Should baby (acetylsalicylic acid) aspirin be discontinued in the event of a lower gastrointestinal (GI) bleed?

Management of Baby Aspirin in Lower GI Bleeding

For patients taking baby aspirin for secondary cardiovascular prevention, aspirin should NOT be discontinued during a lower GI bleed as the mortality benefit of continuing aspirin outweighs the increased risk of rebleeding. 1

Decision Algorithm for Aspirin Management in Lower GI Bleeding

Primary vs. Secondary Prevention

• Primary prevention: Permanently discontinue aspirin if it was being used only for primary prevention, as the cardiovascular benefit does not outweigh bleeding risk 1
• Secondary prevention: Continue aspirin without interruption throughout the bleeding episode 1

Management Approach

1. Initial management: Resuscitate patient and achieve hemostasis through appropriate interventions
2. During active bleeding:
   • Continue aspirin if used for secondary prevention
   • Add proton pump inhibitor (PPI) therapy to reduce risk of recurrent bleeding 1
3. If aspirin was temporarily held: Resume immediately after hemostasis is achieved 1

Evidence Supporting Continuation of Aspirin

The American College of Gastroenterology guidelines strongly support continuing aspirin during lower GI bleeding for patients on secondary prevention, citing evidence of 10x lower all-cause mortality when aspirin is continued (1.3% vs 12.9%) despite a numerically higher rebleeding rate 1.

A 2022 study demonstrated that discontinuing low-dose aspirin after gastrointestinal bleeding was associated with doubled one-year all-cause mortality (HR 2.16,95% CI 1.39-3.35) after adjustment for age, gender, and comorbidities 2. Importantly, continuing aspirin did not significantly increase the risk of rebleeding (9.2% vs 10.2%, p=0.713) 2.

Similarly, a 2016 study found that while aspirin continuation after lower GI bleeding was associated with increased risk of recurrent bleeding (18.9% vs 6.9%), it significantly reduced serious cardiovascular events (22.8% vs 36.5%) and death from other causes (8.2% vs 26.7%) 3.

Special Considerations

Dual Antiplatelet Therapy (DAPT)

• Continue aspirin without interruption
• Temporarily withhold P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel)
• Restart P2Y12 inhibitor within 5 days after hemostasis 1
• Never discontinue both antiplatelet agents simultaneously due to high risk of stent thrombosis

Risk Reduction Strategies

• Add PPI therapy to reduce risk of recurrent bleeding 4
• Avoid concomitant use of NSAIDs, which significantly increases bleeding risk 5, 4
• Monitor closely for signs of rebleeding, especially in high-risk patients (age ≥60, history of ulcers, concomitant anticoagulants) 5

Common Pitfalls to Avoid

1. Prolonged discontinuation: Delaying restart beyond 5-7 days increases thrombotic risk unnecessarily 1
2. Ignoring indication: Failing to distinguish between primary and secondary prevention leads to inappropriate management decisions
3. Overlooking drug interactions: NSAIDs and steroids significantly increase bleeding risk when combined with aspirin 5
4. Inadequate gastroprotection: Not adding PPI therapy after a GI bleed in patients continuing aspirin therapy 4

The evidence clearly demonstrates that the cardiovascular mortality benefit of continuing aspirin for secondary prevention outweighs the increased risk of rebleeding, making continuation the recommended approach despite lower GI bleeding.