidogrel ASA + esomeprazole Doggrell SA. Expert Opin Pharmacother 2005

35 Clopidogrel vs aspirin plus esomeprazole Cumulative incidence of recurrent ulcer bleeding at 12 months Clopidogrel P=0.001 ASA + esomeprazole Chan FK et al. N Engl J Med 2005;352(3):238-44

36 PPI + ASPIRIN OR PPI + CLOPIDOGREL?

37 PPI + Plavix PPI + aspirin All ulcers GU DU GU+DU Ng FH et al. Aliment Pharmacol Ther 2004

38 Clopidogrel vs PPI plus aspirin Among patients with previous history of aspirin induced ulcer bleeding Aspirin plus esomeprazole is superior to clopidogrel in the prevention of recurrent ulcer bleeding Early conversion of aspirin to clopidogrel or continuing with aspirin, both in the presence of PPI, are equally safe PPI plus clopidogrel may not be safer than PPI plus aspirin

39 Conclusions Balancing CV and GI risks is important PPI reduces risk of PUD in patients taking NSAID and aspirin Both coxib and NSAID increases CV risks except naproxen Aspirin does not reverse the CV risk of NSAID/coxib and negate GI toxicity sparing effect of coxib

40 THANK YOU

A. Ketorolac*** B. Naproxen C. Ibuprofen D. Celecoxib

A. Ketorolac*** B. Naproxen C. Ibuprofen D. Celecoxib 1. A man, 66 years of age, with a history of knee osteoarthritis (OA) is experiencing increasing pain at rest and with physical activity. He also has a history of depression and coronary artery disease.

More information

Articles Presented. Journal Presentation. Dr Albert Lo. Dr Albert Lo

Articles Presented. Journal Presentation. Dr Albert Lo. Dr Albert Lo * This presentation is prepared by the author in one s personal capacity for the purpose of academic exchange and does not represent the views of his/her organisations on the topic discussed. Journal Presentation

More information

New Anticoagulants and GI bleeding

New Anticoagulants and GI bleeding New Anticoagulants and GI bleeding DR DANNY MYERS MD FRCP(C) CLINICAL ASSISTANT PROFESSOR OF MEDICINE, UBC Conflicts of Interest None I am unbiased in the use of NOAC s vs Warfarin based on risk benefit

More information

What s the Deal with NSAIDs?

What s the Deal with NSAIDs? Focus on CME at the Memorial xxx University of Newfoundland What s the Deal with NSAIDs? Majed M. Khraishi, MB, BCh, FRCPC Presented at Wednesday at Noon Ask the Consultant Arthritis is one of the most

More information

Alimentary Pharmacology & Therapeutics

Alimentary Pharmacology & Therapeutics Alimentary Pharmacology & Therapeutics Changing perceptions and practices regarding aspirin, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs among

More information

Guidelines for Use of Clopidogrel (Plavix )

Guidelines for Use of Clopidogrel (Plavix ) East Lancashire Medicines Management Board representing East Lancashire Hospitals NHS Trust, Lancashire Care Trust, Blackburn with Darwen PCT, East Lancs PCT Licensed Indications Guidelines for Use of

More information

Gloucestershire Hospitals

Gloucestershire Hospitals TRUST GUIDELINE In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the document. The Policy framework requires that the policy is fully

More information

Guidelines for Prevention of NSAID-Related Ulcer Complications

Guidelines for Prevention of NSAID-Related Ulcer Complications 728 ACG PRACTICE GUIDELINES nature publishing group Guidelines for Prevention of NSAID-Related Ulcer Complications Frank L. L anza, MD, FACG 1,2, Fr anc is K.L. C han, M D, FRCP, FACG 3, E amonn M.M. Q

More information

Getting smart about dyspnea and life saving drug therapy in ACS patients. Kobi George Kaplan Medical Center Rehovot

Getting smart about dyspnea and life saving drug therapy in ACS patients. Kobi George Kaplan Medical Center Rehovot Getting smart about dyspnea and life saving drug therapy in ACS patients Kobi George Kaplan Medical Center Rehovot 78 year old female Case description Presented with resting chest pain and dyspnea Co morbidities:

More information

Canadian consensus guidelines on long-term nonsteroidal anti-inflammatory drug therapy and the need for gastroprotection: benefits versus risks

Canadian consensus guidelines on long-term nonsteroidal anti-inflammatory drug therapy and the need for gastroprotection: benefits versus risks Alimentary Pharmacology & Therapeutics Canadian consensus guidelines on long-term nonsteroidal anti-inflammatory drug therapy and the need for gastroprotection: benefits versus risks A. ROSTOM*, P. MOAYYEDI

More information

A. Approval for the indications of osteoarthritis and rheumatoid arthritis at a dose of 10mg/day and dysmenorrhea at a dose of 20-mg bid as needed.

