New guideline offers recommendations on managing antithrombotic drugs during GI bleeds, endoscopies

The American College of Gastroenterology and the Canadian Association of Gastroenterology offered suggestions for management of patients on warfarin, direct oral anticoagulants, and antiplatelet agents.

The American College of Gastroenterology and the Canadian Association of Gastroenterology recently released a new guideline on managing anticoagulants and antiplatelets during GI bleeding and before endoscopy.

The societies convened a multidisciplinary working group to create a focused, pragmatic guideline based on published literature that would address clinical questions that arise in common emergent and elective settings. The clinical practice guideline was published in the American Journal of Gastroenterology on March 17.

The guideline includes the following recommendations for managing acute GI bleeding:

  • For patients on warfarin, the group suggested against giving fresh frozen plasma or vitamin K; if needed, it suggested prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration.
  • For patients on direct oral anticoagulants (DOACs), the group suggested against PCC administration; for those on dabigatran, it suggested against the administration of idarucizumab; and for those on rivaroxaban or apixaban, it suggested against andexanet alfa administration.
  • For patients on antiplatelet agents, the group suggested against platelet transfusions.
  • For patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, the group suggested against holding it, but in cases where ASA has been interrupted, the group suggested resumption on the day hemostasis is endoscopically confirmed.

In the setting of planned endoscopy, the guideline suggested continuation of warfarin rather than temporary interruption; however, if warfarin is held for procedures with high risk of GI bleeding, the authors suggested against bridging anticoagulation unless the patient has a mechanical heart valve. For patients on DOACs, the guideline suggested temporary interruption. Similarly, for patients on dual antiplatelet therapy for secondary prevention, it suggested temporary interruption of the P2Y12 receptor inhibitor while continuing ASA. On the other hand, the guideline suggested against interruption in patients on cardiac ASA monotherapy for secondary prevention.

The guideline authors found insufficient evidence to recommend for or against PCC administration in patients taking warfarin who have acute GI bleeding or for or against temporary interruption of a single P2Y12 receptor inhibitor for endoscopy. They could also not determine whether to resume warfarin, a DOAC, or a P2Y12 receptor inhibitor the same day as a procedure versus one to seven days afterward.

The guideline authors called for additional research, saying that “there is a fundamental knowledge gap in the evaluation and characterization of GI endoscopic procedural bleeding risk groups.”