From the Guidelines
For a 71-year-old female patient on lifelong aspirin and 12-month Brilinta therapy who is experiencing bright red rectal bleeding, I recommend temporarily holding the Brilinta while continuing the aspirin therapy, as aspirin is more critical for her underlying cardiovascular condition. This approach is supported by the British Society of Gastroenterology guidelines, which suggest that aspirin for secondary prevention should not be routinely stopped, and if stopped, should be restarted as soon as haemostasis is achieved 1. The patient should be monitored closely with a complete blood count to assess for anemia and hemodynamic stability should be confirmed. A digital rectal examination should be performed to check for obvious sources of bleeding such as hemorrhoids or fissures. The patient should be advised to increase fiber intake, maintain adequate hydration, and use stool softeners to prevent constipation which could exacerbate bleeding.
While waiting for the GI referral, the patient should be instructed to monitor the frequency and volume of bleeding and report any worsening symptoms immediately. According to the guidelines, P2Y12 receptor antagonist therapy, such as Brilinta, should be reinstated within 5 days 1. This timeframe is based on a large number of studies of discontinuation of antiplatelet therapy in patients with drug-eluting stents, and represents an optimal balance between haemorrhage and thrombosis. The Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines also recommend continuing aspirin and withholding clopidogrel (or other P2Y12 inhibitor) in acute non-variceal upper GI bleeding 1.
Key considerations in managing this patient include:
- Balancing the risk of bleeding with the cardiovascular benefits of antiplatelet therapy
- Monitoring the patient closely for signs of bleeding or cardiovascular complications
- Reinstating Brilinta within 5 days to minimize the risk of thrombosis
- Maintaining aspirin therapy to protect against cardiovascular events
- Addressing potential underlying causes of bleeding, such as hemorrhoids or fissures, through digital rectal examination and lifestyle modifications.
From the Research
Patient Presentation
The patient is a 71-year-old female with a history of recent standing in January, currently on lifelong aspirin therapy and Brilinta (ticagrelor) therapy for 12 months, presenting with bright red blood from the rectum for the last few days.
Potential Causes and Management
- Rectal bleeding can have various causes, ranging from benign to life-threatening 2
- The patient's current medication regimen, including aspirin and ticagrelor, may increase the risk of gastrointestinal bleeding 3, 4
- However, studies suggest that the risk of gastrointestinal bleeding with ticagrelor-based dual antiplatelet therapy is not significantly different from clopidogrel-based therapy 3
- A rectal bleeding algorithm can help identify patients who can be safely managed in primary care, reducing unnecessary emergency admissions 5
Diagnostic Evaluation
- Diagnostic evaluation for rectal bleeding is complex and may involve assessing risk factors for colorectal cancer, as well as ordering colonoscopies when indicated 6
- The patient's age and comorbidities should be taken into account when evaluating the risk of colorectal cancer and determining the need for colonoscopy 6
Management Options
- Reducing the dose of aspirin from 75-100 mg to 50 mg daily may help reduce bleeding events without increasing ischemic risk in patients taking ticagrelor 4
- The patient's current medication regimen and bleeding risk should be carefully evaluated and managed to minimize the risk of further bleeding events 3, 4
- Referral to a gastroenterologist (G.I) may be necessary for further evaluation and management of the patient's rectal bleeding, but other management options should also be considered 2, 5