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

From the Guidelines

No, aspirin should not be withheld in upper gastrointestinal bleeding, as the benefits of continued therapy outweigh the risks, with a significant reduction in all-cause mortality 1. When considering the management of patients on aspirin monotherapy for secondary prophylaxis who present with upper GI bleeding, the evidence suggests that continued therapy is beneficial. A prospective placebo-controlled RCT demonstrated a reduction in all-cause mortality in the group receiving low-dose aspirin, with an acceptable increase in non-fatal bleeds 1. Key points to consider in the management of these patients include:

• The importance of continuing aspirin therapy in patients on aspirin monotherapy for secondary prophylaxis, as it reduces all-cause mortality 1
• The need for a plan to restart antithrombotic therapy as soon as haemostasis has been achieved, to minimize the risk of thrombotic events and mortality 1
• The consideration of the risk-benefit assessment for each patient, taking into account their individual risk of thrombotic events and recurrent bleeding 1 In clinical practice, this means that aspirin should be continued in patients with upper GI bleeding, unless there are compelling reasons to discontinue it, such as a high risk of recurrent bleeding or other contraindications. The decision to restart aspirin should be made in consultation with relevant specialists, weighing the thrombotic risk against the risk of recurrent bleeding 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 use of aspirin in patients with upper gastrointestinal bleeding is a complex issue, with studies suggesting different approaches to management 3, 4, 5, 6, 7.
• According to a guideline for the management of patients with ulcer bleeding, patients with established cardiovascular disease who require aspirin should start proton pump inhibitors (PPIs) and generally re-institute aspirin soon after bleeding ceases (within 7 days and ideally 1-3 days) 3.
• A study on upper gastrointestinal bleeding in patients with acute coronary syndromes found that the risk of bleeding is relatively low and does not appear to be significantly reduced by the use of PPIs 4.
• A systematic review and meta-analysis found that aspirin plus PPIs was associated with a significantly lower risk of recurrent upper gastrointestinal events and bleeding compared to clopidogrel alone in patients with aspirin-induced ulcer bleeding 5.
• Another study found that clopidogrel use was associated with a greater risk of mortality, but the significance did not hold in propensity score-matched cohort analysis 6.
• The incidence of gastrointestinal bleeding in aspirin study groups was found to be around 0.8%, and several risk factors for gastrointestinal bleeding were reported, including history of peptic ulcer or gastrointestinal bleeding, high aspirin dose, and concomitant use of non-steroidal anti-inflammatory drugs and anti-platelet agents 7.

Management Strategies

• Prevention strategies for gastrointestinal complications induced by anti-platelet agents include treatment with proton pump inhibitors, histamine-2 receptor antagonists, prostaglandin analogs, prostaglandin inducers, and H. pylori eradication therapy 7.
• The use of PPIs in combination with aspirin or clopidogrel may be beneficial in reducing the risk of recurrent upper gastrointestinal events and bleeding 5, 6.
• However, the choice of anti-platelet agent and the use of PPIs should be individualized based on the patient's risk factors and medical history 3, 4, 5, 6, 7.