Gastrointestinal Bleeding Prophylaxis in Patients Taking Colchicine and Allopurinol
Risk Assessment and Patient Evaluation
- A systematic risk assessment should be performed when considering PPI prophylaxis for patients on colchicine and allopurinol, including history of prior upper GI bleeding and multiple risk factors for GI bleeding, such as advanced age, concomitant use of anticoagulants, steroids, NSAIDs, and Helicobacter pylori infection 1, 2
- Patients without risk factors for GI bleeding, such as advanced age, concomitant use of anticoagulants, steroids, NSAIDs, and Helicobacter pylori infection, do not require routine PPI prophylaxis 1, 3
Guideline Recommendations
- The American Gastroenterological Association (AGA) recommends that patients should not use any medication when there is not a reasonable expectation of benefit based on scientific evidence, and routine use of PPIs is not recommended for patients at low risk of GI bleeding 1
- The American College of Cardiology Foundation/American College of Gastroenterology/American Heart Association consensus document states that routine use of either a PPI or an H2RA is not recommended for patients at lower risk of upper GI bleeding 2
- The European League Against Rheumatism (EULAR) guidelines recommend PPI coverage when using NSAIDs for acute gout flares, but do not specifically recommend PPI prophylaxis for patients on maintenance colchicine and allopurinol alone 4
Management and Monitoring
- For patients on colchicine and allopurinol without PPI, monitoring for GI symptoms and reassessing risk factors periodically is recommended, and PPI should be considered if risk factors change or symptoms develop 2
- H2-receptor antagonists may be considered as an alternative for patients with mild symptoms who don't require PPI, but cimetidine should be avoided if using colchicine due to potential CYP2C19 inhibition 2