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New Recommendations on Anticoagulant and Antiplatelet Management During Acute GI Bleeding and the Periendoscopic Period

Douglas K. Rex, MD, MASGE, reviewing Abraham NS, et al. Am J Gastroenterol 2022 Apr.

A new GRADE guideline from the American College of Gastroenterology and Canadian Association of Gastroenterology includes recommendations for the periendoscopic management of anticoagulants and antiplatelets in the settings of acute GI bleeding and elective endoscopic procedures.

Among the recommendations and supporting commentary regarding antithrombotic therapy management in the setting of acute GI bleeding:

  • Patients receiving warfarin should not be given fresh frozen plasma (FFP) or vitamin K. A recommendation was not reached regarding prothrombin complex concentrate (PCC), but it is preferred over FFP.
  • Commentary indicates it is reasonable to stop warfarin for high-risk procedures (polypectomy of polyps ≥1 cm, PEG/PEJ, ERCP with sphincterotomy, EMR/ESD, EUS-endoscopic fine-needle aspiration, endoscopic hemostasis excluding argon plasma coagulation, radiofrequency ablation, peroral endoscopic myotomy, varices treatment, therapeutic balloon enteroscopy, tumor ablation, cystogastrostomy, ampullary resection, pneumatic or bougie dilation, and laser ablation and coagulation).
  • Commentary indicates that although most warfarin recipients with acute GI bleeding do not need warfarin reversal, it could be considered in the event of a life-threatening GI bleed or substantially supratherapeutic international normalized ratio, or when massive blood transfusion is undesirable because of its impact on coagulopathy or the dilution of blood components. 
  • Regarding direct oral anticoagulants (DOACs), it is recommended that idarucizumab not be given to patients receiving dabigatrin, andexanet alfa not be administered to patients receiving rivaroxaban or apixaban, and PCC not be given to patients taking DOACs in general.
  • Commentary indicates that consideration of DOAC reversal is recommended only in the case of a life-threatening bleed.
  • Platelet transfusions for antiplatelet agents or holding aspirin are not recommended. If aspirin is held, then the recommendation is to resume it on the day hemostasis is endoscopically confirmed.

 All recommendations were conditional with very low certainty of evidence. 

Among the statements regarding antithrombotic therapy management in the elective periendoscopic period: 

  • Warfarin should be continued rather than temporarily interrupted.
  • If warfarin is held, bridging anticoagulation should not be used.
  • DOACs should be temporarily interrupted.
  • Patients receiving dual antiplatelet agents are okay to have interruption of the P2Y12 inhibitor but should continue aspirin.
  • No recommendation could be reached regarding interruption of single antiplatelet therapy with P2Y12. 
  • Patients taking a single-agent aspirin dose of 81 to 325 mg per day should continue treatment through the procedure.
  • For patients with interruption of warfarin, DOACs, or a P2Y12 inhibitor, no recommendation was reached for resuming therapy on the same day as the procedure versus 1 to 7 days after the procedure.

All recommendations were, again, conditional with very low certainty of evidence.

Douglas K. Rex, MD, FASGE

COMMENT

The discussion sections of the paper highlight the high level of uncertainty regarding the best management, lack of agreement about what constitutes high-risk endoscopic procedures for bleeding, and that patient preferences in many individual circumstances could impact management decisions.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

CITATION(S)

Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol 2022;117:542-558. (https://doi.org/10.14309/ajg.0000000000001627)

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