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Major GI bleeding in older persons using aspirin: incidence and risk factors in the ASPREE randomised controlled trial
  1. Suzanne E Mahady1,2,
  2. Karen L Margolis3,
  3. Andrew Chan4,
  4. Galina Polekhina1,
  5. Robyn L Woods1,
  6. Rory Wolfe1,
  7. Mark R Nelson5,
  8. Jessica E Lockery1,
  9. Erica M Wood1,
  10. Christopher Reid1,6,
  11. Michael E Ernst7,
  12. Anne Murray8,9,
  13. LTP Thao1,
  14. John J McNeil1
  1. 1 School of Public Health & Preventive Medicine, Monash University Faculty of Medicine Nursing and Health Sciences, Melbourne, Victoria, Australia
  2. 2 Gastroenterology, Melbourne Health, Parkville, Victoria, Australia
  3. 3 HealthPartners Institute, Minneapolis, Minnesota, USA
  4. 4 Clinical and Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
  5. 5 Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
  6. 6 School of Public Health, Curtin University, Perth, Western Australia, Australia
  7. 7 Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, Iowa City, Iowa, USA
  8. 8 Division of Geriatrics, Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
  9. 9 Berman Center for Outcomes and Clinical Research, Hennepin Healthcare Research Institute, Hennepin Healthcare, Minneapolis, Minnesota, USA
  1. Correspondence to Dr Suzanne E Mahady, Research Methodology, School of Public Health & Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC 3004, Australia; suzanne.mahady{at}


Objective There is a lack of robust data on significant gastrointestinal bleeding in older people using aspirin. We calculated the incidence, risk factors and absolute risk using data from a large randomised, controlled trial.

Design Data were extracted from an aspirin versus placebo primary prevention trial conducted throughout 2010–2017 (‘ASPirin in Reducing Events in the Elderly (ASPREE)’, n=19 114) in community-dwelling persons aged ≥70 years. Clinical characteristics were collected at baseline and annually. The endpoint was major GI bleeding that resulted in transfusion, hospitalisation, surgery or death, adjudicated independently by two physicians blinded to trial arm.

Results Over a median follow-up of 4.7 years (88 389 person years), there were 137 upper GI bleeds (89 in aspirin arm and 48 in placebo arm, HR 1.87, 95% CI 1.32 to 2.66, p<0.01) and 127 lower GI bleeds (73 in aspirin and 54 in placebo arm, HR 1.36, 95% CI 0.96 to 1.94, p=0.08) reflecting a 60% increase in bleeding overall. There were two fatal bleeds in the placebo arm. Multivariable analyses indicated age, smoking, hypertension, chronic kidney disease and obesity increased bleeding risk. The absolute 5-year risk of bleeding was 0.25% (95% CI 0.16% to 0.37%) for a 70 year old not on aspirin and up to 5.03% (2.56% to 8.73%) for an 80 year old taking aspirin with additional risk factors.

Conclusion Aspirin increases overall GI bleeding risk by 60%; however, the 5-year absolute risk of serious bleeding is modest in younger, well individuals. These data may assist patients and their clinicians to make informed decisions about prophylactic use of aspirin.

Trial registration number ASPREE. NCT01038583.

  • elderly
  • gastrointestinal bleeding
  • aspirin
  • epidemiology
  • clinical trials

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  • Contributors Study conception and design: SEM, JJM, RLW, AC, KLM and MRN. Data analysis: GP, RLW, LTPT and JEL. Manuscript writing and revision: All authors.

  • Funding SEM is funded by the Vincent Fairfax Family Foundation Establishment Fellowship & Hugh Rogers Fellowship. ASPREE was supported by the National Institute on Aging and the National Cancer Institute at the National Institutes of Health (grant number U01AG029824); the National Health and Medical Research Council of Australia (grant numbers 334047, 1127060); Monash University (Australia); and the Victorian Cancer Agency (Australia).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Requests for data access will be via the ASPREE Principal Investigators with details for applications provided through the website,, and in accord with the NIH policy on data sharing, details available at