A. Approval for the indications of osteoarthritis and rheumatoid arthritis at a dose of 10mg/day and dysmenorrhea at a dose of 20-mg bid as needed. Agent: Valdecoxib Indication: Analgesia, Dysmenorrhea Osteoarthritis, and Rheumatoid Arthritis Reviewer: Kent Johnson, MD Date: November 7, 2001 NDA: 21,341 EXECUTIVE SUMMARY 1-RECOMMENDATIONS A. Approval

More information

DUAL ANTIPLATELET THERAPY. Dr Robert S Mvungi, MD(Dar), Mmed (Wits) FCP(SA), Cert.Cardio(SA) Phy Tanzania Cardiac Society Dar es Salaam Tanzania

DUAL ANTIPLATELET THERAPY. Dr Robert S Mvungi, MD(Dar), Mmed (Wits) FCP(SA), Cert.Cardio(SA) Phy Tanzania Cardiac Society Dar es Salaam Tanzania DUAL ANTIPLATELET THERAPY Dr Robert S Mvungi, MD(Dar), Mmed (Wits) FCP(SA), Cert.Cardio(SA) Phy Tanzania Cardiac Society Dar es Salaam Tanzania DUAL ANTIPLATELET THERAPY (DAPT) Dual antiplatelet regimen

More information

VIOXX Gastrointestinal Outcomes Research Trial (VIGOR) Bonnie Goldmann, M.D. Regulatory Affairs Merck Research Laboratories

VIOXX Gastrointestinal Outcomes Research Trial (VIGOR) Bonnie Goldmann, M.D. Regulatory Affairs Merck Research Laboratories VIOXX Gastrointestinal Outcomes Research Trial (VIGOR) Bonnie Goldmann, M.D. Regulatory Affairs Merck Research Laboratories 1 Arachidonic Acid CO 2 H COX-1 NSAIDs COX-2 Prostanoids Prostanoids Protection

More information

What can I eat? Peptic ulcers. What are peptic ulcers? What tests are needed? Will the ulcer come back? What causes a peptic ulcer?

What can I eat? Peptic ulcers. What are peptic ulcers? What tests are needed? Will the ulcer come back? What causes a peptic ulcer? In association with: INFORMATION ABOUT Peptic ulcers www.corecharity.org.uk What are peptic ulcers? What causes a peptic ulcer? How are NSAIDs and aspirin involved? How do I know if I ve got an ulcer?

More information

Cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and

Cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and Health Technology Assessment 2008; Vol. 12: No. 11 Cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and lumiracoxib) for

More information

Aspirin to Prevent Heart Attack and Stroke: What s the Right Dose?

Aspirin to Prevent Heart Attack and Stroke: What s the Right Dose? The American Journal of Medicine (2006) 119, 198-202 REVIEW Aspirin to Prevent Heart Attack and Stroke: What s the Right Dose? James E. Dalen, MD, MPH Professor Emeritus, University of Arizona, Tucson

More information

New Oral Anticoagulants

New Oral Anticoagulants New Oral Anticoagulants Tracy Minichiello, MD Associate Professor of Medicine Chief, San FranciscoVA Anticoagulation and Thrombosis Service Ansell, J. Hematology Copyright 2010 American Society of Hematology.

More information

None. Dual Antiplatelet Therapy Plus Systemic Anticoagulation: Bleeding Risk and Management. 76 year old male LINGO 1/5/2015

None. Dual Antiplatelet Therapy Plus Systemic Anticoagulation: Bleeding Risk and Management. 76 year old male LINGO 1/5/2015 Financial Disclosure Information Dual Antiplatelet Therapy Plus Systemic Anticoagulation: Bleeding Risk and Management Robert D. McBane, M.D. Division of Cardiology Mayo Clinic Rochester Dual Antiplatelet

More information

Novel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations

Novel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations Novel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations Dardo E. Ferrara MD Cardiac Electrophysiology North Cascade Cardiology PeaceHealth Medical Group Which anticoagulant

More information

Dual Antiplatelet Therapy. Stephen Monroe, MD FACC Chattanooga Heart Institute

Dual Antiplatelet Therapy. Stephen Monroe, MD FACC Chattanooga Heart Institute Dual Antiplatelet Therapy Stephen Monroe, MD FACC Chattanooga Heart Institute Scope of Talk Identify the antiplatelet drugs and their mechanisms of action Review dual antiplatelet therapy in: The medical

More information

Perspectives on the Selection and Duration of Dual Antiplatelet Therapy

Perspectives on the Selection and Duration of Dual Antiplatelet Therapy Perspectives on the Selection and Duration of Dual Antiplatelet Therapy Dominick J. Angiolillo, MD, PhD, FACC, FESC, FSCAI Director of Cardiovascular Research Associate Professor of Medicine University

More information

Comparative Effectiveness Review Number 4. Comparative Effectiveness and Safety of Analgesics for Osteoarthritis

Comparative Effectiveness Review Number 4. Comparative Effectiveness and Safety of Analgesics for Osteoarthritis This report is based on research conducted by the Oregon Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-0024).

