Should aspirin (acetylsalicylic acid) be withheld in upper gastrointestinal bleeding?

From the Guidelines

No, aspirin should not be withheld in upper gastrointestinal bleeding for patients on aspirin monotherapy for secondary prophylaxis, as it has been shown to reduce all-cause mortality 1. The benefits of continued aspirin therapy in these patients outweigh the risks, as demonstrated by a prospective placebo-controlled RCT that showed a reduction in all-cause mortality in the group receiving low-dose aspirin 1.

Key Points to Consider

• The study found that there was an excess of bleeds in the aspirin group, but none were fatal, and five patients in the placebo arm died of thromboembolic events 1.
• If aspirin is stopped, it should be reintroduced as soon as haemostasis has been achieved 1.
• A retrospective study also found that discontinuing antithrombotic therapy permanently increased the risk of thrombotic events and mortality compared to restarting therapy 1.

Clinical Implications

• The decision to restart aspirin therapy should be made on a case-by-case basis, taking into account the individual patient's risk of thrombotic events and bleeding 1.
• A careful risk-benefit assessment should be performed before restarting aspirin therapy, considering the patient's underlying cardiovascular risk and the severity of the bleeding 1.
• The plan for consideration of restarting antithrombotic therapy should be in place for all patients presenting with GI haemorrhage 1.

From the FDA Drug Label

Stomach bleeding warning: This product contains an NSAID, which may cause severe stomach bleeding Ask a doctor before use if stomach bleeding warning applies to you

• The FDA drug label warns about the risk of severe stomach bleeding associated with aspirin use.
• It is recommended to consult a doctor if stomach bleeding warning applies to you, especially with a history of stomach problems.
• Given the risk of severe stomach bleeding, it is prudent to withhold aspirin in upper gastrointestinal bleeding to avoid exacerbating the condition 2 2.

From the Research

Aspirin Use in Upper Gastrointestinal Bleeding

• The management of patients with upper gastrointestinal bleeding involves assessing hemodynamic status, resuscitation, and risk stratification 3.
• For patients with established cardiovascular disease who require aspirin, it is recommended to start proton pump inhibitors (PPIs) and re-institute aspirin soon after bleeding ceases, ideally within 1-3 days 3.
• A study on acute coronary syndromes found that the risk of upper gastrointestinal bleeding is relatively low in patients hospitalized with ACS, and the use of PPIs does not appear to significantly reduce this risk 4.
• The American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline suggests against holding cardiac acetylsalicylic acid (ASA) for secondary prevention in patients presenting with acute GI bleeding, but if the ASA has been interrupted, resumption is suggested on the day hemostasis is endoscopically confirmed 5.
• Strategies to reduce the GI risks of antiplatelet therapy include the use of gastroprotective agents such as proton pump inhibitors and eradication of Helicobacter pylori 6.

Recommendations for Aspirin Use

• Patients on cardiac ASA for secondary prevention should not have their ASA withheld, but if it has been interrupted, it should be resumed on the day hemostasis is confirmed 5.
• The use of PPIs is recommended for patients with upper gastrointestinal bleeding who are taking antiplatelet agents, including aspirin 3, 4.
• Aspirin should be re-instituted soon after bleeding ceases, ideally within 1-3 days, in patients with established cardiovascular disease who require aspirin 3.

Considerations for Aspirin Use

• The risk of upper gastrointestinal bleeding is increased in patients taking aspirin, particularly in those with a prior history of ulcer or GI bleeding, and in those taking concomitant NSAIDs, anticoagulants, or additional antiplatelet drugs 6.
• The use of gastroprotective agents and eradication of Helicobacter pylori can help minimize the risk of upper GI side effects in patients taking aspirin 6.