Stopping aspirin after ulcer bleeding: More risk than benefit

When patients with coronary artery disease or cerebrovascular disease develop GI bleeding and undergo endoscopic therapy, a question that most gastroenterologists face is whether aspirin, clopidogrel, or both should be restarted, and if so, when. Many of these patients are at high risk for bleeding-related complications due to advanced age and comorbidities and are also at increased risk for cardiovascular or cerebrovascular complications due to advanced vascular disease. 
There are four possible courses of action for the practitioner: Discontinue the aspirin and clopidogrel with no intent to resume them, discontinue aspirin and resume clopidogrel, resume both antiplatelet drugs after endoscopic hemostasis is achieved, or withhold antiplatelet drugs for 7-10 days after endoscopic hemostasis has been achieved.
Although we do not have a complete and valid evidence base to guide our current practice, several important points can be made from recent studies. Ms. Derogar and her colleagues show us that discontinuing aspirin completely is associated with a high rate of death or cardiovascular complications. Rebleeding, on the other hand, was rare patients in whom aspirin was continued. In a recent randomized controlled trial, patients on low-dose aspirin who developed a GI bleed were randomized to continued aspirin or no aspirin after endoscopic hemostasis (Ann. Intern. Med. 2010;152:1-9). Recurrent ulcer bleeding within 30 days was 10.3% in the aspirin group and 5.4% in the placebo group. Patients who received aspirin had lower all-cause mortality rates than patients who received placebo (1.3% vs. 12.9%). Other studies have shown that resuming aspirin with a proton pump inhibitor is superior to administering clopidogrel alone.
There is little evidence to guide us as to whether aspirin or clopidogrel should be held for a short period of time or resumed immediately after endoscopic hemostasis is achieved. This decision should probably be individualized based on the magnitude of the bleeding, the severity of the underlying cardiovascular and cerebrovascular disease, and concurrent comorbid illnesses. The available evidence is clear that it is unwise to discontinue aspirin in patients receiving this agent for cardiovascular or cerebrovascular disease due to the high rate of adverse outcomes.
Nimish Vakil, M.D., AGAF, is a clinical professor of medicine at the University of Wisconsin School of Medicine and Public Health, Madison. He is a consultant to AstraZeneca, Takeda, Otsuka, Xenoport, Orexo, Ironwood, and Restech, and has stock options in Orexo and Meridian Bioscience.