What is the management approach for a 71-year-old female patient on lifelong aspirin (acetylsalicylic acid) therapy and Brilinta (ticagrelor) therapy for 12 months, presenting with rectal bleeding characterized by bright red blood?

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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 critical for her cardiovascular protection. The patient should be monitored closely with a complete blood count to assess for anemia and hemodynamic stability should be confirmed. A fecal occult blood test would help quantify the bleeding. While waiting for GI consultation, the patient should be advised to increase fluid intake, avoid NSAIDs and other medications that may exacerbate bleeding, and report any worsening symptoms immediately. The rectal bleeding is likely related to the dual antiplatelet therapy, which increases bleeding risk, particularly in older patients. Brilinta (ticagrelor) can be temporarily suspended with less risk of stent thrombosis compared to completely stopping all antiplatelet therapy, as supported by the guidelines from the British Society of Gastroenterology 1. However, this is a temporary measure until proper GI evaluation can determine the bleeding source and appropriate treatment. If bleeding worsens or the patient becomes hemodynamically unstable, immediate emergency evaluation would be necessary. It's also important to note that the management of antiplatelet therapy in patients undergoing invasive procedures should be individualized, taking into account the type of procedure, the patient's risk factors, and the potential benefits and risks of continuing or discontinuing antiplatelet therapy, as recommended by the French working group on perioperative haemostasis and the French study group on thrombosis and haemostasis 1. Additionally, the Asian Pacific Association of Gastroenterology and the Asian Pacific Society for Digestive Endoscopy also provide guidelines for the management of patients on antithrombotic agents undergoing emergency and elective endoscopy, which support the temporary suspension of Brilinta in this scenario 1.

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, 5
  • However, studies suggest that the risk of gastrointestinal bleeding with ticagrelor-based dual antiplatelet therapy is not significantly different from clopidogrel-based therapy 3
  • Reducing the dose of aspirin to 50 mg daily may decrease the risk of bleeding events without increasing ischemic risk in patients taking ticagrelor 4

Diagnostic Evaluation

  • A 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 comorbid conditions should be taken into account when determining the likelihood of colorectal cancer and the need for further evaluation 6

Next Steps

  • In addition to referring the patient to a gastroenterologist, the patient's medication regimen and potential risk factors for gastrointestinal bleeding should be carefully evaluated 2, 3, 4, 5
  • Consider reducing the dose of aspirin to 50 mg daily to minimize the risk of bleeding events 4
  • Ensure the patient is aware of the importance of adhering to their medication regimen and reporting any further bleeding or symptoms 4

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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