More information

Use of Aspirin and NSAIDS in patients with Heart Disease

Use of Aspirin and NSAIDS in patients with Heart Disease Use of Aspirin and NSAIDS in patients with Heart Disease Shawn W. Robinson, MD Assistant Professor of Medicine, Physiology University of Maryland School of Medicine Chief of Cardiology, VA Maryland Health

More information

Apixaban Plus Mono vs. Dual Antiplatelet Therapy in Acute Coronary Syndromes: Insights from the APPRAISE-2 Trial

Apixaban Plus Mono vs. Dual Antiplatelet Therapy in Acute Coronary Syndromes: Insights from the APPRAISE-2 Trial Apixaban Plus Mono vs. Dual Antiplatelet Therapy in Acute Coronary Syndromes: Insights from the APPRAISE-2 Trial Connie N. Hess, MD, MHS, Stefan James, MD, PhD, Renato D. Lopes, MD, PhD, Daniel M. Wojdyla,

More information

Clopidogrel versus Aspirin and Esomeprazole to Prevent Recurrent Ulcer Bleeding

Clopidogrel versus Aspirin and Esomeprazole to Prevent Recurrent Ulcer Bleeding The new england journal of medicine original article Clopidogrel versus Aspirin and Esomeprazole to Prevent Recurrent Ulcer Bleeding Francis K.L. Chan, M.D., Jessica Y.L. Ching, M.P.H., Lawrence C.T. Hung,

More information

Analgesics for Osteoarthritis: An Update of the

Analgesics for Osteoarthritis: An Update of the Comparative Effectiveness Review Number 38 Analgesics for Osteoarthritis: An Update of the 2006 Comparative Effectiveness Review Comparative Effectiveness Review Number 38 Analgesics for Osteoarthritis:

More information

ΠΟΙΟ ΑΝΤΙΠΗΚΤΙΚΟ ΓΙΑ ΤΟΝ ΑΣΘΕΝΗ ΜΟΥ? ΚΛΙΝΙΚΑ ΠΑΡΑΔΕΙΓΜΑΤΑ. Σωκράτης Παστρωμάς Καρδιολόγος Νοσοκομείο Ερρίκος Ντυνάν

ΠΟΙΟ ΑΝΤΙΠΗΚΤΙΚΟ ΓΙΑ ΤΟΝ ΑΣΘΕΝΗ ΜΟΥ? ΚΛΙΝΙΚΑ ΠΑΡΑΔΕΙΓΜΑΤΑ. Σωκράτης Παστρωμάς Καρδιολόγος Νοσοκομείο Ερρίκος Ντυνάν ΠΟΙΟ ΑΝΤΙΠΗΚΤΙΚΟ ΓΙΑ ΤΟΝ ΑΣΘΕΝΗ ΜΟΥ? ΚΛΙΝΙΚΑ ΠΑΡΑΔΕΙΓΜΑΤΑ Σωκράτης Παστρωμάς Καρδιολόγος Νοσοκομείο Ερρίκος Ντυνάν The AF epidemic Mayo Clinic data (assuming a continued increase in the AF incidence) Mayo

More information

Inhibit terminal acid secretion from parietal cells by blocking H + /K + - ATPase pump

Inhibit terminal acid secretion from parietal cells by blocking H + /K + - ATPase pump Chris J. Taylor, Pharm.D., BCPS Clinical Pharmacist Phoenix VA Health Care System Review pharmacology of PPIs Discuss possible association between PPI use and development of the following: Pneumonia (community-acquired

More information

US Health Statistics: Americans Most Over-Prescribed Country in the World

US Health Statistics: Americans Most Over-Prescribed Country in the World US Health Statistics: Americans Most Over-Prescribed Country in the World A vitally important story reported in the April 15, 1998, issue of the Journal of the American Medical Association (JAMA), sums

More information

Cilostazol versus Clopidogrel after Coronary Stenting

Cilostazol versus Clopidogrel after Coronary Stenting Cilostazol versus Clopidogrel after Coronary Stenting Seong-Wook Park, MD, PhD, FACC Division of Cardiology, Asan Medical Center University of Ulsan College of Medicine Seoul, Korea AMC, 2004 Background

More information

New Oral AntiCoagulants (NOAC) in 2015

New Oral AntiCoagulants (NOAC) in 2015 New Oral AntiCoagulants (NOAC) in 2015 William R. Hiatt, MD Professor of Medicine and Cardiology University of Colorado School of Medicine President CPC Clinical Research Disclosures Received research

More information

National Digestive Diseases Information Clearinghouse

National Digestive Diseases Information Clearinghouse Gastritis National Digestive Diseases Information Clearinghouse U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH What is gastritis? Gastritis is a condition in which the stomach

More information

FOR THE PREVENTION OF ATRIAL FIBRILLATION RELATED STROKE

FOR THE PREVENTION OF ATRIAL FIBRILLATION RELATED STROKE www.bpac.org.nz keyword: warfarinaspirin FOR THE PREVENTION OF ATRIAL FIBRILLATION RELATED STROKE Key Concepts In atrial fibrillation (AF) warfarin is more effective than aspirin for stroke prevention.

