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

    Official guideline from the American College of Gastroenterology.

    Strength
    Conditional recommendation
    Evidence
    Low quality evidence
    Very low quality evidence

    Management (Acute GI Bleeding)

    Acetylsalicylic Acid
    1. For patients with GI bleeding on cardiac ASA for secondary prevention, we suggest against holding the ASA.
    2. For patients with GI bleeding on ASA for secondary cardiovascular prevention whose ASA was held, we suggest the ASA be resumed on the day hemostasis is endoscopically confirmed.
    Vitamin K Antagonist Reversal
    1. For patients on warfarin who are hospitalized or under observation with acute GI bleeding, we suggest against FFP administration.
    2. For patients on warfarin who are hospitalized or under observation with acute GIB, we suggest PCC administration compared with FFP administration.
    3. For patients on warfarin who are hospitalized or under observation with acute GIB (upper and/or lower), we suggest against the use of vitamin K.
    4. For patients on warfarin who are hospitalized or under observation with acute GIB, we could not reach a recommendation for or against PCC administration.
    DOAC Reversal
    1. For patients on DOACs who are hospitalized or under observation with acute GIB, we suggest against PCC administration.
    Antiplatelet Reversal
    1. For patients on antiplatelet agents who are hospitalized or under observation with acute GIB, we suggest against platelet transfusions.
    Direct Thrombin Inhibitor Reversal
    1. For patients on dabigatran who are hospitalized or under observation with acute GIB, we suggest against the administration of idarucizumab.
    Rivaroxaban/Apixaban Reversal
    1. For patients on rivaroxaban or apixaban who are hospitalized or under observation with acute GIB, we suggest against andexanet alfa administration.

    Management (Elective Endoscopy)

    Anticoagulants
    1. For patients on warfarin, who hold warfarin in the periprocedural period for elective/planned endoscopic GI procedures, we suggest against bridging anticoagulation.
    2. For patients on warfarin undergoing elective/planned endoscopic GI procedures, we suggest warfarin be continued, as opposed to temporarily interrupted (1–7 days)
    3. For patients on DOACs who are undergoing elective/planned endoscopic GI procedures, we suggest temporarily interrupting DOACs rather than continuing DOACs.
    4. 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.
    5. 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.
    Antiplatelets
    1. For patients on dual antiplatelet therapy for secondary prevention who are undergoing elective endoscopic GI procedures, we suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA.
    2. For patients on ASA 81–325 mg/d (i.e., cardiac ASA monotherapy) for secondary prevention, we suggest against interruption of ASA.
    3. For patients on single antiplatelet therapy with a P2Y12 receptor inhibitor who are undergoing elective endoscopic GI procedures, we could not reach a recommendation for or against temporary interruption of the P2Y12 receptor inhibitor.
    P2Y12 Inhibitor
    1. 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.
    What do the icons mean?  
    Research PaperAbraham 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(4):542-558.