Aspirin Management in Acute Lower Gastrointestinal Bleeding

1. Indication‑Based Decision Making

2. Timing of Aspirin Resumption for Secondary Prevention

3. Clinical Outcomes of Continuing vs Stopping Aspirin

4. Management of Patients on Dual Antiplatelet Therapy (DAPT)

5. Practical Implementation at Discharge

Management of Antithrombotic Therapy in Patients with Hematochezia

Introduction to Antithrombotic Management

• The American College of Cardiology recommends temporarily withholding DOACs and withholding aspirin if the bleeding is serious or life-threatening, with resumption of therapy once hemostasis is achieved based on thrombotic risk assessment 4, 5

Aspirin Management

• For patients on aspirin for primary prophylaxis, permanent discontinuation should be considered when presenting with blood in stool 5, 6
• For patients on aspirin for secondary prevention, aspirin should not be routinely stopped unless bleeding is severe or life-threatening 6
• If stopped due to serious bleeding, aspirin should be recommenced as soon as hemostasis is achieved 7, 6

DOAC Management

• It is recommended to interrupt DOAC therapy at presentation with hematochezia 5, 8
• For life-threatening bleeding on DOACs, consider treatment with specific inhibitors such as idarucizumab (for dabigatran) or andexanet (for factor Xa inhibitors) 5
• Activated charcoal may be used if the last dose of DOAC was taken within 3 hours 9
• DOACs should be restarted at a maximum of 7 days after hemorrhage has stopped 5

Risk Stratification Approach

Thrombotic Risk Assessment

• High thrombotic risk includes conditions such as acute coronary syndrome or PCI <6 months ago 4, 10, prosthetic metal heart valve 11, 7, atrial fibrillation with mitral stenosis 7, <3 months after venous thromboembolism 6, and severe thrombophilia 4
• Low to moderate thrombotic risk includes conditions such as stable coronary artery disease 10, atrial fibrillation without high-risk factors 11, and >6 months after venous thromboembolism 4

Bleeding Severity Assessment

• For serious or life-threatening bleeding, withhold all antithrombotic agents initially and consider endoscopic evaluation and intervention 4, 5
• For minor bleeding, consider continuing aspirin if used for secondary prevention and temporarily interrupt DOACs 6, 5

Resumption of Therapy

• For aspirin used in secondary prevention, resume as soon as hemostasis is achieved 6
• For P2Y12 receptor antagonists, resume within 5 days maximum due to high thrombosis risk 8, 6
• For DOACs, resume at a maximum of 7 days after bleeding stops and consider bridging with low molecular weight heparin at 48 hours after hemorrhage stops for patients with high thromboembolic risk 5, 6

Important Considerations

• The decision to stop or continue antithrombotic therapy should balance the risk of thrombotic events against the risk of continued bleeding 8, 7
• For patients with coronary stents, management should be in liaison with a consultant interventional cardiologist 7

Common Pitfalls to Avoid

• Stopping aspirin for secondary prevention without careful consideration of thrombotic risk 6
• Prolonged discontinuation of P2Y12 inhibitors beyond 5 days in high-risk cardiac patients 8
• Failure to consider specific reversal agents for life-threatening bleeding on DOACs 5
• Not accounting for renal function when planning DOAC resumption 11