More information

Rivaroxaban for acute coronary syndromes

Rivaroxaban for acute coronary syndromes Northern Treatment Advisory Group Rivaroxaban for acute coronary syndromes Lead author: Nancy Kane Regional Drug & Therapeutics Centre (Newcastle) May 2014 2014 Summary Current long-term management following

More information

Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial

Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial Camillo Autore Università di Roma Sapienza II Facoltà di Medicina e Chirurgia

More information

New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation. Joy Wahawisan, Pharm.D., BCPS April 25, 2012

New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation. Joy Wahawisan, Pharm.D., BCPS April 25, 2012 New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation Joy Wahawisan, Pharm.D., BCPS April 25, 2012 Stroke in Atrial Fibrillation % Stroke 1991;22:983. Age Range (years) CHADS 2 Risk

More information

Update on Antiplatelets and anticoagulants. Outlines. Antiplatelets and Anticoagulants 1/23/2013. Timir Paul, MD, PhD

Update on Antiplatelets and anticoagulants. Outlines. Antiplatelets and Anticoagulants 1/23/2013. Timir Paul, MD, PhD Update on Antiplatelets and anticoagulants Timir Paul, MD, PhD Antiplatelets Indications Doses Long term use (beyond 12 months) ASA and combination use of NSAIDS ASA resistance Plavix resistance Plavix

More information

Peptic Ulcer. Anatomy The stomach is a hollow organ. It is located in the upper abdomen, under the ribs.

Peptic Ulcer. Anatomy The stomach is a hollow organ. It is located in the upper abdomen, under the ribs. Peptic Ulcer Introduction A peptic ulcer is a sore in the lining of your stomach or duodenum. The duodenum is the first part of your small intestine. Peptic ulcers may also develop in the esophagus. Nearly

More information

Survey conducted into patient experience of life with osteoarthritis. A collaboration between Pro Bono Bio, Arthritis Research UK, and LloydsPharmacy

Survey conducted into patient experience of life with osteoarthritis. A collaboration between Pro Bono Bio, Arthritis Research UK, and LloydsPharmacy Survey conducted into patient experience of life with osteoarthritis. A collaboration between Pro Bono Bio, Arthritis Research UK, and LloydsPharmacy Executive summary Over 400 people with joint conditions

More information

understanding GI bleeding

understanding GI bleeding understanding GI bleeding a consumer education brochure American College of Gastroenterology 4900B South 31st Street, Arlington, VA 22206 703-820-7400 www.acg.gi.org American College of Gastroenterology

More information

Thrombosis and Bleeding

Thrombosis and Bleeding Many questions, few answers Thrombosis and Bleeding Pierre Noel MD Mayo Arizona Scope of the Problem Thrombosis PV 12-39% ET 11-25% MF 10% 60-70% of thrombosis are arterial Splanchnic and cerebral thrombosis

More information

CHAPTER 1 INTRODUCTION

CHAPTER 1 INTRODUCTION CHAPTER 1 INTRODUCTION Rheumatoid Arthritis (RA) is a chronic syndrome characterised by non-specific, usually symmetric inflammation of the peripheral joints, potentially resulting in progressive destruction

More information

The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era. CCRN State of the Heart 2012 June 2, 2012

The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era. CCRN State of the Heart 2012 June 2, 2012 The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era CCRN State of the Heart 2012 June 2, 2012 Disclosures I have I have been involved in trials of new anticoagulants and have received

More information

Xarelto (Rivaroxaban)

Xarelto (Rivaroxaban) Xarelto (Rivaroxaban) Hightly selective, reversible, direct oral FXa inhibitor Maxium concentratiion after 2 to 4 hrs High bioavailability(66%),increase with food ( suggest with food) 1/3 from renal excretion,

More information

Antiplatelet therapy:

Antiplatelet therapy: Balanced information for better care Antiplatelet therapy: Aggregating the latest evidence Evaluating the choices for a preventive therapy with impressive benefits and important risks Antiplatelet agents

More information

Antiplatelet and Antithrombotic Therapy. Dr Curry Grant Stroke Prevention Clinic Quinte Health Care

Antiplatelet and Antithrombotic Therapy. Dr Curry Grant Stroke Prevention Clinic Quinte Health Care Antiplatelet and Antithrombotic Therapy Dr Curry Grant Stroke Prevention Clinic Quinte Health Care Disclosure of Potential for Conflict of Interest Dr. F.C. Grant Atrial Fibrillation FINANCIAL DISCLOSURE:

More information

Endoscopy & ACS. 8/1/2014 Dr. Whang

Endoscopy & ACS. 8/1/2014 Dr. Whang Endoscopy & ACS 8/1/2014 Dr. Whang Outline I. Antiplatelets II. Coronary Artery Disease in U.S. III. GI Bleeding in ACS IV. ACC/AHA guidelines: Dual Antiplatelet Therapy in CAD V. PPI and Plavix Controversy

More information

Antiaggreganti. STEMI : cosa c è di nuovo? Heartline 2015. Genova 13 14 Novembre 2015

Antiaggreganti. STEMI : cosa c è di nuovo? Heartline 2015. Genova 13 14 Novembre 2015 Heartline 2015 Genova 13 14 Novembre 2015 STEMI : cosa c è di nuovo? Antiaggreganti Luigi Oltrona Visconti Divisione di Cardiologia IRCCS Fondazione Policlinico S. Matteo Pavia STEMI : cosa c è di nuovo?

