When should Aspirin (acetylsalicylic acid) be discontinued before an endoscopic Percutaneous Endoscopic Gastrostomy (PEG) tube procedure?

From the Guidelines

Aspirin should be continued before an endoscopic percutaneous endoscopic gastrostomy (PEG) tube procedure in most cases. According to the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update 1, for high-risk endoscopic procedures in patients at low thrombotic risk, aspirin can be continued. The guideline recommends discontinuing P2Y12 receptor antagonists 7 days before the procedure, but suggests continuing aspirin in patients on dual antiplatelet therapy (DAPT).

The bleeding risk associated with PEG tube placement is considered low, with a risk of haemorrhage of 1.5% in a case series of 950 patients 1. Additionally, studies have shown that continuing antiplatelet therapy, such as clopidogrel, may be safe during PEG insertion 1. A German retrospective study found no evidence of increased haemorrhage in patients on aspirin, clopidogrel, or combinations of antithrombotics during PEG insertion 1.

However, if a patient is on high-dose aspirin or has additional bleeding risk factors, such as liver disease, coagulopathy, or concurrent use of other anticoagulants, the physician may recommend discontinuing aspirin 5-7 days before the procedure based on individual risk assessment. The decision should always be made in consultation with the patient's cardiologist or primary physician who prescribed the aspirin. After the procedure, aspirin therapy can typically be resumed within 24 hours if there are no signs of bleeding complications.

Key points to consider:

• PEG tube placement is considered a low bleeding risk procedure
• The thrombotic risk of discontinuing antiplatelet therapy often exceeds the bleeding risk for patients with cardiovascular indications
• Aspirin can be continued in most cases, but individual risk assessment is necessary for patients with high-dose aspirin or additional bleeding risk factors
• The decision to discontinue aspirin should be made in consultation with the patient's cardiologist or primary physician 1.

From the Research

Aspirin Discontinuation Before Endoscopic PEG Tube Procedure

• The decision to discontinue aspirin before an endoscopic PEG tube procedure should be based on the individual patient's risk of bleeding and thromboembolism 2, 3, 4.
• According to some studies, aspirin does not need to be discontinued for low-risk endoscopic procedures, such as PEG tube placement 2, 4.
• A systematic review and meta-analysis found that maintaining aspirin treatment during PEG tube insertion did not significantly increase the risk of bleeding 4.
• Another study found that an intervention to educate patients and staff on the continuation of aspirin therapy prior to outpatient endoscopy significantly reduced inappropriate alteration of aspirin therapy 5.
• However, some guidelines recommend discontinuing antiplatelet agents, including aspirin, 7-10 days before high-risk procedures, such as those with a high risk of bleeding or thromboembolism 2, 6.

Risk of Bleeding and Thromboembolism

• The risk of bleeding and thromboembolism should be carefully weighed when deciding whether to discontinue aspirin before an endoscopic PEG tube procedure 2, 3, 4.
• Patients with a high risk of thromboembolism may require alternative anticoagulation therapy, such as heparin or low molecular weight heparin, during the period of aspirin discontinuation 2, 3.
• The use of aspirin and other antiplatelet agents should be individualized based on the patient's underlying medical conditions and the specific procedure being performed 4, 6.

Clinical Recommendations

• Aspirin can be continued in patients undergoing PEG tube placement, unless there are specific concerns about bleeding or thromboembolism 4, 5.
• Patients should be educated on the importance of continuing aspirin therapy as prescribed, unless instructed otherwise by their healthcare provider 5.
• Healthcare providers should carefully evaluate the risks and benefits of aspirin discontinuation on a case-by-case basis, taking into account the individual patient's medical history and the specific procedure being performed 2, 3, 4, 6.