Is it common practice to stop aspirin (acetylsalicylic acid) or Direct Oral Anticoagulants (DOACs) in patients presenting with hematochezia (blood in stool)?

Management of Aspirin and DOACs in Patients with Hematochezia

In patients presenting with hematochezia, it is recommended to temporarily withhold DOACs and to withhold aspirin if the bleeding is serious or life-threatening, with resumption of therapy once hemostasis is achieved based on thrombotic risk assessment. 1

Aspirin Management

• For patients on aspirin for primary prophylaxis, permanent discontinuation should be considered when presenting with blood in stool 1
• For patients on aspirin for secondary prevention (e.g., history of cardiovascular events):
  • Aspirin should not be routinely stopped unless bleeding is severe or life-threatening 1
  • If stopped due to serious bleeding, aspirin should be recommenced as soon as hemostasis is achieved 1
  • The risk-benefit analysis depends on the indication for aspirin and severity of hemorrhage 1

DOAC Management

• It is recommended to interrupt DOAC therapy at presentation with hematochezia 1
• For life-threatening bleeding on DOACs:
  • Consider treatment with specific inhibitors such as idarucizumab (for dabigatran) or andexanet (for factor Xa inhibitors) 1
  • Activated charcoal may be used if the last dose of DOAC was taken within 3 hours 1
• DOACs should be restarted at a maximum of 7 days after hemorrhage has stopped 1

Risk Stratification Approach

Thrombotic Risk Assessment

High Thrombotic Risk:

• Acute coronary syndrome or PCI <6 months ago 1
• Prosthetic metal heart valve 1
• Atrial fibrillation with mitral stenosis 1
• <3 months after venous thromboembolism 1
• Severe thrombophilia 1

Low to Moderate Thrombotic Risk:

• Stable coronary artery disease 1
• Atrial fibrillation without high-risk factors 1

• 6 months after venous thromboembolism 1

Bleeding Severity Assessment

• For serious or life-threatening bleeding:
  • Withhold all antithrombotic agents initially 1
  • Consider endoscopic evaluation and intervention 1
• For minor bleeding:
  • Consider continuing aspirin if used for secondary prevention 1
  • Temporarily interrupt DOACs 1

Resumption of Therapy

• For aspirin used in secondary prevention:
  • Resume as soon as hemostasis is achieved 1
• For P2Y12 receptor antagonists (e.g., clopidogrel):
  • Resume within 5 days maximum due to high thrombosis risk 1
• For DOACs:
  • Resume at a maximum of 7 days after bleeding stops 1
  • For patients with high thromboembolic risk, consider bridging with low molecular weight heparin at 48 hours after hemorrhage stops 1

Important Considerations

• Gastrointestinal bleeding in DOAC-treated patients appears to be less severe and requires less intensive management compared to warfarin 2, 3
• Concomitant use of proton pump inhibitors has been shown to lower mortality odds in patients on anticoagulation who present with GI bleeding 4
• The decision to stop or continue antithrombotic therapy should balance the risk of thrombotic events against the risk of continued bleeding 1
• For patients with coronary stents, management should be in liaison with a consultant interventional cardiologist 1

Common Pitfalls to Avoid

• Stopping aspirin for secondary prevention without careful consideration of thrombotic risk 1
• Prolonged discontinuation of P2Y12 inhibitors beyond 5 days in high-risk cardiac patients 1
• Failure to consider specific reversal agents for life-threatening bleeding on DOACs 1
• Not accounting for renal function when planning DOAC resumption 1
• Overlooking the need for proton pump inhibitor prophylaxis in patients requiring continued antithrombotic therapy 5