Five things to check before stopping an antiplatelet

Stopping an antiplatelet looks like one of the easiest wins on a repeat list: aspirin or clopidogrel that nobody remembers starting, in a patient who bruises easily. It is also one of the deprescribing decisions that can go most seriously wrong, because the cost of stopping the wrong antiplatelet is not a rash, it can be a stent thrombosis or a stroke. Before you stop aspirin, clopidogrel, ticagrelor or prasugrel, make these five checks every time. They sit naturally inside a structured medication review.

This is general guidance to support practice. Always individualise the decision, check the current BNF, and follow your local and specialist guidance.

Check one: the true indication, and who started it

The first job is to reconstruct why the antiplatelet exists. Secondary prevention (after a myocardial infarction, coronary stent, ischaemic stroke, TIA or symptomatic peripheral arterial disease) is a different proposition from primary prevention, where aspirin is no longer routinely recommended in UK practice because the bleeding risk generally offsets the benefit. Secondary prevention is usually lifelong; an absent reason in the record is a prompt to dig, not a licence to stop.

Work backwards through the notes: hospital letters, old problem codes, the date the drug first appeared. Who started it matters, because it tells you whose plan you might be interrupting: cardiology after a stent, the stroke team after a TIA, a GP for primary prevention, or the patient buying aspirin over the counter.

Check two: stents and the DAPT danger window

After a coronary stent, patients are usually on dual antiplatelet therapy (DAPT): aspirin plus a P2Y12 inhibitor such as clopidogrel, ticagrelor or prasugrel. The duration is individualised, commonly around twelve months after an acute coronary syndrome, often shorter after elective stenting, and adjusted for ischaemic and bleeding risk. That plan is the most important document in the review: do not stop, hold or switch either component of DAPT without it in front of you; if it is missing from the record, obtaining it is the action.

The reason is the danger window: stopping DAPT prematurely, especially in the early months after insertion, is one of the strongest predictors of stent thrombosis, which typically presents as a myocardial infarction and carries a high mortality. Well-meaning interruptions count too: a dentist or surgeon asking for antiplatelets to be held before a procedure should trigger a conversation with cardiology, not an automatic stop.

Check three: what exactly is the bleeding concern?

"Bleeding risk" is not a finding; it is a category. Pin down what has actually happened or what you are worried about: dyspepsia, iron deficiency anaemia, an overt GI bleed, easy bruising, a planned procedure, or age and frailty. Many of these do not require the antiplatelet to stop.

For gastrointestinal risk, gastroprotection with a PPI is often the better move than sacrificing proven cardiovascular protection. If the patient takes clopidogrel, remember the interaction: MHRA advice is to avoid omeprazole and esomeprazole with clopidogrel because they can reduce its effect, so lansoprazole or pantoprazole is commonly preferred; check the BNF and local guidance. Also look for modifiable contributors: Helicobacter pylori, alcohol, uncontrolled blood pressure, other bleeding-risk drugs. Any red-flag bleeding symptom needs proper assessment, not a quiet discontinuation that hides the problem.

Check four: the rest of the medicines

Antiplatelet decisions are rarely about the antiplatelet alone. The highest-value finding is an anticoagulant plus an antiplatelet with no documented indication for the combination. The combination is legitimate for a limited period after an acute coronary syndrome or stenting in someone who also needs anticoagulation, but the long-term plan is usually anticoagulation alone, and the aspirin is frequently the item left behind when the letters stop. Apixaban and aspirin together on a repeat with no stated plan is a question for the prescriber and often for cardiology, and while you are there it is worth confirming the anticoagulant itself is right, as covered in how to check a DOAC dose in primary care.

Then scan for the drugs that multiply bleeding risk: NSAIDs (including over-the-counter ibuprofen), SSRIs and SNRIs, corticosteroids, and any second antithrombotic. Sometimes the safest intervention is not touching the antiplatelet at all, but stopping the NSAID that sits next to it.

Check five: the decision trail

Be clear whose decision this is. Stopping primary prevention aspirin after a shared conversation may sit within a practice-level review with the prescriber's agreement; ending DAPT early, or stopping anything a specialist started for a defined duration, is the specialist's call, and your role is to surface the question and route it well.

Whatever is decided, write it down: the indication you reviewed, what was stopped or continued and why, who agreed it, and what the patient was told. Then safety-net in both directions. If the antiplatelet continues, the patient should know the bleeding symptoms that need urgent review, such as black tarry stools or unexplained bruising. If it stops, they should know the thrombotic symptoms that mean call 999, including chest pain and the FAST stroke signs. There are worked phrasings in safety-netting examples for primary care.

A worked example (entirely fictional)

This case is entirely fictional. Mrs B, 79, takes apixaban for atrial fibrillation alongside aspirin 75 mg daily. The aspirin dates from a myocardial infarction four years ago, managed with a stent: the cardiology letters show clopidogrel was correctly stopped at twelve months with a plan for anticoagulation alone thereafter, but the aspirin was never removed from the repeat. Three years of combined therapy, and avoidable bleeding risk, with no current indication. The pharmacist raises it with the GP, the plan is confirmed, the aspirin is stopped, the reasoning is documented against the cardiology letter, and Mrs B is told what to look out for in both directions.

Putting the checks into practice

None of this requires heroics, just the discipline to reconstruct the indication, find the plan, name the actual risk, read the whole list and leave a clear trail. If interaction questions are the sticking point, our drug interaction reference is built for exactly this kind of review.

How Medicine in Practice helps: our case-based training works through antiplatelet, anticoagulant and combination reviews, so you practise the decision as well as the rule.

Frequently asked questions

Can clopidogrel be stopped after a coronary stent?

Only in line with the cardiology plan. DAPT after a stent runs for an individualised duration, and premature discontinuation is one of the strongest predictors of stent thrombosis. If the plan is not in the record, obtain it before making any change.

Should a patient take an anticoagulant and an antiplatelet together?

Usually only for a documented, time-limited indication, such as a defined period after an acute coronary syndrome or stenting. A long-term combination with no recorded plan should be raised with the prescriber.

Which PPI can be used with clopidogrel?

MHRA advice is to avoid omeprazole and esomeprazole with clopidogrel because they can reduce its antiplatelet effect. Lansoprazole or pantoprazole is commonly preferred where gastroprotection is needed; confirm against the BNF and local guidance.