From the Guidelines
For microscopic hematuria, aspirin (ASA) should typically be continued unless the hematuria is severe or there are other concerning features, with consideration of temporary discontinuation for 7-10 days to assess its contribution to the hematuria, as supported by the American College of Chest Physicians clinical practice guideline 1. When considering the management of ASA in patients with microscopic hematuria, it's crucial to weigh the risks of bleeding against the cardiovascular benefits of ASA continuation. The decision to hold ASA should be individualized, taking into account the patient's cardiovascular risk profile.
- For patients at high cardiovascular risk, such as those with recent stents, stroke history, or acute coronary syndrome, the risk of stopping ASA may outweigh the potential benefits of temporarily discontinuing it to assess its impact on hematuria, as evidenced by the POISE-2 trial which showed an increased risk of major bleeding with ASA initiation/continuation but no reduction in non-fatal myocardial infarction or death 1.
- In contrast, for patients on ASA for primary prevention, the risk of temporary discontinuation is lower, and holding ASA for 7-10 days may be a reasonable approach to determine if it's contributing to the hematuria. Key considerations in the management of ASA for microscopic hematuria include:
- The mechanism by which ASA causes hematuria, which is through its antiplatelet effects, potentially unmasking underlying urological conditions or exacerbating minor bleeding 1.
- The importance of using the lowest effective dose of ASA (typically 81mg daily) if it's deemed necessary after temporary discontinuation.
- The need for appropriate urological evaluation to rule out serious underlying conditions, regardless of the decision regarding ASA management.
From the Research
Duration of ASA Hold for Microscopic Hematuria
There is no specific guideline on the duration of holding ASA (Aspirin) for microscopic hematuria. However, the following points can be considered:
- The American Urological Association has published guidelines for the management of asymptomatic microscopic hematuria, but it does not provide specific recommendations on the duration of holding ASA 2.
- A study found that taking regular doses of aspirin was accompanied by a higher rate of microscopic hematuria in the elderly, but it does not provide guidance on the duration of holding ASA 3.
- Another study found that patients taking aspirin had a lower prevalence of normal evaluation compared to those taking warfarin, but it does not provide information on the duration of holding ASA 4.
- The yield of CT urography for upper urinary tract malignancy is low, and it is not recommended to hold ASA solely based on the presence of microscopic hematuria 5.
Key Considerations
- The decision to hold ASA should be based on individual patient factors, such as the risk of bleeding and the presence of other medical conditions.
- Patients with microscopic hematuria should undergo a thorough evaluation to determine the underlying cause, including laboratory tests, imaging studies, and referral to nephrology and urology subspecialists 6, 2.
- The presence of dysmorphic red blood cells, cellular casts, proteinuria, elevated creatinine levels, or hypertension in the presence of microscopic hematuria should prompt concurrent nephrologic and urologic referral 2.