How to manage Upper Gastrointestinal (UGI) bleed in patients on antiplatelet therapy?

Management of Upper Gastrointestinal Bleeding in Patients on Antiplatelet Therapy

For patients with upper gastrointestinal bleeding on antiplatelet therapy, aspirin for secondary prevention should not be routinely stopped, and if temporarily withheld, it should be restarted as soon as hemostasis is achieved, while P2Y12 receptor antagonists should be reinstated within 5 days after endoscopic hemostasis. 1

Initial Management of UGI Bleeding on Antiplatelet Therapy

• For patients on aspirin for primary prophylaxis of cardiovascular events, permanently discontinue aspirin as the bleeding risk outweighs cardiovascular benefit 1
• For patients on aspirin for secondary prevention (established cardiovascular disease), temporarily withhold aspirin only during active serious or life-threatening bleeding 1
• For patients on dual antiplatelet therapy (DAPT), never withhold both antiplatelet agents simultaneously due to high risk of stent thrombosis, which can occur in as little as 7 days 1
• In patients on DAPT with aspirin and clopidogrel, continue aspirin and temporarily withhold clopidogrel during active bleeding 1
• For patients on direct oral anticoagulants (DOACs), interrupt therapy at presentation with UGI bleeding 1

Timing of Antiplatelet Resumption After Hemostasis

• For patients on aspirin for secondary prevention, restart aspirin as soon as hemostasis is achieved (typically immediately after successful endoscopic therapy) 1, 2
• For patients on P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor), restart therapy within 5 days after endoscopic hemostasis 1
• For patients on ticagrelor (reversible P2Y12 inhibitor), consider earlier resumption (within 2-3 days) compared to clopidogrel or prasugrel (irreversible inhibitors) 1
• For patients on DOACs, consider restarting treatment at a maximum of 7 days after bleeding has stopped 1

Risk Stratification and Decision-Making

• The risk-benefit analysis of discontinuing antiplatelet therapy depends on:

  • Indication for antiplatelet therapy (primary vs. secondary prevention) 1
  • Type of coronary stent and timing of placement (highest risk within 6 weeks of placement) 1
  • Severity of bleeding 1
  • Success of endoscopic hemostasis 1

• For patients with very high thrombotic risk (acute coronary syndrome or percutaneous coronary intervention within 6 weeks):

  • Consult with a cardiologist before any changes to antiplatelet therapy 1
  • Continue aspirin throughout the bleeding episode if possible 1
  • Temporarily withhold P2Y12 inhibitor only if absolutely necessary 1

Protective Strategies to Prevent Rebleeding

• Initiate high-dose proton pump inhibitor (PPI) therapy for all patients with UGI bleeding on antiplatelet therapy 1, 2
• Continue PPI therapy after discharge in patients who need to resume antiplatelet therapy 3, 4
• For patients with aspirin-induced ulcer bleeding, the combination of aspirin plus PPI is associated with significantly lower risk of recurrent UGI events compared to clopidogrel alone (OR: 0.06,95% CI: 0.01-0.32) 4
• Test for and eradicate Helicobacter pylori if present, as this reduces risk of recurrent bleeding 3

Mortality and Outcome Considerations

• Discontinuation of aspirin for secondary prevention is associated with a nearly sevenfold increase in risk for death or acute cardiovascular events (HR 6.9; 95% CI 1.4-34.8) 1
• All-cause mortality is 10 times lower in patients who resume aspirin immediately after endoscopic hemostasis compared to those who discontinue it (1.3% vs 12.9%) 1, 2
• Patients who experience both UGI bleeding and thrombotic events have the worst prognosis, with approximately two-thirds mortality 5

Common Pitfalls to Avoid

• Unnecessarily prolonged discontinuation of antiplatelet therapy, especially aspirin for secondary prevention, increases thrombotic risk and mortality 1, 2
• Simultaneous discontinuation of both antiplatelet agents in patients on DAPT, which can lead to stent thrombosis in as little as 7 days 1
• Failure to provide concurrent PPI therapy when restarting antiplatelet therapy 3, 4
• Overlooking the potential drug-drug interaction between PPIs and clopidogrel, particularly in Asian populations with high prevalence of CYP2C19 slow metabolizers 1
• Administering platelet transfusions for patients on antiplatelet therapy with GI bleeding, which has not been shown to reduce rebleeding and may be associated with higher mortality 1