Peptic ulcer disease gastrointestinal bleeding with

Previous peptic ulcer disease or upper gastrointestinal bleeding Cardiovascular disease and other comorbid conditions Multiple NSAID use (e.g., low-dose aspirin in conjunction with another NSAID)... 

Patients at increased risk of NSAID-induced gastrointestinal adverse effects (e.g., dyspepsia, peptic ulcer formation, and bleeding) include the elderly, those with peptic ulcer disease, coagulopathy, and patients receiving high doses of concurrent corticosteroids. Nephrotoxicity is more common in the elderly, patients with creatinine clearance values less than 50 mL/minute, and those with volume depletion or on diuretic therapy. NSAIDs should be used with caution in patients with reduced cardiac output due to sodium retention and in patients receiving antihypertensives, warfarin, and lithium. 

Important susceptibility factors include age, endogenous coagulation defects, thrombocytopenia, hypertension, cerebrovascular disease, thyroid disease, renal insufficiency, liver disease, tumors, cerebrovascular disease, alcoholism, a history of gastrointestinal bleeding (peptic ulcer disease alone without past bleeding is not associated with an increased risk of bleeding), and an inability to adhere to the regimen. 

Relative (1) patients with serious gastrointestinal events and other risk factors known to be associated with peptic ulcer disease such as alcoholism, smoking, etc. (2) Elderly and debilitated patients who cannot tolerate ulceration or bleeding well. (3) Patients with bronchospastic reactivity (e.g. asthma), nasal polyps, or those with a history of angioedema can have an anaphylactoid reaction after ibuprofen. (4) Patients with advanced renal disease should be monitored closely during the treatment of ibuprofen. 

Aspirin also places patients at risk for gastrointestinal bleeding, ulceration and perforation. Patients with a history of significant GI bleeding or peptic ulcer disease should not be prescribed aspirin. Patients who are already taking another type of NS AID should not take aspirin, as this increases the risk for upper GI bleeding even more. 

Levy, M. (1974) Aspirin use in patients with major upper gastrointestinal bleeding and peptic ulcer disease. New Engl J. Med., 290,1158. 

Iron deficiency is commonly caused by insufficient dietary intake, excessive menstrual flow, multiple births, and gastrointestinal bleeding (occult or patent) due to medications (aspirin, steroids), hiatal hernia, peptic ulcers, gastritis associated with alcoholism, anemia of chronic disease, geophagia, and tumors. After these patients are carefully diagnosed, iron supplementation is administered using oral ferrous sulfate or by intravenous therapy with an iron-dextran complex (Imferon) [28,29]. 

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