Recommencing aspirin following a peptic ulcer bleed: when is the time right?

As the population ages it is increasingly common for patients who present with a peptic ulcer bleed to have concomitant cerebrovascular or cardiovascular disease. Traditionally antiplatelet therapy, including aspirin, is stopped for a period of 4-8 weeks following an acute bleed although this approach is not evidence based. A study by Sung et al [1] addressed the issue of what to do with aspirin prescription in this scenario with a single-center double-blind parallel randomized placebocontrolled trial. To be included in the study, participants had to be taking up to 325 mg of aspirin per day for secondary prophylaxis and present with an upper gastrointestinal (GI) bleed. The study required endoscopic findings of a peptic ulcer with active bleeding or stigmata of recent hemorrhage (visible vessel or adherent clot). All participants received dual endoscopic therapy with adrenaline and heater probe to achieve hemostasis. Participants were then commenced on a 72-hour continuous intravenous infusion of proton pump inhibitor (PPI) and randomized to either aspirin (80 mg/day) or placebo for 8 weeks. Both groups received oral PPI (pantoprazole 40mg/day) for the duration of the study. The primary endpoint of the study was recurrent peptic ulcer bleeding within 30 days of the index endoscopy. The study recruited 156 participants (78 in each arm) and was powered as a non-inferiority study to detect a 10% difference in recurrent peptic ulcer bleeding rates at 30 days. The results demonstrated a recurrent bleed rate of 10.3% (95% CI 3.4 17.2) in the aspirin group compared with 5.4% (95% CI 0.3 10.5) in the placebo group (a difference of 4.9 percentage points (95% CI -3.6 13.4) at 30 days. The authors