From the Guidelines
Aspirin and Plavix should be held temporarily in patients with low hemoglobin, particularly if it drops below 8 g/dL or if there are signs of active bleeding, as recommended by the most recent guidelines 1. The decision to hold these medications should be made in consultation with the prescribing physician, taking into account the patient's underlying cardiovascular condition and the risks of stopping these medications.
- The patient's hemoglobin levels should be monitored closely, aiming for at least 8-10 g/dL before considering restarting the medications.
- The duration of discontinuation should be as short as possible, typically ranging from a few days to a week, while addressing the cause of low hemoglobin.
- For patients with recent stent placement or high risk of thrombotic events, alternative anticoagulation strategies may be necessary during the hold period. The rationale for this recommendation is based on the fact that aspirin and Plavix (clopidogrel) are antiplatelet drugs that inhibit blood clotting, which can increase the risk of bleeding in patients with low hemoglobin 1.
- Low hemoglobin suggests possible blood loss, and continuing these medications could exacerbate the situation.
- By temporarily discontinuing them, you allow the body to form clots more easily, potentially stopping any ongoing bleeding and allowing hemoglobin levels to recover. It is essential to weigh the risks and benefits of stopping these medications, considering the patient's individual characteristics, the nature of the bleed, and the intensity of anticoagulation, as outlined in the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1.
From the FDA Drug Label
5.2 General Risk of Bleeding 4.1 Active Bleeding 7.4 Nonsteroidal Anti-inflammatory Drugs (NSAIDs) 7.7 Other Antiplatelet Agents
Aspirin (acetylsalicylic acid) and Plavix (clopidogrel) should be used with caution in patients with bleeding risks.
- Bleeding risk is a concern with both medications.
- Anemia (low hemoglobin) may be a sign of bleeding, and the use of these medications may exacerbate this condition.
- The FDA drug label for Plavix recommends caution with bleeding risks, but does not directly address the management of anemia.
- Given the potential for increased bleeding risk, it is reasonable to consider holding aspirin and Plavix in the setting of anemia (low hemoglobin) until the condition is stabilized or resolved 2.
From the Research
Management of Anemia
- The management of anemia, particularly in patients with very low hemoglobin levels, is crucial in determining outcomes 3, 4, 5, 6.
- Studies have shown that a restrictive transfusion strategy, where transfusions are only given to patients with a hemoglobin level below 6-8 g/dL, is associated with better outcomes than a more liberal transfusion strategy 4, 6.
- The use of "Bloodless Medicine and Surgery" (BMS) strategies, which focus on optimizing the patient's hematopoietic capacity, minimizing blood loss, and providing supportive care, has been shown to be effective in managing patients with severe anemia who decline blood transfusions 5.
Medication Management
- There is no direct evidence to suggest that aspirin (acetylsalicylic acid) and Plavix (clopidogrel) should be held in the setting of anemia (low hemoglobin) 3, 4, 5, 7, 6.
- However, it is essential to consider the patient's overall clinical condition, including their hemoglobin level, when managing medications that may affect bleeding or clotting 4, 5.
Patient Blood Management
- Patient Blood Management (PBM) strategies, which aim to optimize the patient's hematopoietic capacity, minimize blood loss, and provide supportive care, have been shown to be effective in managing patients with anemia 3, 5, 6.
- PBM strategies can help reduce the need for blood transfusions and improve patient outcomes, particularly in patients with severe anemia who decline blood transfusions 5.