Do we withhold aspirin (acetylsalicylic acid) in acute gastrointestinal (GI) bleed?

Management of Aspirin in Acute GI Bleeding

In acute gastrointestinal bleeding, aspirin for secondary cardiovascular prevention should not be routinely discontinued, but should be restarted as soon as hemostasis is achieved. 1

Decision Algorithm for Aspirin Management in Acute GI Bleeding

Primary vs Secondary Prevention

• Aspirin for primary prophylaxis of cardiovascular events should be permanently discontinued in patients with acute GI bleeding 1
• Aspirin for secondary prevention (established cardiovascular disease) should be continued or restarted as soon as hemostasis is achieved 1

Severity-Based Management

• In patients with life-threatening or serious GI bleeding:
  • Temporarily withhold aspirin until initial hemostasis is achieved 1
  • Restart aspirin as soon as hemostasis is achieved 1
• In patients with non-life-threatening GI bleeding:
  • Continue aspirin without interruption, especially in those with high cardiovascular risk 1

Dual Antiplatelet Therapy (DAPT) Considerations

• If patient is on DAPT (aspirin plus P2Y12 inhibitor):
  • Continue aspirin if possible 1
  • Temporarily withhold only the P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) 1
  • Restart P2Y12 inhibitor within 5 days maximum to prevent stent thrombosis 1

Evidence Supporting Continued/Early Restarted Aspirin

• A randomized controlled trial showed that continuing aspirin after GI bleeding resulted in 10 times lower all-cause mortality (1.3% vs 12.9%) compared to discontinuing aspirin, despite a numerically higher but non-significant rebleeding rate 1, 2
• Discontinuation of aspirin therapy is associated with a threefold increased risk of major adverse cardiac events 1
• A retrospective study demonstrated that patients who discontinued aspirin after GI bleeding had almost sevenfold increased risk of death or acute cardiovascular events (HR 6.9) compared to those who continued therapy 1
• Another study showed that discontinuing aspirin after GI bleeding doubled one-year all-cause mortality (HR 2.16) without decreasing the risk of rebleeding 3

Risk Mitigation Strategies

• Always initiate a proton pump inhibitor (PPI) when restarting aspirin after GI bleeding 2
• The combination of aspirin with a PPI has been shown to be superior to clopidogrel alone for preventing recurrent bleeding 2, 4
• For patients with coronary stents on DAPT, consult with a cardiologist before making any changes to the antiplatelet regimen 1

Important Caveats and Pitfalls

• Unnecessarily delaying aspirin resumption increases thrombotic risk, which can lead to higher mortality than the risk of rebleeding 1, 2
• Discontinuing both antiplatelet agents simultaneously in patients on DAPT can lead to stent thrombosis in as little as 7 days 1
• The risk of GI bleeding with low-dose aspirin is 1.5 times higher compared to placebo, but this risk is outweighed by cardiovascular benefits in secondary prevention 5
• Aspirin irreversibly inhibits platelet function for 5-7 days, so even short interruptions can increase thrombotic risk 1
• The timing of restarting aspirin should balance the risk of rebleeding against the risk of thrombotic events 1