Do you hold antiplatelet (antiplatelet) agents, such as aspirin or clopidogrel, in the setting of a gastrointestinal (GI) bleed?

Management of Antiplatelet Therapy During GI Bleeding

For patients with GI bleeding who are on antiplatelet therapy, aspirin should be continued without interruption if used for cardiovascular protection, while P2Y12 inhibitors like clopidogrel should be temporarily discontinued and resumed within 3-5 days after endoscopic hemostasis is achieved. 1

Aspirin Management

• Continue aspirin if used for secondary cardiovascular prevention, even during active GI bleeding 1
• Evidence strongly supports this approach as discontinuing aspirin in patients with cardiovascular disease significantly increases mortality risk
• A randomized trial showed that patients who continued aspirin after GI bleeding had 10 times lower all-cause mortality at 8 weeks compared to those who discontinued it (1.3% vs 12.9%) 1
• The cardiovascular protection benefit outweighs the slightly increased risk of rebleeding

P2Y12 Inhibitor Management (Clopidogrel, Prasugrel, Ticagrelor)

• Temporarily discontinue P2Y12 inhibitors during active GI bleeding 1
• Resume after endoscopic hemostasis is achieved:
  • Ticagrelor: Resume within 2-3 days (reversible inhibitor with faster recovery) 1
  • Clopidogrel/Prasugrel: Resume within 5 days (irreversible inhibitors) 1

Dual Antiplatelet Therapy (DAPT) Considerations

• For patients on DAPT with coronary stents who develop GI bleeding:
  • Continue aspirin without interruption
  • Temporarily discontinue clopidogrel/P2Y12 inhibitor 1, 2
  • Never discontinue both agents simultaneously - risk of stent thrombosis increases dramatically (median time to thrombosis is only 7 days with both drugs withheld vs 122 days with only clopidogrel withheld) 1
• Always consult with cardiology before any changes to antiplatelet therapy, particularly for patients with:
  • Acute coronary syndrome within 6 months
  • Recent coronary stent placement
  • High risk of stent thrombosis 1, 2

Platelet Transfusions

• Avoid platelet transfusions in patients with GI bleeding who are on antiplatelet therapy 1, 3
• Evidence shows platelet transfusions:
  • Do not reduce rebleeding risk
  • May be associated with higher mortality
  • Provide no clinical benefit in this setting 3

Resumption of Therapy

• If antiplatelet therapy must be interrupted:
  • Restart as soon as hemostasis is achieved 4
  • The FDA label for clopidogrel specifically states: "If clopidogrel must be temporarily discontinued, restart it as soon as possible" 4
• For patients with drug-eluting coronary stents:
  • Prioritize earlier resumption of antiplatelet therapy to prevent stent thrombosis 1

GI Bleeding Prevention

• Add proton pump inhibitor (PPI) therapy for all patients on antiplatelet therapy with history of GI bleeding 1, 5, 6
• PPIs are more effective than H2-receptor antagonists in preventing upper GI bleeding in patients on antiplatelet therapy 1
• Consider PPI prophylaxis for patients on DAPT, especially those with additional risk factors:
  • History of peptic ulcer disease
  • Advanced age
  • Concomitant anticoagulant or NSAID use
  • H. pylori infection 1, 5

Common Pitfalls to Avoid

• Discontinuing both antiplatelet agents simultaneously in patients with coronary stents
• Prolonged interruption of antiplatelet therapy, especially in high cardiovascular risk patients
• Using platelet transfusions which provide no benefit and may increase mortality
• Failing to use PPI prophylaxis in high-risk patients
• Restarting antiplatelet therapy too late after hemostasis is achieved

Remember that the mortality risk from cardiovascular events after discontinuing antiplatelet therapy often exceeds the risk from continued GI bleeding, especially for patients with recent coronary stents or acute coronary syndrome.