From the Guidelines
Aspirin should not be withheld in a patient with upper gastrointestinal bleeding, as the benefits of continued therapy outweigh the risks, with a reduction in all-cause mortality and thromboembolic events, as demonstrated in a prospective placebo-controlled RCT 1. The decision to continue or restart aspirin therapy in patients with upper gastrointestinal bleeding should be based on the individual patient's risk-benefit ratio, considering the indication for aspirin therapy, the severity of the bleeding event, and the patient's overall cardiovascular risk.
- Key considerations include:
- The risk of thromboembolic events, which can be fatal, if aspirin is discontinued 1
- The potential for increased bleeding risk with continued aspirin therapy, although this risk may be manageable with endoscopic therapeutic measures 1
- The importance of reassessing the need for aspirin therapy once the bleeding has stopped and the patient is stable, typically after 3-7 days 1
- In patients taking aspirin for secondary prevention of cardiovascular disease, the risk-benefit ratio may favor continued therapy, even in the presence of upper gastrointestinal bleeding, due to the high risk of thromboembolic events if aspirin is discontinued 1.
- A retrospective study of 118 patients on antiplatelets or anticoagulants presenting with acute GI haemorrhage found that discontinuing antithrombotic therapy was associated with a higher risk of thrombotic events and mortality compared to restarting therapy 1.
- The British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guidelines recommend considering the risks and benefits of continuing or restarting aspirin therapy in patients with upper gastrointestinal bleeding, taking into account the individual patient's risk factors and the severity of the bleeding event 1.
From the FDA Drug Label
Stomach bleeding warning: This product contains an NSAID, which may cause severe stomach bleeding The chance is higher if you are age 60 or olderHave had stomach ulcers or bleeding problems Ask a doctor before use if stomach bleeding warning applies to you you ahistory of stomach problems such as heart burn
Aspirin should be withheld in a patient with upper gastrointestinal bleeding, as the drug label warns that aspirin may cause severe stomach bleeding, and the chance is higher if the patient has had stomach ulcers or bleeding problems 2. It is recommended to ask a doctor before use if stomach bleeding warning applies to the patient 2.
- Key considerations: stomach bleeding warning, history of stomach problems, stomach ulcers or bleeding problems.
From the Research
Aspirin and Upper Gastrointestinal Bleeding
- Aspirin (acetylsalicylic acid) is associated with an increased risk of upper gastrointestinal bleeding, as shown in studies 3, 4, 5.
- The risk of upper gastrointestinal bleeding is higher in patients with a history of previous upper gastrointestinal bleeding or peptic ulcer disease 3, 6, 5.
- The use of proton pump inhibitors (PPIs) can decrease the rate of upper gastrointestinal bleeding in patients receiving aspirin or other antiplatelet agents 3, 4, 7.
Management of Aspirin Therapy in Patients with Upper Gastrointestinal Bleeding
- In patients with a recent history of upper gastrointestinal ulceration or bleeding, treatment with a PPI is a useful precaution when starting or continuing aspirin therapy 3.
- Patients should be carefully monitored for recurrence of upper gastrointestinal bleeding when taking aspirin, especially if they have risk factors such as a history of peptic ulcer disease or hypertension 5.
- Discontinuation of aspirin therapy may be necessary in some cases to prevent further bleeding, but this decision should be made on a case-by-case basis, considering the patient's individual risk factors and medical history 7.