More information

ABOUT XARELTO CLINICAL STUDIES

ABOUT XARELTO CLINICAL STUDIES ABOUT XARELTO CLINICAL STUDIES FAST FACTS Xarelto (rivaroxaban) is a novel, oral direct Factor Xa inhibitor. On September 30, 2008, the European Commission granted marketing approval for Xarelto for the

More information

Acute behandeling van longembolie. Peter Verhamme. Bloedings- en Vaatziekten UZ Leuven. Research support and/or honoraria:

Acute behandeling van longembolie. Peter Verhamme. Bloedings- en Vaatziekten UZ Leuven. Research support and/or honoraria: Acute behandeling van longembolie Peter Verhamme Bloedings- en Vaatziekten UZ Leuven Disclosures Research support and/or honoraria: Bayer, Boehringer-Ingelheim, Daiichi-Sankyo, Pfizer, BMS, Sanofi, Leo-pharma

More information

gastrointestinal ulcers and ulcer complications 2 (COX2) enzyme might reduce this burden. 8 To date, two groups of investigators have attempted to

gastrointestinal ulcers and ulcer complications 2 (COX2) enzyme might reduce this burden. 8 To date, two groups of investigators have attempted to Comparison of lumiracoxib with naproxen and ibuprofen in the Therapeutic Arthritis Research and Gastrointestinal Event Trial (TARGET), reduction in ulcer complications: randomised controlled trial Thomas

More information

New Anticoagulants: What to Use What to Avoid

New Anticoagulants: What to Use What to Avoid New Anticoagulants: What to Use What to Avoid Bruce Davidson, MD, MPH Clinical Professor of Medicine Pulmonary and Critical Care Medicine Division University of Washington School of Medicine Seattle USA

More information

Review of Non-VKA Oral AntiCoagulants (NOACs) and their use in Great Britain

Review of Non-VKA Oral AntiCoagulants (NOACs) and their use in Great Britain Review of Non-VKA Oral AntiCoagulants (NOACs) and their use in Great Britain Dr Alexander (Ander) Cohen Guy s and St Thomas Hospitals, King s College London, UK Pavia Spring Meeting 13 June 2014 Overview

More information

L'aspirina è diventata obsoleta nell'era dei nuovi inbitori P2Y12? Leonardo Bolognese MD, FESC, FACC Cardiovascular Department, Arezzo, Italy ISO 9001

L'aspirina è diventata obsoleta nell'era dei nuovi inbitori P2Y12? Leonardo Bolognese MD, FESC, FACC Cardiovascular Department, Arezzo, Italy ISO 9001 L'aspirina è diventata obsoleta nell'era dei nuovi inbitori P2Y12? Leonardo Bolognese MD, FESC, FACC Cardiovascular Department, Arezzo, Italy Scientific Advances and Cardiovascular Mortality Nabel and

More information

criteria Dr. Cristín Ryan Queen s University Belfast c.ryan@qub.ac.uk

criteria Dr. Cristín Ryan Queen s University Belfast c.ryan@qub.ac.uk The basics of the STOPP/START criteria Dr. Cristín Ryan Queen s University Belfast c.ryan@qub.ac.uk Overview Why & how STOPP/START was developed Aims of STOPP/START Contents of STOPP/START STOPP/START

More information

Atrial Fibrillation: Stroke and Thromboprophylaxis. Derek Waller

Atrial Fibrillation: Stroke and Thromboprophylaxis. Derek Waller Atrial Fibrillation: Stroke and Thromboprophylaxis Derek Waller Atrial Fibrillation in the Elderly: Risk of Stroke Framingham study AGE 50-59 60-69 70-79 80-89 Prevalence of AF % Attributable Risk of AF

More information

Marco Ferlini Struttura Semplice di Emodinamica, UO Cardiologia Dipartimento Cardiotoracovascolare Fondazione IRCCS, Policlinico San Matteo

Marco Ferlini Struttura Semplice di Emodinamica, UO Cardiologia Dipartimento Cardiotoracovascolare Fondazione IRCCS, Policlinico San Matteo Marco Ferlini Struttura Semplice di Emodinamica, UO Cardiologia Dipartimento Cardiotoracovascolare Fondazione IRCCS, Policlinico San Matteo Acute Coronary Syndromes: oral antithrombotic therapy Focus on

More information

Ask Your Doctor if There May Be a SMARTER CHOICE

Ask Your Doctor if There May Be a SMARTER CHOICE If you have osteoarthritis, rheumatoid arthritis or ankylosing spondylitis, Could Your NSAID Pain Medicine Be Hurting Your Stomach? Ask Your Doctor if There May Be a SMARTER CHOICE 1 of 8 Making Smart

More information

New in Atrial Fibrillation

New in Atrial Fibrillation New in Atrial Fibrillation September 2011 Stroke prevention more options Rhythm Control -drugs - alternatives to drugs; ablation Rate Control - pace + ablate A-FIB Dell Stroke Risk AFib Two Principles

More information

How to manage a patient who needs thrombolysis in acute stroke, ablation or angioplasty/stenting? Janet M McComb Freeman Hospital Newcastle upon Tyne

How to manage a patient who needs thrombolysis in acute stroke, ablation or angioplasty/stenting? Janet M McComb Freeman Hospital Newcastle upon Tyne How to manage a patient who needs thrombolysis in acute stroke, ablation or angioplasty/stenting? Janet M McComb Freeman Hospital Newcastle upon Tyne What do the guidelines say? What happens with warfarin

