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服用阿司匹林易致胃肠道出血，该如何应对？

2022-06-12 beartwo MedSci原创

阿司匹林胃肠道出血
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如何利用这把“双刃剑”。

随着人口老龄化以及心血管疾病的负担加重，阿司匹林的应用已经较为广泛。作为预防心脑血管疾病的常用药物，其胃损伤作用一直是临床绕不开的话题。今天就和大家一起讨论学习一下阿司匹林的胃粘膜损伤问题。
一、阿司匹林引起胃粘膜损伤的机制
1、局部作用：阿司匹林药品本身呈酸性，长期使用可以对胃粘膜引起损伤；
2、全身作用：阿司匹林属于非甾体类抗炎药物，通过抑制环氧合酶（COX-1）活性，减少前列腺素PGs的合成，引起胃粘膜血流量减少，减少粘液及碳酸氢盐的分泌，使粘膜防御能力降低，进而出现胃糜烂、溃疡等症。
二、阿司匹林胃粘膜损伤的预防、治疗策略
1、使用之前，充分权衡获益风险
如果计划长期服用阿司匹林，在使用之前必须对患者基础情况进行评估，评估包括两个方面：
(1)评估阿司匹林使用的必要性。
即患者的心脑血管病情是否需要确需使用；有研究表明：对心血管危险水平较低的人群，阿司匹林心血管疾病的一级预防不能获益反而胃肠道微出血事件风险升高。
(2)评估患者的胃肠道出血风险。
在使用阿司匹林之前，建议询问消化系统症状、病史。高龄、既往消化道溃疡病史、肾小球滤过率低是阿司匹林服用后胃粘膜损伤出血的高危因素，必要时行相关检查。
2、根除幽门螺杆菌
有研究表明，幽门螺杆菌和非甾体类药物是独立的、增加胃溃疡风险的因素。患者同时拥有这两个因素，即感染HP的患者，较一般患者，服用非甾体类药物出现消化道溃疡的风险更高。因此建议在服用之前，检查幽门螺杆菌，行根治治疗。
3、小剂量维持
由于阿司匹林的胃肠道反应呈剂量依赖性，因此在必须应用的前提下，可尽可能的降低剂量。
4、阿司匹林胃粘膜损伤预防治疗用药
如果确需使用，则在使用阿司匹林的同时即开始采取必要的措施预防胃粘膜损伤。
1、胃保护药
1）米索前列醇
本药为PG类似物，可以补充阿司匹林引起的PGs合成减少，预防阿司匹林引起的胃粘膜损伤。
2、胃粘膜保护剂
1）硫糖铝
本药可以在胃粘膜表面形成覆膜，减少胃粘膜上皮细胞的暴露，对胃粘膜起保护作用。
2）抑酸药
质子泵抑制剂和组胺H2受体拮抗剂，通过抑制胃酸分泌以及清除自由基来保护胃粘膜。
有研究表明，PPI可以显著降低双抗治疗（阿司匹林+氯吡格雷）引起胃肠道出血事件风险。
预防NSAIDs所致的上消化道并发症的国内和国际指南一致推荐使用PPIs。
尽管组胺H2受体拮抗剂对NSAIDs所致胃溃疡有帮助，但是对胃出血改善意义不大，因此不推荐。
参考文献：
赵辽辽,陈晶,杜雅菊.阿司匹林及氯比格雷相关胃损伤治疗新进展[J].胃肠病学和肝病学杂志,2016,25(04):461-464.

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    2022-09-18 ms4000001530839250

    看来用之前查下HP是有用的

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1778551, encodeId=1b411e785517b, content=看来用之前查下HP是有用的, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7da05593338, createdName=ms4000001530839250, createdTime=Sun Sep 18 09:49:37 CST 2022, time=2022-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1239249, encodeId=7cef1239249df, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=99206163724, createdName=ms9000000236829232, createdTime=Wed Aug 17 11:32:13 CST 2022, time=2022-08-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1236559, encodeId=5f6f12365592c, content=心、脑血管科医护人员应该学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ab606579033, createdName=ms8000001408294061, createdTime=Thu Aug 04 12:27:24 CST 2022, time=2022-08-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1346383, encodeId=fa6c134638333, content=<a href='/topic/show?id=339e8332035' target=_blank style='color:#2F92EE;'>#胃肠道#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83320, encryptionId=339e8332035, topicName=胃肠道)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e03212, createdName=liao1619, createdTime=Tue Jun 14 09:23:11 CST 2022, time=2022-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1390991, encodeId=f8e1139099140, content=<a href='/topic/show?id=6e618332871' target=_blank style='color:#2F92EE;'>#胃肠道出血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83328, encryptionId=6e618332871, topicName=胃肠道出血)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1b6a2500070, createdName=124987a0m66(暂无昵称), createdTime=Tue Jun 14 09:23:11 CST 2022, time=2022-06-14, status=1, ipAttribution=)]
    2022-08-17 ms9000000236829232

    学习了

    0

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    2022-08-04 ms8000001408294061

    心、脑血管科医护人员应该学习

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1778551, encodeId=1b411e785517b, content=看来用之前查下HP是有用的, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7da05593338, createdName=ms4000001530839250, createdTime=Sun Sep 18 09:49:37 CST 2022, time=2022-09-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1239249, encodeId=7cef1239249df, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=99206163724, createdName=ms9000000236829232, createdTime=Wed Aug 17 11:32:13 CST 2022, time=2022-08-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1236559, encodeId=5f6f12365592c, content=心、脑血管科医护人员应该学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ab606579033, createdName=ms8000001408294061, createdTime=Thu Aug 04 12:27:24 CST 2022, time=2022-08-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1346383, encodeId=fa6c134638333, content=<a href='/topic/show?id=339e8332035' target=_blank style='color:#2F92EE;'>#胃肠道#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83320, encryptionId=339e8332035, topicName=胃肠道)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e03212, createdName=liao1619, createdTime=Tue Jun 14 09:23:11 CST 2022, time=2022-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1390991, encodeId=f8e1139099140, content=<a href='/topic/show?id=6e618332871' target=_blank style='color:#2F92EE;'>#胃肠道出血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83328, encryptionId=6e618332871, topicName=胃肠道出血)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1b6a2500070, createdName=124987a0m66(暂无昵称), createdTime=Tue Jun 14 09:23:11 CST 2022, time=2022-06-14, status=1, ipAttribution=)]
    2022-06-14 liao1619

    #胃肠道#

    0

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    2022-06-14 124987a0m66(暂无昵称)

    #胃肠道出血#

    0

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