Is aspirin necessary for a patient with Acute Coronary Syndrome (ACS) already taking Eliquis (apixaban) and Plavix (clopidogrel)?

Management of Aspirin in ACS Patients Already on Eliquis and Plavix

Aspirin should be discontinued in patients with Acute Coronary Syndrome (ACS) who are already taking Eliquis (apixaban) and Plavix (clopidogrel), as the triple therapy significantly increases bleeding risk without providing additional thrombotic protection. 1

Initial Management in ACS

When a patient with ACS is initially presenting:

• A loading dose of aspirin (162-325 mg) should be administered at first presentation of ACS 1
• After this initial loading dose, aspirin should be discontinued while continuing:
  • Eliquis (apixaban) at therapeutic dose
  • Plavix (clopidogrel) 75 mg daily

Rationale for Discontinuing Aspirin

The decision to discontinue aspirin in patients already on Eliquis and Plavix is based on:

1. Increased bleeding risk with triple therapy: The combination of aspirin, Plavix, and Eliquis (triple therapy) significantly increases bleeding risk compared to dual therapy 2, 3

   • Major bleeding rates are substantially higher with triple therapy without additional ischemic protection
   • TIMI major bleeding (OR: 2.45), TIMI minor bleeding (OR: 3.12), and ISTH major bleeding (OR: 2.49) are all significantly increased with triple therapy 4

2. Similar efficacy with dual therapy: Dual therapy with a P2Y12 inhibitor (clopidogrel) plus anticoagulation (apixaban) provides similar protection against thrombotic events compared to triple therapy 2

   • Studies have demonstrated that "triple therapy" is no better than a P2Y12 inhibitor + anticoagulant at preventing thrombotic events 2

Special Considerations

Time Since ACS Event

• Acute presentation: Initial loading dose of aspirin (162-325 mg), then discontinue
• Less than 12 months post-ACS: Continue P2Y12 inhibitor (clopidogrel) with Eliquis, no aspirin 1
• More than 12 months post-ACS: Eliquis alone is sufficient 1

Post-PCI Management

• Less than 6 months post-PCI: Continue clopidogrel and Eliquis, discontinue aspirin 1
• 6-12 months post-PCI: Either clopidogrel or aspirin (preferably clopidogrel) with Eliquis 1
• More than 12 months post-PCI: Eliquis alone 1

Caveats and Exceptions

1. Very high thrombotic risk patients: In rare cases with exceptionally high risk for stent thrombosis (complex coronary lesions, history of stent thrombosis), low-dose aspirin (75-100 mg) may be considered temporarily, but only with:

   • Proton pump inhibitor co-therapy to reduce GI bleeding risk 2
   • Regular reassessment to determine when aspirin can be safely discontinued

2. Mechanical heart valves: Patients with mechanical heart valves require different management (warfarin plus aspirin) and should not receive DOACs like Eliquis 2

Monitoring Recommendations

• Regular assessment of bleeding risk using validated scoring systems
• Monitor for signs of bleeding (bruising, melena, hemoptysis, etc.)
• Evaluate thrombotic risk periodically to determine if antiplatelet therapy can be further reduced

Conclusion

The evidence strongly supports discontinuing aspirin in patients with ACS who are already on Eliquis and Plavix, except for the initial loading dose at ACS presentation. This approach optimizes the balance between thrombotic protection and bleeding risk, prioritizing patient safety and mortality outcomes.