More information

The Role of the Newer Anticoagulants

The Role of the Newer Anticoagulants The Role of the Newer Anticoagulants WARFARIN = Coumadin DAGIBATRAN = Pradaxa RIVAROXABAN = Xarelto APIXABAN = Eliquis INDICATION DABIGATRAN (Pradaxa) RIVAROXABAN (Xarelto) APIXABAN (Eliquis) Stroke prevention

More information

Improving Appropriate Use of Proton Pump Inhibitors as Gastrointestinal Prophylaxis in the Hospital Setting

Improving Appropriate Use of Proton Pump Inhibitors as Gastrointestinal Prophylaxis in the Hospital Setting Improving Appropriate Use of Proton Pump Inhibitors as Gastrointestinal Prophylaxis in the Hospital Setting DATE Educating for Quality Improvement & Patient Safety 1 The Team Division CS&E Participants

More information

Overview of Rheumatology

Overview of Rheumatology Overview of Rheumatology Griffin Hospital Mini Med School Stephen Moses, MD Valley Medical Associates 135 Division St. Ansonia, CT 06401 203.735.9354 Topics I. Anatomy of a Joint II. Osteoarthritis III.

More information

at our institution, was $1.8 million in 1999. While some patients require PPI therapy, many could control their symptoms with a histamine H 2

at our institution, was $1.8 million in 1999. While some patients require PPI therapy, many could control their symptoms with a histamine H 2 A Practice-Based Approach for Converting from Proton Pump Inhibitors to Less Costly Therapy CASE REPORT LINDA M. LUCAS, MD MARTHA S. GERRITY, MD, PhD THOMAS ANDERSON, MD Department of Veterans Affairs

More information

Novel OAC s : How should we use them?

Novel OAC s : How should we use them? Novel OAC s : How should we use them? Jean C. Grégoire MD, FRCP(c), FACC, FACP Associate Professor, Université de Montréal, IntervenJonal Cardiologist, InsJtut de cardiologie de Montréal Disclosures Speaker

More information

Optimizing Anticoagulation Selection for Your Patient. C. Andrew Brian MD, FACC NCVH 2015

Optimizing Anticoagulation Selection for Your Patient. C. Andrew Brian MD, FACC NCVH 2015 Optimizing Anticoagulation Selection for Your Patient C. Andrew Brian MD, FACC NCVH 2015 Who Needs to Be Anticoagulated and What is the Patient s Risk? 1. Atrial Fibrillation ( nonvalvular ) 2. What regimen

More information

New Approaches to, and Indications for, Antiplatelet Therapy

New Approaches to, and Indications for, Antiplatelet Therapy New Approaches to, and Indications for, Antiplatelet Therapy Kenneth A. Bauer, MD Professor of Medicine, Harvard Medical School Chief, Hematology Section, VA Boston Healthcare System Director, Thrombosis

More information

Prevention of nonsteroidal anti-inflammatory drug-induced gastropathy

Prevention of nonsteroidal anti-inflammatory drug-induced gastropathy J Gastroenterol 2009; 44[Suppl XIX]:44 52 DOI 10.1007/s00535-008-2275-5 Prevention of nonsteroidal anti-inflammatory drug-induced gastropathy BARRY SCHLANSKY and JOO HA HWANG University of Washington School

More information

Rubén Casado Arroyo, 1,2 Mónica Polo-Tomas, 2 Maria P Roncalés, 2 James Scheiman, 3 Ángel Lanas 2,3,4 ORIGINAL ARTICLE. Antiplatelet therapy

Rubén Casado Arroyo, 1,2 Mónica Polo-Tomas, 2 Maria P Roncalés, 2 James Scheiman, 3 Ángel Lanas 2,3,4 ORIGINAL ARTICLE. Antiplatelet therapy ORIGINAL ARTICLE Lower GI bleeding is more common than upper among patients on dual antiplatelet therapy: long-term follow-up of a cohort of patients commonly using PPI co-therapy Rubén Casado Arroyo,

More information

What is an NNT? What is...? series Second edition Statistics. Supported by sanofi-aventis

What is an NNT? What is...? series Second edition Statistics. Supported by sanofi-aventis ...? series Second edition Statistics Supported by sanofi-aventis What is an NNT? Andrew Moore MA DPhil DSc CChem FRSC Senior Research Fellow, Pain Research and Nuffield Department of Anaesthetics, University

More information

RR 0.88 (95% CI: 0.77 1.00) P=0.051 (superiority) 3.75

RR 0.88 (95% CI: 0.77 1.00) P=0.051 (superiority) 3.75 ALL-CAUSE MORTALITY RR 0.88 (95% CI: 0.77 1.00) P=0.051 (superiority) Rate per year (%) 5.0 4.0 3.0 2.0 1.0 0 3.64 D150 mg BID 3.75 D110 mg BID RR 0.91 (95% CI: 0.80 1.03) P=0.13 (superiority) 4.13 Warfarin

More information

Anticoagulation For Atrial Fibrillation

Anticoagulation For Atrial Fibrillation Anticoagulation For Atrial Fibrillation New Agents In A New Era Arjun V Gururaj, MD Arrhythmia and Electrophysiology Nevada Heart and Vascular Center Disclosures Biotronik Speaker Clinical investigator

More information

What Effects do Provincial Drug Plan Coverage Policies for New Drugs have on Patterns of Use and Cost?

