For a patient undergoing elective percutaneous endoscopic gastrostomy (PEG) tube placement who is on low‑dose aspirin 81 mg daily, should aspirin be held before the procedure, and what is the recommended timing for discontinuation and resumption?

Aspirin Management for Elective PEG Tube Placement

Aspirin should be continued without interruption for elective PEG tube placement, regardless of whether the patient is on low-dose aspirin for primary or secondary prevention. 1

Procedure Risk Classification

PEG tube placement is classified as a high-risk bleeding procedure by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) 2021 guidelines. 1 However, this classification does not mandate aspirin discontinuation—the guidelines explicitly recommend continuing aspirin through high-risk procedures when patients have any indication for antiplatelet therapy. 1

Evidence-Based Recommendation for Aspirin Continuation

Guideline Recommendations

• For high-risk endoscopic procedures (including PEG) in patients at high thrombotic risk, the BSG/ESGE guidelines strongly recommend continuing aspirin throughout the procedure. 1

• Even for patients at low thrombotic risk undergoing high-risk procedures, aspirin continuation is the preferred approach when already prescribed. 1

• The 2005 ESPEN guidelines noted that PEGs can be placed safely in patients taking low-dose aspirin without increased complication risk, though formal discontinuation 5 days prior was mentioned as an option. 1 This older guidance has been superseded by the 2021 BSG/ESGE recommendations favoring continuation. 1

Supporting Research Evidence

• A large cohort study of 1,613 consecutive PEG procedures found only 0.39% significant bleeding events, with zero bleeding complications in the 535 patients on uninterrupted aspirin. 2 All bleeding events occurred in patients on subcutaneous heparin, not aspirin. 2

• A systematic review and meta-analysis of 6,233 patients (3,665 on antiplatelet therapy) found no statistically significant increased bleeding risk with aspirin continuation (pooled RR 1.43; 95% CI 0.89-2.29). 3

• Multiple smaller studies confirm the safety profile: a retrospective cohort of 990 patients found no association between aspirin use and post-PEG bleeding (adjusted OR not significant), and a prospective German study of 450 patients reported zero post-PEG bleeding events regardless of anticoagulation status. 4, 5

Practical Management Algorithm

Pre-Procedure Assessment

1. Identify the indication for aspirin:

   • Secondary prevention (prior MI, stroke, coronary stent, established cardiovascular disease) = high thrombotic risk 1, 6
   • Primary prevention (no prior cardiovascular event) = low thrombotic risk 6

2. Continue aspirin 81 mg daily through the morning of the procedure without interruption. 1, 2

3. Ensure coagulation parameters are acceptable: INR <1.5, platelets >50,000/mm³, PTT <50 seconds. 1 Note that aspirin itself does not significantly alter these laboratory values. 1

Peri-Procedure Considerations

• Administer prophylactic antibiotics (e.g., 2 g cefazolin IV) as per standard PEG protocol. 1 This is unrelated to aspirin but remains important for infection prevention. 1

• Use the "pull" method rather than the modified introducer method when possible, as it provides better pressure hemostasis at the insertion site. 7 This may be particularly relevant for patients on any antithrombotic therapy. 7

Post-Procedure Management

• Continue aspirin without interruption after the procedure. 1 There is no need to hold or delay resumption. 1

• If aspirin were hypothetically discontinued (which is not recommended), it should be resumed within 1-2 days after the procedure for patients at high thrombotic risk. 1 However, the preferred approach is never to stop it in the first place. 1

• Counsel patients that there is a small increased risk of post-procedure hemorrhage compared to those not on antiplatelets (absolute risk remains <3%), but this does not justify discontinuation given thrombotic risks. 1, 3

Critical Mortality Data Supporting Continuation

For patients on aspirin for secondary prevention, discontinuation is associated with catastrophic outcomes:

• All-cause mortality is nearly 10-fold higher (12.9% vs 1.3%) when aspirin is stopped versus continued after GI procedures requiring hemostasis. 6

• Thrombotic event risk increases with a hazard ratio of 5.77, and all-cause mortality increases with HR 3.32 when aspirin is discontinued. 6

• These mortality risks far outweigh the modest 5% absolute increase in rebleeding associated with aspirin continuation. 6

Special Situations

Dual Antiplatelet Therapy (DAPT)

• If the patient is on both aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor), aspirin must be continued. 1

• The P2Y12 inhibitor should be discontinued 7 days before the procedure only after consultation with an interventional cardiologist, particularly if the patient has a coronary stent placed within the past 6-12 months. 1

• Restart the P2Y12 inhibitor within 1-2 days after the procedure to avoid stent thrombosis risk. 1

Primary Prevention Patients

• Even for primary prevention, current guidelines favor aspirin continuation during PEG placement. 1 The older practice of discontinuation for primary prevention applies mainly to acute GI bleeding scenarios, not elective procedures. 1, 6

Common Pitfalls to Avoid

• Do not reflexively stop aspirin simply because PEG is labeled "high-risk"—the guidelines explicitly state to continue it. 1

• Do not confuse PEG management with acute GI bleeding management, where primary prevention aspirin may be permanently discontinued. 1, 6

• Do not stop both antiplatelet agents in DAPT patients—aspirin must always be maintained. 1

• Do not delay aspirin resumption beyond 2-3 days if it were held, as thrombotic risk escalates rapidly after day 5. 1, 6

• Be aware that serotonin reuptake inhibitors (SRIs), not aspirin, are associated with increased post-PEG bleeding risk (adjusted OR 4.1). 4 Consider this in your overall risk assessment. 4