Aspirin vs. P2Y12 Inhibitor Rivalry: Which One Can be Continued During Gastrointestinal Bleeding

Authors

  • Muhammad Begawan Bestari Division of Gastroenterohepatology Department of Internal Medicine Faculty of Medicine - University of Padjadjaran Hasan Sadikin General Hospital Bandung - Indonesia
  • Ignatius R Joewono Division of Gastroenterohepatology Department of Internal Medicine Faculty of Medicine - University of Padjadjaran Hasan Sadikin General Hospital Bandung - Indonesia

Keywords:

dual anti platelet, gastrointestinal bleeding, aspirin, clopidogrel

Abstract

Dual antiplatelet therapy (DAPT) is the mainstay of secondary prevention treatment for acute coronary syndrome (ACS) and ischemic stroke, especially after coronary intervention. DAPT consists of aspirin and P2Y12 receptor inhibitor (e.g. clopidogrel), and the use of DAPT has been increased over time. The most serious and common adverse effect is gastrointestinal bleeding. Guidelines in managing such condition are available among Gastroenterologist Societies and Cardiologist Societies. Most guidelines are consistent with each other to continue the use of aspirin while withholding P2Y12. However, European Society of Cardiologist (ESC) guideline in 2017 recommends P2Y12 receptor inhibitor as the preferred antiplatelet for patient with upper gastrointestinal bleeding. This review will look on the guidelines and other supporting evidence for the justification on the antiplatelet of choice.

References

Yasuda H, Matsuo Y, Sato Y et al. Treatment and prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy. World J Crit Care Med. 2015;4(1):40-6.

Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. European Heart Journal. 2018;39:213–54.

Population Division. Department of Economic and Social Affairs. United Nations. Revision of World Population Prospects. https://esa.un.org/unpd/wpp/.

Lanas A, Wu P, Medin J, et al. Low doses of acetylsalicylic acid increase risk of gastrointestinal bleeding in a meta-analysis. Clin Gastroenterol Hepatol. 2011;9:762–8.

Koskinas KC, Räber L, Zanchin T, et al. Clinical impact of gastrointestinal bleeding in patients undergoing percutaneous coronary interventions. Circ Cardiovasc Interv. 2015;8(5):e002053.

Scott MJ, Veitch A, Thachil J. Reintroduction of anti-thrombotic therapy after a gastrointestinal haemorrhage: if and when? Brit J Haematol. 2017;177:185–97.

Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. New Engl J Med. 2009;361:1045–57.

Alli O, Smith C, Hoffman M, et al. Incidence, predictors, and outcomes of gastrointestinal bleeding in patients on dual antiplatelet therapy with aspirin and clopidogrel. J Clin Gastroenterol. 2011;45:410–4.

Bestari MB, Laksono B. Current guidelines on antithrombotic management in patients undergoing gastrointestinal endoscopy. Acta Med Indones - Indones J Intern Med. 2019;51(1):86-92.

Gralnek IM, Dumonceau JM, Kuipers EJ, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015;47:1–46.

Acosta RD, Abraham NS, Chandrasekhara V, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointestinal Endoscopy. 2016;83(1):3-16.

Sung JJ, Chiu PW, Chan FKL, et al. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut. 2018;67(10):1757–1768.

Chan FKL, Goh KL, Reddy N, et al. Management of patients on antithrombotic agents undergoing emergency and elective endoscopy: joint Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines. Gut. 2018;67:405-17.

Halvorsen S, Storey RF, Rocca B, et al. Management of antithrombotic therapy after bleeding in patients with coronary artery disease and/or atrial fibrillation: expert consensus paper of the European Society of CardiologyWorking Group on Thrombosis. European Heart J. 2017;38:1455–62.

Becker RC, Scheiman J, Dauerman HL, et al. Management of platelet directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. Am J Gastroenterol. 2009;104:2903-17.

Eisenberg MJ, Richard PR, Libersan D, et al. Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation. 2009;119:1634–42.

Bauer T, Bouman HJ, Van Werkum JW, et al. Impact of CYP2C19 variant genotypes on clinical efficacy of antiplatelet treatment with clopidogrel: systematic review and meta-analysis. BMJ. 2011;343:d4588.

Begg EJ, Helsby NA, Jensen BP. Pharmacogenetics of drug-metabolizing enzymes:the prodrug hypothesis. Pharmacogenomics. 2012;13:83–9.

Helsby NA, Burns KE. Molecular mechanisms of genetic variation and transcriptional regulation of CYP2C19. Front. Genet. 2012;3:206.

Lee VW, Chau TS, Chan AK, et al. Pharmacogenetics of esomeprazole or rabeprazole based triple therapy in Helicobacter pylori eradication in Hong Kong non-ulcer dyspepsia Chinese subjects. J Clin Pharm Ther. 2010;35:343–50.

Lee SJ. Clinical Application of CYP2C19 Pharmacogenetics Toward More Personalized Medicine. Frontiers in Genetics. 2013;3:318.

U.S. Food and Drug. FDA reminder to avoid concomitant use of Plavix (clopidogrel) and omeprazole. https://www.fda.gov/Drugs/DrugSafety/ucm231161.html.

Chan FK. Anti-platelet therapy and managing ulcer risk. J Gastroenterol Hepatol. 2012;27(2):195–9.

Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding a randomized trial. Ann Intern Med. 2010;152(1):1-9.

Downloads

Published

2019-11-07

How to Cite

Bestari, M. B., & Joewono, I. R. (2019). Aspirin vs. P2Y12 Inhibitor Rivalry: Which One Can be Continued During Gastrointestinal Bleeding. Acta Medica Indonesiana, 51(3), 282. Retrieved from https://actamedindones.org/index.php/ijim/article/view/1204

Issue

Vol. 51 No. 3 (2019): Acta Medica Indonesiana

Section

CLINICAL PRACTICE

License

Copyright

The authors who publish in this journal agree to the following requirements:

  1. Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a  Creative Commons Attribution 4.0 International License (CC BY 4.0) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
  2. Authors can enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
  3. Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) before and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work. (See The Effect of Open Access)

Privacy Statement

The names and email addresses entered in this journal site will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party.