Should aspirin (acetylsalicylic acid) be discontinued in patients with mild thrombophilia?

Management of Aspirin in Mild Thrombophilia

For patients with mild thrombophilia without a history of thrombotic events, aspirin should be discontinued as it provides minimal benefit while increasing bleeding risk. 1

Risk-Benefit Assessment for Aspirin in Thrombophilia

Thrombophilia-Specific Considerations

• The CHEST guidelines (2016) do not recommend aspirin as primary therapy for thrombophilia 1
• Aspirin is only suggested as an option for patients with unprovoked VTE who are stopping anticoagulant therapy, not as a primary prevention strategy for thrombophilia 1
• The guidelines specifically note: "Because aspirin is expected to be much less effective at preventing recurrent VTE than anticoagulants, we do not consider aspirin a reasonable alternative to anticoagulant therapy" 1

Bleeding Risk Considerations

• Aspirin increases bleeding risk, particularly gastrointestinal bleeding 1
• For high-risk endoscopic procedures, aspirin discontinuation should be considered on an individual basis depending on thrombosis versus hemorrhage risk 1
• Template bleeding times normalize within 96 hours after stopping aspirin therapy 2

Decision Algorithm for Aspirin Management in Mild Thrombophilia

1. Assess thrombotic risk:

   • No prior VTE events → Low risk → Discontinue aspirin
   • History of unprovoked VTE → Consider continuing aspirin only if stopping anticoagulation 1

2. Evaluate bleeding risk factors:

   • History of GI bleeding → Discontinue aspirin
   • Upcoming surgical procedures → Discontinue aspirin 5 days before procedure 2
   • Concomitant anticoagulant use → Discontinue aspirin 3

3. Consider alternative indications:

   • Stable coronary artery disease with anticoagulation → Oral anticoagulation alone is sufficient; discontinue aspirin 3
   • More than 12 months since acute coronary syndrome → Oral anticoagulation alone is recommended; discontinue aspirin 3

Special Considerations

Timing of Discontinuation

• If discontinuing aspirin before surgery, stop 5 days prior to allow normalization of platelet function 2
• Platelet function tests normalize within 144 hours after stopping aspirin 2

Monitoring After Discontinuation

• Monitor for any signs of thrombotic events after discontinuation
• For patients with essential thrombocythemia (a more severe form of thrombophilia), aspirin discontinuation should be more carefully considered 4

Pitfalls to Avoid

• Avoid abrupt discontinuation without consultation in patients with recent acute coronary syndrome or stent placement 1
• Do not confuse mild inherited thrombophilia with myeloproliferative disorders like essential thrombocythemia, which may have different recommendations 4
• Do not assume all thrombocytosis requires antiplatelet therapy; reactive thrombocytosis has not been shown to cause thrombosis even at platelet counts >1000 x 10^9/L 4

In conclusion, for patients with mild thrombophilia without a history of thrombotic events, the evidence supports discontinuing aspirin due to its minimal benefit in preventing thrombosis while increasing bleeding risk. The decision should be reconsidered only if the patient has had unprovoked VTE and is stopping anticoagulation therapy.