Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period

Publication Date: March 16, 2022
Last Updated: July 4, 2022

VKA reversal

For patients on warfarin who are hospitalized or under observation with acute GI bleeding, we suggest against fresh frozen plasma (FFP) administration. (C, VL)
620
For patients on warfarin who are hospitalized or under observation with acute GI bleeding, we could not reach a recommendation for or against prothrombin complex concentrate administration. (U, U)
620
For patients on warfarin who are hospitalized or under observation with acute GI bleeding, we suggest prothrombin complex concentrate administration compared with FFP administration. (C, VL)
620
For patients on warfarin who are hospitalized or under observation with acute GI bleeding, we suggest against the use of vitamin K. (C, VL)
620

Direct thrombin inhibitor reversal

For patients on dabigatran who are hospitalized or under observation with acute GI bleeding, we suggest against the administration of idarucizumab. (C, VL)
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Reversal of rivaroxaban or apixaban with andexanet alfa

For patients on rivaroxaban or apixaban who are hospitalized or under observation with acute GI bleeding, we suggest against andexanet alfa administration. (C, VL)
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Reversal of DOACs with PCC

For patients on direct oral anticoagulants who are hospitalized or under observation with acute GI bleeding, we suggest against prothrombin complex concentrate administration. (C, VL)
620

Reversal of antiplatelet with platelet transfusion

For patients on antiplatelet agents who are hospitalized or under observation with acute GI bleeding, we suggest against platelet transfusions. (C, VL)
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Holding ASA vs continuing ASA

For patients with GI bleeding on cardiac ASA for secondary cardiovascular prevention, we suggest against holding the ASA. (C, VL)
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For patients with GI bleeding on ASA for secondary cardiovascular prevention whose ASA was interrupted, we suggest the ASA be resumed on the day hemostasis is endoscopically confirmed. (C, VL)
620

Anticoagulant interruption vs continuation

For patients on warfarin undergoing elective/planned endoscopic GI procedures, we suggest warfarin be continued, as opposed to temporarily interrupted (1–7 days). (C, VL)
620
For patients on warfarin, who hold warfarin in the periprocedural period for elective/planned endoscopic GI procedures, we suggest against bridging anticoagulation. (C, L)
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For patients on direct oral anticoagulants (DOACs) who are undergoing elective/planned endoscopic GI procedures, we suggest temporarily interrupting DOACs rather than continuing DOACs. (C, VL)
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Antiplatelet interruption vs continuation

For patients on dual antiplatelet therapy for secondary cardiovascular prevention who are undergoing elective endoscopic GI procedures, we suggest temporary interruption of the P2Y12 inhibitor while continuing ASA. (C, VL)
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For patients on single antiplatelet therapy with P2Y12 inhibitor agents who are undergoing elective endoscopic GI procedures, we could not reach a recommendation for or against temporary interruption of the P2Y12 inhibitor. (U, U)
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For patients on ASA 81–325 mg/d (monotherapy) for secondary cardiovascular prevention, we suggest against interruption of ASA. (C, VL)
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In patients who are undergoing elective endoscopic GI procedures whose warfarin was interrupted, we could not reach a recommendation for or against resuming warfarin the same day vs 1–7 days after the procedure. (U, U)
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In patients who are undergoing elective endoscopic GI procedures whose DOAC was interrupted, we could not reach a recommendation for or against resuming the DOAC on the same day of the procedure vs 1–7 days after the procedure. (U, U)
620

Timing of P2Y12 inhibitor resumption after endoscopy

In patients who are undergoing elective endoscopic GI procedures whose P2Y12 inhibitor was interrupted, we could not reach a recommendation for or against resuming P2Y12 inhibitor on the same day of the procedure vs 1–7 days after the procedure. (U, U)
620

Recommendation Grading

Overview

Title

Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period

Authoring Organization

American College of Gastroenterology

Publication Month/Year

March 16, 2022

Last Updated Month/Year

September 4, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Prevention

Diseases/Conditions (MeSH)

D000925 - Anticoagulants, D006471 - Gastrointestinal Hemorrhage, D000980 - Antiplatyhelmintic Agents

Keywords

Upper Gastrointestinal bleeding, gastrointestinal bleeding, anticoagulants, antiplatelets

Source Citation

Abraham, Neena S. MD, MSc (Epi), FACG1; Barkun, Alan N. MD, MSc (Epi), FACG, CAGF2; Sauer, Bryan G. MD, MSc (Clin Res), FACG3; Douketis, James MD4; Laine, Loren MD, FACG5,6; Noseworthy, Peter A. MD7; Telford, Jennifer J. MD, MPH, FACG, CAGF8; Leontiadis, Grigorios I. MD, PhD, CAGF9 American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period, The American Journal of Gastroenterology: March 17, 2022 - Volume - Issue - 10.14309/ajg.0000000000001627
doi: 10.14309/ajg.0000000000001627 

Supplemental Methodology Resources

Data Supplement, Data Supplement, Data Supplement

Methodology

Number of Source Documents
100
Literature Search Start Date
December 31, 1984
Literature Search End Date
August 12, 2020