Is aspirin (acetylsalicylic acid) use safe in patients with a history of Roux-en-Y gastric bypass?

Aspirin Use After Roux-en-Y Gastric Bypass

Safety of Low-Dose Aspirin After RYGB

Low-dose aspirin (75-81 mg daily) can be safely used in patients with a history of Roux-en-Y gastric bypass, though careful monitoring for marginal ulceration is recommended. 1, 2

• Recent evidence from the European Society of Cardiology Working Group indicates that low-dose aspirin can be safely resumed post-RYGB, with data showing no increased risk of marginal ulceration with low-dose regimens 1
• However, high-dose aspirin should be avoided as it is associated with significantly increased risk of marginal ulcers (HR 1.90,1.41-2.58) 1

Risk Assessment and Considerations

• A meta-analysis of 24,770 RYGB patients found that aspirin use was associated with a 33% increased risk of marginal ulceration (OR 1.33,95% CI 1.08-1.63) 3
• This risk must be balanced against the cardiovascular benefits of aspirin therapy in appropriate patients 1
• For patients with established cardiovascular disease requiring antiplatelet therapy, the cardiovascular benefits typically outweigh the gastrointestinal risks 1

Recommendations for Aspirin Use After RYGB

• For patients with high cardiovascular risk (recent stents, history of myocardial infarction, or established cardiovascular disease), low-dose aspirin (75-81 mg daily) should be continued or resumed 1
• Patients taking aspirin after RYGB should be monitored for symptoms of marginal ulceration, including epigastric pain, nausea, vomiting, and melena 2, 3
• Concomitant use of proton pump inhibitors (PPIs) is strongly recommended to reduce gastrointestinal risk in patients requiring aspirin therapy after RYGB 1, 4

Risk Mitigation Strategies

• Proton pump inhibitor therapy should be prescribed for all RYGB patients on aspirin to reduce the risk of marginal ulceration 4
• Eradication of Helicobacter pylori infection should be considered in patients with a history of peptic ulcer disease prior to initiating or resuming aspirin therapy 5
• Avoid concomitant use of other NSAIDs, corticosteroids, or anticoagulants when possible, as these significantly increase bleeding risk 5, 4
• Consider enteric-coated aspirin formulations, though evidence for reduced GI complications with these formulations is limited 5

Special Considerations

• Patients who have undergone RYGB for metabolic dysfunction-associated steatotic liver disease (MASLD) may have additional cardiovascular risk factors warranting aspirin therapy 1
• For patients with obstructive sleep apnea who have undergone bariatric surgery, cardiovascular risk assessment should guide aspirin therapy decisions 1
• In patients with dumping syndrome after RYGB, medication absorption may be altered, potentially affecting aspirin efficacy 1

Timing of Aspirin Initiation or Resumption

• For patients who had aspirin discontinued before RYGB surgery, it can typically be resumed within 24-48 hours after surgery once adequate hemostasis has been achieved 6
• For patients with high thrombotic risk (recent coronary stents, stroke history), aspirin should be restarted as soon as possible, ideally within 24 hours post-procedure 6
• For patients on dual antiplatelet therapy, restart aspirin first (within 24 hours) followed by P2Y12 inhibitors within 2-3 days 6

By following these evidence-based recommendations, clinicians can safely manage aspirin therapy in patients with a history of Roux-en-Y gastric bypass while minimizing the risk of complications.