What Effects do Provincial Drug Plan Coverage Policies for New Drugs have on Patterns of Use and Cost? Enhancing the effectiveness of health care for Ontarians through research What Effects do Provincial Drug Plan Coverage Policies for New Drugs have on Patterns of Use and Cost? November 2003 What effects

More information

Measure #257 (NQF 1519): Statin Therapy at Discharge after Lower Extremity Bypass (LEB) National Quality Strategy Domain: Effective Clinical Care

Measure #257 (NQF 1519): Statin Therapy at Discharge after Lower Extremity Bypass (LEB) National Quality Strategy Domain: Effective Clinical Care Measure #257 (NQF 1519): Statin Therapy at Discharge after Lower Extremity Bypass (LEB) National Quality Strategy Domain: Effective Clinical Care 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY

More information

Direct oral anticoagulants in daily care: what do we know today and what are the remaining issues?

Direct oral anticoagulants in daily care: what do we know today and what are the remaining issues? De afbeelding kan niet worden weergegeven. Mogelijk is er onvoldoende geheugen beschikbaar om de afbeelding te openen of is de afbeelding beschadigd. Start de computer opnieuw op en open het bestand opnieuw.

More information

NHS FORTH VALLEY Guidelines for use of high dose Intravenous Esomeprazole in Adults (Previously called the Hong Kong Protocol)

NHS FORTH VALLEY Guidelines for use of high dose Intravenous Esomeprazole in Adults (Previously called the Hong Kong Protocol) NHS FORTH VALLEY Guidelines for use of high dose Intravenous Esomeprazole in Adults (Previously called the Hong Kong Protocol) Date of First Issue 10/05/2010 Approved 16/06/2010 Current Issue Date 18/11/2015

More information

patient group direction

patient group direction DICLOFENAC v01 1/8 DICLOFENAC PGD Details Version 1.0 Legal category Staff grades Approved by POM Paramedic (Non-ECP) Nurse (Non-ECP) Emergency Care Practitioner (Paramedic) Emergency Care Practitioner

More information

Duration of Dual Antiplatelet Therapy After Coronary Stenting

Duration of Dual Antiplatelet Therapy After Coronary Stenting Duration of Dual Antiplatelet Therapy After Coronary Stenting C. DEAN KATSAMAKIS, DO, FACC, FSCAI INTERVENTIONAL CARDIOLOGIST ADVOCATE LUTHERAN GENERAL HOSPITAL INTRODUCTION Coronary artery stents are

More information

Bleeding Peptic Ulcer

Bleeding Peptic Ulcer Summary and Conclusions Bleeding Peptic Ulcer A Systematic Review Swedish Council on Health Technology Assessment SBU Board of Directors and Scientific Advisory Committee Secretariat MÅNS ROSÉN Executive

More information

Prevention of thrombo - embolic complications

Prevention of thrombo - embolic complications Update on atrial fibrillation Prevention of thrombo - embolic complications Felicita Andreotti Dept of Cardiovascular Science Catholic University, Rome, IT Consultant or speaker in past 2 years for Amgen,

More information

Il punto sulla terapia antitrombotica nelle sindromi coronariche acute

Il punto sulla terapia antitrombotica nelle sindromi coronariche acute Santa Margherita Ligure TIGULLIO CARDIOLOGIA 2012 16-17 Febbrajo 2012 Il trattamento dell infarto miocardico acuto ad ST spraslivellato: dal territorio al laboratorio di emodinamica Il punto sulla terapia

More information

Ulcers and Gastrointestinal Bleeding: Protecting Your Health

Ulcers and Gastrointestinal Bleeding: Protecting Your Health AMERICAN COLLEGE OF GASTROENTEROLOGY American College of Gastroenterology 6400 Goldsboro Road, Suite 450 Bethesda, MD 20817 www.acg.gi.org Ulcers and Gastrointestinal Bleeding: Protecting Your Health What

More information

Anticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014

Anticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014 Anticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014 Atrial Fibrillation 2 Atrial Fibrillation The most common arrhythmia encountered

More information

Time of Offset of Action The Trial

Time of Offset of Action The Trial New Antithrombotic Agents DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau - None Consultant Amgen Tom DeLoughery, MD FACP FAWM Oregon Health and Sciences University What I am Talking About

More information

Antiplatelet and Antithrombotics From clinical trials to guidelines

Antiplatelet and Antithrombotics From clinical trials to guidelines Antiplatelet and Antithrombotics From clinical trials to guidelines Ashraf Reda, MD, FESC Prof and head of Cardiology Dep. Menofiya University Preisedent of EGYBAC Chairman of WGLVR One of the big stories

More information

WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION. Van Crisco, MD, FACC, FSCAI First Coast

WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION. Van Crisco, MD, FACC, FSCAI First Coast WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION Van Crisco, MD, FACC, FSCAI First Coast Conflicts of Interest I have been a paid consultant and speaker for AstraZeneca, makers of

