Should aspirin (ASA) be restarted in an 86-year-old male after a 2-week hiatus due to a bladder bleed?

From the Guidelines

The aspirin (ASA) 81mg should be restarted in this 86-year-old male as soon as possible, considering the high risk of cardiovascular or cerebrovascular events associated with its interruption, as evidenced by a three-fold increased risk of such events, with 70% occurring within 7-10 days after interruption 1. When evaluating the risk-benefit ratio, it's crucial to consider the patient's original indication for aspirin therapy.

• If the patient was taking aspirin for secondary prevention of cardiovascular disease, the benefits of restarting aspirin likely outweigh the risks, given the significant reduction in vascular events and deaths associated with its long-term use 1.
• The patient's recent bladder bleed, although a concern, does not necessarily preclude the restart of aspirin, especially if the bleeding has been adequately managed and the patient is at high risk for thrombotic events. Key points to consider when restarting aspirin include:
• The patient's individual risk factors for bleeding and thrombosis
• The presence of any conditions that may increase the risk of bleeding, such as gastrointestinal issues
• The potential need for strategies to reduce bleeding risk, such as the use of proton pump inhibitors
• Regular monitoring for signs of recurrent bleeding or thrombotic events Given the potential for significant morbidity and mortality associated with cardiovascular events, the decision to restart aspirin should prioritize the prevention of these outcomes, while taking steps to minimize the risk of bleeding complications 1.

From the FDA Drug Label

Warnings Stomach bleeding warning: This product contains an NSAID, which may cause severe stomach bleeding The chance is higher if you are age 60 or older Have had stomach ulcers or bleeding problems Take a blood thinning (Anticogulant) or steroid drug Take other drugs containing prescription or nonprescription NSAIDs (aspirin, ibuprofen, naproxen, or others) have 3 or more alcoholic drinks every day using this product

The patient is 86 years old and was stopped from taking ASA due to a bladder bleed. Considering the patient's age and history of bleeding, the risk of stomach bleeding is higher.

• The patient has had a recent bleeding event, which increases the risk of further bleeding.
• The patient is older than 60, which also increases the risk of stomach bleeding. It is recommended not to restart ASA due to the increased risk of bleeding 2.

From the Research

Aspirin Therapy Considerations

• The patient was on ASA 81mg, which is a low-dose aspirin regimen, commonly used for cardiovascular disease prevention 3, 4.
• The patient was stopped from taking ASA for 2 weeks due to a bladder bleed, which may indicate a bleeding risk associated with aspirin therapy 5, 6.
• Aspirin has been shown to have anti-ischemic benefits, including reducing the risk of myocardial infarction and stroke, but it also carries bleeding risks 3, 4, 6, 7.

Bleeding Risks and Benefits

• A study found that patients taking antiplatelet or anticoagulant therapy, including aspirin, may experience hematuria at an earlier stage or grade of bladder cancer, which could be relevant to the patient's bladder bleed 5.
• The USPSTF recommends individualized use of aspirin based on factors including age, 10-year atherosclerotic cardiovascular disease risk score, and bleeding risk 6.
• Aspirin therapy has been associated with a reduction in nonfatal stroke, but the effect on cardiovascular events and mortality is less clear, particularly in patients with peripheral artery disease 7.

Decision to Restart Aspirin

• The decision to restart aspirin therapy should be based on a careful weighing of the potential benefits and risks, considering the patient's individual characteristics and medical history 6.
• Tools such as the Aspirin-Guide can provide personalized benefit-to-risk assessments and facilitate informed decisions about initiating or restarting aspirin therapy 6.