Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period
Official guideline from the American College of Gastroenterology.
Management (Acute GI Bleeding)
Acetylsalicylic Acid
For patients with GI bleeding on cardiac ASA for secondary prevention, we suggest against holding the ASA.
Conditional recommendation
Very low quality evidence
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.
Conditional recommendation
Very low quality evidence
Vitamin K Antagonist Reversal
For patients on warfarin who are hospitalized or under observation with acute GI bleeding, we suggest against FFP administration.
Conditional recommendation
Very low quality evidence
For patients on warfarin who are hospitalized or under observation with acute GIB, we suggest PCC administration compared with FFP administration.
Conditional recommendation
Very low quality evidence
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.
Conditional recommendation
Very low quality evidence
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
For patients on DOACs who are hospitalized or under observation with acute GIB, we suggest against PCC administration.
Conditional recommendation
Very low quality evidence
Antiplatelet Reversal
For patients on antiplatelet agents who are hospitalized or under observation with acute GIB, we suggest against platelet transfusions.
Conditional recommendation
Very low quality evidence
Direct Thrombin Inhibitor Reversal
For patients on dabigatran who are hospitalized or under observation with acute GIB, we suggest against the administration of idarucizumab.
Conditional recommendation
Very low quality evidence
Rivaroxaban/Apixaban Reversal
For patients on rivaroxaban or apixaban who are hospitalized or under observation with acute GIB, we suggest against andexanet alfa administration.
Conditional recommendation
Very low quality evidence
Management (Elective Endoscopy)
Anticoagulants
For patients on warfarin, who hold warfarin in the periprocedural period for elective/planned endoscopic GI procedures, we suggest against bridging anticoagulation.
Conditional recommendation
Low quality evidence
For patients on warfarin undergoing elective/planned endoscopic GI procedures, we suggest warfarin be continued, as opposed to temporarily interrupted (1–7 days)
Conditional recommendation
Very low quality evidence
For patients on DOACs who are undergoing elective/planned endoscopic GI procedures, we suggest temporarily interrupting DOACs rather than continuing DOACs.
Conditional recommendation
Very low quality evidence
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.
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
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.
Conditional recommendation
Very low quality evidence
For patients on ASA 81–325 mg/d (i.e., cardiac ASA monotherapy) for secondary prevention, we suggest against interruption of ASA.
Conditional recommendation
Very low quality evidence
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
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?
How strong is the ACG's recommendation?
Conditional recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.Low quality evidence
Further research expected to have important impact in confidence in estimate of effect.Very low quality evidence
Any estimate of effect is very uncertain.Literature