More information

Management of the new antiplatelets and anticoagulants

Management of the new antiplatelets and anticoagulants Management of the new antiplatelets and anticoagulants Session No.: 1 Name: C. Boustiere, T Ponchon Guidelines : Anti-thrombotic agents and digestive endoscopy 2006 : French guideline (SFED) 2007 : Japanese

More information

Review of the evidence for H. Pylori treatment regimens. Dr Lennita Wannmacher

Review of the evidence for H. Pylori treatment regimens. Dr Lennita Wannmacher 18th Expert Committee on the Selection and Use of Essential Medicines (21 to 25 March 2011) Review Section 17.1 (Antacids and other antiulcer medicines) -- Adults and children Review of the evidence for

More information

The Link Between Obesity and Diabetes The Rapid Evolution and Positive Results of Bariatric Surgery

The Link Between Obesity and Diabetes The Rapid Evolution and Positive Results of Bariatric Surgery The Link Between Obesity and Diabetes The Rapid Evolution and Positive Results of Bariatric Surgery Michael E. Farkouh, MD, MSc Peter Munk Chair in Multinational Clinical Trials Director, Heart and Stroke

More information

New Treatments for Stroke Prevention in Atrial Fibrillation. John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013

New Treatments for Stroke Prevention in Atrial Fibrillation. John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 New Treatments for Stroke Prevention in Atrial Fibrillation John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 Classification Paroxysmal atrial fibrillation (AF) Last < 7

More information

Anticoagulation in Atrial Fibrillation

Anticoagulation in Atrial Fibrillation Anticoagulation in Atrial Fibrillation Parag P. Patel, MD FACC Disclosures Eliquis Speakers Bureau 1 Clinical Scenario Ms. L is a 76F admitted to the stroke service with a dense right sided hemiparesis

More information

Nonsteroidal anti-inflammatory drugs and upper and lower gastrointestinal mucosal damage

Nonsteroidal anti-inflammatory drugs and upper and lower gastrointestinal mucosal damage REVIEW Nonsteroidal anti-inflammatory drugs and upper and lower gastrointestinal mucosal damage Carlos Sostres 1,2, Carla J Gargallo 1,2 and Angel Lanas* 1,2,3,4 Abstract NSAIDs are among the most commonly

More information

Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013

Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013 Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013 Family physician with Rivergrove Medical Clinic Practice in the north end since 1985 Medical Director of the Wellness

More information

University of Ulsan College of Medicine, Asan Medical Center on behalf of the REAL-LATE and the ZEST-LATE trial

University of Ulsan College of Medicine, Asan Medical Center on behalf of the REAL-LATE and the ZEST-LATE trial Duration of Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation A Pooled Analysis of the REAL-LATE and the ZEST-LATE Trial Seung-Jung Park MD PhD Seung-Jung Park, MD, PhD, University of Ulsan

More information

4/9/2015. Risk Stratify Our Patients. Stroke Risk in AF: CHADS2 Scoring system JAMA 2001; 285: 2864-71

4/9/2015. Risk Stratify Our Patients. Stroke Risk in AF: CHADS2 Scoring system JAMA 2001; 285: 2864-71 Anticoagulation in the 21 st Century Adam Karpman, D.O. Saint Francis Medical Center/Oklahoma State University Medical Center Disclosures: None Atrial Fibrillation Most common arrhythmia in clinical practice.

More information

Issues and Challenges in ACS Management. Dr.Nakul Sinha MD.DM, FACC. Sahara Hospital, LUCKNOW

Issues and Challenges in ACS Management. Dr.Nakul Sinha MD.DM, FACC. Sahara Hospital, LUCKNOW 1 Issues and Challenges in ACS Management Dr.Nakul Sinha MD.DM, FACC. Sahara Hospital, LUCKNOW 2 Disclaimer Presentation are intended for educational purposes only and do not replace independent professional

More information

Atrial Fibrillation, Chronic - Antithrombotic Treatment - OBSOLETE

Atrial Fibrillation, Chronic - Antithrombotic Treatment - OBSOLETE Atrial Fibrillation, Chronic - Antithrombotic Treatment - OBSOLETE Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with

More information

Cardiovascular Effects of Drugs to Treat Diabetes

Cardiovascular Effects of Drugs to Treat Diabetes Cardiovascular Effects of Drugs to Treat Diabetes Steven E. Nissen MD Chairman, Department of Cardiovascular Medicine Cleveland Clinic Disclosure Consulting: Many pharmaceutical companies Clinical Trials:

More information

National Institute for Clinical Excellence

National Institute for Clinical Excellence National Institute for Clinical Excellence 11 Strand London WC2N 5HR Web: www.nice.org.uk N0016 50k 1P July 01 (ABA) Technology Appraisal Guidance - No.27 Guidance on the use of cyclo-oxygenase (Cox) II

More information

23/06/2014. Implications for the Gastroenterologist. No financial interests I am not a hematologist

23/06/2014. Implications for the Gastroenterologist. No financial interests I am not a hematologist Implications for the Gastroenterologist Dr. Daniel Sadowski Royal Alexandra Hospital Edmonton, Ab. No financial interests I am not a hematologist 65 y.o. male referred for iron deficiency anemia (FIT positive)

More information