(186) Efficacy of Rectal Dual Antiplatelet Therapy After Percutaneous Coronary Intervention

Introduction: A 63-year-old female with a complicated past medical history presented with hematemesis and chest pain. Electrocardiogram (EKG) findings were consistent with posterior STEMI. The patient received two drug eluting stents to the proximal and distal circumflex with aspirin 325mg and clopidogrel 600mg loading doses.

Description: In the intensive care unit, CT imaging findings of free air consistent with viscus perforation, prompted an emergent surgery consultation. Surgical intervention showed duodenal perforation proximal to the ligament of Treitz, requiring partial duodenectomy and end-to-end anastomosis. Enteral access for medication or nutrition was contraindicated postoperatively. Recent stent placement necessitated further antiplatelet therapy to prevent acute stent thrombosis. Eptifibatide was considered high-bleeding risk, and other IV antiplatelet agents were not in supply. Rectal aspirin and ticagrelor were started, and patient was closely monitored with telemetry, serial EKGs and by P2Y12 levels to assess for treatment response to her dual antiplatelet therapy (DAPT). The patient’s P2Y12 level 48 hours after rectal ticagrelor loading dose was 8 PRU (194-418PRU); subsequent P2Y12 level monitoring showed continued suppression, with levels ranging from 40-70PRU. The patient eventually had return of bowel function and was transitioned to enteral nutrition and medications including her DAPT.

Discussion: Rectal DAPT was initiated to mitigate the risk for in-stent thrombosis and balance the risk for repeat GI bleeding following her duodenal rupture. P2Y12 levels were monitored as a proxy to measure therapeutic drug efficacy, with P2Y12 levels orally and rectally showing similar findings within the 40-70PRU range. While rectal clopidogrel was considered, invivo biotransformation would be missed with rectal administration. While rectal aspirin has been studied for patients with acute coronary syndrome, rectal routes of other antiplatelet agents have not been widely studied. Our case suggests in the uncommon circumstance, rectal absorption is a viable temporary option for patients who otherwise have limited enteral access