Should Plavix (clopidogrel) or aspirin be stopped in a patient with a gastrointestinal (GI) bleed and a stent?

From the Guidelines

In a patient with a gastrointestinal bleed and a stent, aspirin should be continued if possible, while clopidogrel (Plavix) is typically temporarily discontinued during active bleeding but should be restarted as soon as hemostasis is achieved, usually within 5 days, as recommended by the British Society of Gastroenterology 1.

Key Considerations

• The management of antiplatelet therapy in patients with gastrointestinal bleeding and a stent requires careful consideration of both bleeding and thrombotic risks.
• Aspirin should not be routinely stopped, even during active GI bleeding, especially in patients with recent coronary stent placement, due to the high risk of stent thrombosis and subsequent myocardial infarction or stroke.
• Clopidogrel (Plavix) should be reinstated within 5 days of stopping, as the risk of thrombosis increases significantly after this timeframe, as supported by the guidelines from the British Society of Gastroenterology 1.
• Proton pump inhibitors should be administered to reduce rebleeding risk, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1.

Risks and Benefits

• The risk of GI bleeding is increased with antiplatelet therapy, but the benefits of antithrombotic effects in preventing myocardial infarction and stroke must be weighed against this risk.
• Patients with prior GI bleeding are at highest risk for recurrent bleeding on antiplatelet therapy, and other clinical characteristics such as advanced age, concurrent use of anticoagulants, steroids, or nonsteroidal anti-inflammatory drugs (NSAIDs) also increase the risk of GI bleeding, as noted in the ACCF/ACG/AHA 2010 expert consensus document 1.
• The use of proton pump inhibitors may reduce the risk of GI bleeding, but their concomitant use with clopidogrel may also reduce the antiplatelet effects of clopidogrel, as suggested by pharmacokinetic and pharmacodynamic studies 1.

Clinical Decision-Making

• Clinical decisions regarding antiplatelet therapy management in patients with gastrointestinal bleeding and a stent must balance overall risks and benefits, considering both cardiovascular and gastrointestinal complications.
• Cardiology consultation is essential before stopping either medication, especially in patients with very recent stent placement (within 30 days) or high thrombotic risk.
• The timing of antiplatelet therapy resumption should balance the risk of stent thrombosis against recurrent bleeding, and dual antiplatelet therapy should be resumed promptly once bleeding is controlled, as premature discontinuation significantly increases the risk of stent thrombosis, which carries a high mortality rate, as recommended by the British Society of Gastroenterology 1.

From the FDA Drug Label

5.3 Discontinuation of Clopidogrel Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. Risk factors for bleeding include concomitant use of other drugs that increase the risk of bleeding (e.g., anticoagulants, antiplatelet agents, and chronic use of NSAIDs)

• Stopping Plavix or Aspirin in GI Bleeding with Stent:
  • The decision to stop Plavix (clopidogrel) or aspirin in a patient with a gastrointestinal (GI) bleed and a stent should be made with caution, considering the risk of cardiovascular events.
  • Discontinuation of clopidogrel increases the risk of cardiovascular events, but it may be necessary to temporarily discontinue it to treat bleeding.
  • It is recommended to restart clopidogrel as soon as possible after the bleeding is treated.
  • The use of antiplatelet agents, such as clopidogrel and aspirin, increases the risk of bleeding, and the risk factors for bleeding should be carefully considered in patients with a GI bleed and a stent 2.

From the Research

Management of GI Bleeding in Patients with Stent

• The management of gastrointestinal (GI) bleeding in patients with a stent is a complex issue, requiring a balance between the risk of stent thrombosis and further bleeding 3, 4.
• Dual antiplatelet therapy with aspirin and clopidogrel is mandatory after drug-eluting stent implantation to prevent late stent thrombosis, but it increases the risk of bleeding 3.
• The risk of GI bleeding is higher in patients with a history of peptic ulcer disease, advanced age, and co-administration of non-steroidal anti-inflammatory drugs or anticoagulants 5.

Role of Proton Pump Inhibitors (PPIs)

• Proton pump inhibitors (PPIs) can reduce the risk of GI bleeding in patients on dual antiplatelet therapy 6, 7.
• The use of PPIs is recommended for patients with a history of upper GI bleeding or prespecified risk factors for GI bleeding 6.
• PPI therapy can be beneficial in reducing GI events, regardless of aspirin dose, in patients requiring dual antiplatelet therapy 7.

Discontinuation of Antiplatelet Therapy

• Discontinuation of antiplatelet therapy, particularly clopidogrel, is a strong independent risk factor for the development of stent thrombosis 4.
• The decision to stop or continue antiplatelet therapy in a patient with GI bleeding and a stent should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 3, 4.
• Close combined management between gastroenterologist and cardiologist is advocated to optimize patient outcomes 3.