Associated with adverse drug interactions - gastrointestinal bleeding

Red flags

Haematemesis/melaena in a patient on NSAID, antiplatelet, or anticoagulant
Shock index >1, ongoing bleeding despite resuscitation
Bleeding on combined antiplatelet + anticoagulant + NSAID (highest-risk combination)
Elderly, H. pylori positive, prior ulcer - highest-risk group for NSAID bleeding

Ulcer/erosive

NSAIDs/aspirin - COX-1 inhibition -> reduced mucosal prostaglandin protection
Corticosteroids (additive risk with NSAIDs, not alone at typical doses)
Bisphosphonates (oesophagitis/erosion if not taken upright with water)

Anticoagulant/antiplatelet-related bleeding (from any GI lesion)

Warfarin, DOACs, aspirin, clopidogrel/ticagrelor - unmask or worsen bleeding from an existing lesion rather than causing one

Drug-induced colitis

SSRI-potentiated bleeding

Platelet serotonin depletion - additive risk when combined with NSAID/antiplatelet/anticoagulant

Full medication reconciliation - OTC NSAIDs/aspirin frequently omitted on direct questioning
Prior ulcer disease, H. pylori status
Combination therapy (dual antiplatelet, antiplatelet + anticoagulant, any of these + NSAID/SSRI)
Alcohol use (additive mucosal risk)

FBE, coagulation profile, group and hold/crossmatch, UEC (raised urea:creatinine ratio in upper GI bleed)
Endoscopy for source identification and risk stratification (Forrest classification)
H. pylori testing

Stop the causative NSAID/antiplatelet as safely as possible; weigh cardiovascular risk of stopping antiplatelet against rebleeding risk
High-dose PPI, endoscopic haemostasis per standard GI bleed pathway
Gastroprotection (PPI co-prescription) when NSAID cannot be avoided in high-risk patients (elderly, prior ulcer, concurrent antiplatelet/anticoagulant)
H. pylori eradication if positive
Reassess ongoing need for NSAID/dual antithrombotic therapy at every review

Patients routinely deny NSAID use unless asked about specific OTC brands and topical formulations
Restarting aspirin early after a bleed (once haemostasis secured) reduces overall mortality in secondary prevention - stopping indefinitely is not automatically safer
Combining SSRI with NSAID/antiplatelet/anticoagulant is an under-recognised additive bleeding risk

1. Ask about every over-the-counter agent by name

"Direct questioning about ibuprofen, Nurofen, Voltaren specifically - not just 'any painkillers'."

2. Gastroprotect rather than simply refuse the NSAID

"If the NSAID is genuinely needed, co-prescribe a PPI rather than leaving an at-risk patient unprotected."

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