When to hold daptomycin (Dapt) in the setting of an acute bleed?

Management of Dual Antiplatelet Therapy (DAPT) During Acute Bleeding

In the setting of acute bleeding, one antiplatelet agent should be temporarily discontinued while maintaining the other (preferably aspirin) to balance bleeding and thrombotic risks. 1

Assessment of Bleeding and Thrombotic Risk

Bleeding Severity Evaluation

• Assess hemodynamic stability
• Quantify blood loss
• Identify bleeding source
• Evaluate laboratory parameters (hemoglobin, platelet count, coagulation studies)

Thrombotic Risk Stratification

• Time since coronary intervention/stent placement
• Type of stent (drug-eluting vs. bare metal)
• Indication for DAPT (acute coronary syndrome vs. stable coronary disease)
• Patient-specific risk factors for stent thrombosis

Management Algorithm

For Active Bleeding:

1. Maintain at least one antiplatelet agent

   • Continue aspirin (75-100mg daily) if possible 1
   • Temporarily discontinue P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel) 1

2. Never discontinue both antiplatelet agents simultaneously

   • This significantly increases risk of stent thrombosis (median time to thrombosis: 7 days with both agents withheld vs. 122 days with only clopidogrel withheld) 1

3. Prioritize hemostasis measures

   • Direct pressure/endoscopic intervention for accessible bleeding
   • Consider proton pump inhibitors for GI bleeding
   • Transfuse blood products as needed

4. Timing of P2Y12 inhibitor resumption

   • Resume once adequate hemostasis is achieved 1
   • For ticagrelor: can resume within 2-3 days (reversible agent)
   • For clopidogrel/prasugrel: can resume within 5 days 1

Special Considerations:

High Thrombotic Risk Patients (within 30 days of stent placement or ACS):

• Consult cardiology before any antiplatelet modification 1
• Consider bridging with short-acting antiplatelet agents if both oral agents must be discontinued

Triple Therapy Patients (DAPT + Anticoagulant):

• If bleeding occurs on triple therapy, discontinue one antiplatelet agent (usually P2Y12 inhibitor) 1
• If bleeding occurs on dual therapy (anticoagulant + single antiplatelet), consider temporarily holding antiplatelet agent 1

Evidence Quality and Recommendations

The European Society of Gastrointestinal Endoscopy (ESGE) and Asian Pacific Association of Gastroenterology (APAGE) guidelines provide strong recommendations against discontinuing both antiplatelet agents simultaneously during bleeding episodes 1. These recommendations are based on evidence showing extremely high risk of stent thrombosis when both agents are withheld.

A randomized trial of aspirin users with bleeding peptic ulcers showed that patients who continued aspirin immediately after endoscopic hemostasis had significantly lower all-cause mortality compared to those who discontinued aspirin (1.3% vs 12.9%), despite a numerically higher rebleeding rate 1.

Common Pitfalls to Avoid

• Discontinuing both antiplatelet agents simultaneously - carries extremely high risk of stent thrombosis 1
• Prolonged discontinuation of P2Y12 inhibitors - risk increases after 5 days without therapy 1
• Failure to consult cardiology - interdisciplinary management is essential, especially for patients with recent stent placement 1
• Overlooking the differential risk of antiplatelet agents - ticagrelor and prasugrel have higher bleeding risk than clopidogrel 1

By following this approach, clinicians can effectively balance the competing risks of continued bleeding versus catastrophic thrombotic events in patients on DAPT who experience acute bleeding.