Should a patient with hematuria stop taking Plavix (clopidogrel) or aspirin?

Management of Hematuria in Patients on Plavix or Aspirin

In patients with hematuria who are on antiplatelet therapy, aspirin should be continued while clopidogrel (Plavix) should be temporarily discontinued for 5 days, especially if the bleeding is moderate to severe. 1

Assessment of Bleeding Severity and Underlying Causes

• Hematuria in patients on antiplatelet therapy requires investigation for underlying urologic pathology, as tumors are found in approximately 25% of cases 2, 3
• The severity of hematuria should be classified as mild, moderate, or severe based on visual estimation 4
• Anticoagulants are more likely to cause hematuria than antiplatelet agents (76 times higher risk), with aspirin having 6.7 times higher risk than clopidogrel 3

Management Recommendations Based on Antiplatelet Type

For Patients on Dual Antiplatelet Therapy (DAPT)

• For patients with coronary stents on DAPT, never withhold both antiplatelet agents due to high risk of stent thrombosis 1
• For patients on DAPT with aspirin and clopidogrel, continue aspirin and temporarily withhold clopidogrel 1
• In patients with drug-eluting coronary stents, early resumption of P2Y12 receptor inhibitor (clopidogrel) is recommended, preferably within 5 days after bleeding is controlled 1

For Patients on Clopidogrel (Plavix) Only

• Temporarily discontinue clopidogrel for 5 days to facilitate hemostasis 5
• Resume clopidogrel as soon as hemostasis is achieved to reduce cardiovascular risk 5
• Consider that clopidogrel is less likely to cause hematuria compared to aspirin, but more likely to cause major hematuria when it does occur 3

For Patients on Aspirin Only

• Aspirin can generally be continued during episodes of mild hematuria 1, 4
• For moderate to severe hematuria, consider temporarily discontinuing aspirin for 1-2 days until bleeding is controlled 4
• Be aware that aspirin is associated with hemorrhagic cystitis in some patients, which was not observed with warfarin in comparative studies 2

Special Considerations

• Dual antiplatelet therapy with aspirin and clopidogrel is associated with increased requirement for bladder irrigation (92%) compared to other forms of anticoagulation (84%) or no anticoagulation (62%) 6
• Rivaroxaban and warfarin appear to be the most dangerous medications in terms of hematuria risk, while apixaban is the safest among anticoagulants 7
• Patients with recent coronary stent placement (especially drug-eluting stents within 6-12 months) have high thrombotic risk if antiplatelet therapy is discontinued 1

Resumption of Therapy

• For mild hematuria: antiplatelet therapy can often be continued without interruption 4
• For moderate to severe hematuria: resume antiplatelet therapy as soon as adequate hemostasis is achieved 1, 5
• In patients with drug-eluting coronary stents, P2Y12 inhibitors should be resumed within 5 days 1
• Consider consulting a cardiologist before stopping antiplatelet therapy in patients with recent coronary stent placement (within 12 months) 1

Monitoring After Resumption

• Monitor for recurrence of hematuria after resumption of antiplatelet therapy 4
• Consider switching to a different antiplatelet agent if hematuria recurs (e.g., from aspirin to clopidogrel or vice versa) 1
• Be aware that antiplatelet therapy discontinuation is associated with high risk of stent thrombosis (HR of 161 for death and MI) 1

Remember that while managing hematuria is important, the cardiovascular protection provided by antiplatelet therapy is critical for patient survival, particularly in those with recent coronary stent placement. The decision to discontinue therapy must carefully balance bleeding risk against thrombotic risk.