Can aspirin be discontinued in a patient with bleeding issues, such as hemorrhoids and nosebleeds, who is within 30 days post-carotid stent placement and currently on aspirin, Plavix (clopidogrel), and Eliquis (apixaban)?

Do Not Discontinue Aspirin in This High-Risk Patient

You should NOT discontinue aspirin in a patient within 30 days of carotid stent placement, even with minor bleeding complications like hemorrhoids and nosebleeds. The risk of catastrophic stent thrombosis far outweighs the nuisance bleeding risk in this critical early post-stent period 1, 2.

The Critical 30-Day Window

• Within 30 days of any stent placement (carotid or coronary), dual antiplatelet therapy (DAPT) must be continued unless the bleeding risk literally outweighs the benefit of preventing stent thrombosis 1
• The first 30 days post-stent carry the highest risk of stent thrombosis, with 80% of thrombotic events occurring in this window 3
• Stent thrombosis in this period is catastrophic—leading to stroke, myocardial infarction, or death in the majority of cases 2
• Premature withdrawal of antiplatelet agents is associated with a 10% risk of all vascular events 4

The Real Problem: Triple Antithrombotic Therapy

Your patient's bleeding issues stem from being on triple therapy (aspirin + Plavix + Eliquis), which is excessive and not indicated for carotid stenting alone 2, 5:

• The culprit is likely the Eliquis (apixaban), not the aspirin
• If the patient has a separate indication for anticoagulation (atrial fibrillation, DVT/PE), then triple therapy may have been appropriate initially, but aspirin should be discontinued at 1 week, NOT Plavix 2, 3
• If there is NO indication for anticoagulation, Eliquis should be discontinued entirely 2

Management Algorithm

Step 1: Determine if Anticoagulation is Indicated

• If YES (atrial fibrillation, mechanical valve, VTE):

  • Discontinue aspirin after 1 week of triple therapy 2, 3
  • Continue Plavix + Eliquis for at least 3-6 months 2, 3
  • Add proton pump inhibitor for GI bleeding prophylaxis 2

• If NO anticoagulation indication:

  • Discontinue Eliquis immediately 2
  • Continue aspirin + Plavix for minimum 30 days, ideally 3-6 months 1
  • Add proton pump inhibitor 2

Step 2: Address the Bleeding

• For hemorrhoids: Topical treatments, stool softeners, increased fiber, sitz baths—do NOT stop antiplatelet therapy 5
• For epistaxis: Local measures (pressure, humidification, topical vasoconstrictors, nasal packing if needed)—do NOT stop antiplatelet therapy 5
• These are minor bleeding complications that can be managed conservatively 5

Step 3: If Aspirin Must Be Temporarily Held (Only After 30 Days)

• After the 30-day mark, if aspirin absolutely must be discontinued:
  • Continue Plavix at minimum 1
  • Consider bridging with IV antiplatelet therapy in very high-risk patients 1
  • Resume aspirin as soon as bleeding is controlled 1

Key Pitfalls to Avoid

• Never discontinue both aspirin AND Plavix simultaneously within 6 months of stent placement 5, 4
• Do not substitute heparin or LMWH for antiplatelet therapy—it does not prevent stent thrombosis 5
• Do not assume all three agents are necessary without a clear anticoagulation indication 2, 3
• Minor bleeding (hemorrhoids, epistaxis) does NOT constitute "high bleeding risk" that would justify stopping aspirin in the first 30 days 1, 5

The Bottom Line

Maintain aspirin + Plavix through at least 30 days post-carotid stent. If the patient is on Eliquis without a clear anticoagulation indication, discontinue the Eliquis, not the aspirin 2. If anticoagulation is indicated, you should have already discontinued aspirin at 1 week and kept Plavix + Eliquis 2, 3. Treat the minor bleeding with local measures and gastroprotection 2, 5.