What is the role of oral anticoagulation (OAC) in patients post gastrectomy?

From the Guidelines

Oral anticoagulation for post-gastrectomy patients should be managed based on the individual's bleeding risk, with high bleeding risk patients requiring more cautious management, as outlined in the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1.

Key Considerations

• The management of perioperative bleeding risk and direct oral anticoagulant (DOAC) or vitamin K antagonist (VKA) schedule should incorporate team-based decision-making, especially in high thrombotic risk patients or when undergoing procedures with higher risks of adverse outcome, should bleeding occur 1.
• The 2024 guideline provides a table outlining the perioperative management of DOACs and VKAs based on the type of procedure, bleeding risk, and renal impairment 1.

Bleeding Risk Assessment

• Minimal bleeding risk is defined as a 30-day risk of major bleeding of 0%, while low/moderate bleeding risk is defined as a 30-day risk of major bleeding of less than 2%, and high bleeding risk is defined as a 30-day risk of major bleeding of 2% or greater 1.

Anticoagulation Management

• For patients with high bleeding risk, DOACs such as apixaban, edoxaban, and rivaroxaban should be withheld for a longer period, while for patients with low/moderate bleeding risk, these medications can be withheld for a shorter period 1.
• VKAs, such as warfarin, require more careful management, with bridging anticoagulation with parenteral heparin considered in select high thrombotic risk patients 1.

Reversal of Anticoagulation

• Rapid reversal of anticoagulation can be achieved with prothrombin complex concentrates, andexanet alfa for factor Xa inhibitors, or idarucizumab for dabigatran 1.

Monitoring and Follow-up

• Regular monitoring for both thrombotic and bleeding complications is essential, with particular attention to signs of gastrointestinal bleeding which may be more difficult to detect in post-gastrectomy patients 1.

Individualized Approach

• The choice of anticoagulant and duration of therapy should be individualized based on the patient's risk factors, such as cancer diagnosis, immobility, or history of venous thromboembolism 1. In summary, oral anticoagulation for post-gastrectomy patients requires a careful and individualized approach, taking into account the patient's bleeding risk, renal function, and other factors, with the goal of minimizing the risk of thrombotic and bleeding complications 1.

From the Research

Oral Anticoagulation for Post-Gastrectomy Patients

• The use of direct oral anticoagulants (DOACs) in patients after gastrectomy has been studied in several research papers 2, 3.
• A retrospective analysis found that DOACs, particularly factor Xa inhibitors (FXaI), were adequately absorbed in cancer patients after gastrectomy 2.
• However, the study also noted that one patient treated with dabigatran had recurrent thromboembolic events, suggesting cautious use in this specific patient population 2.
• Another study reviewed clinical data on DOAC use in patients with major surgical resection or bypass and found that there is uncertainty about the efficacy of rivaroxaban and dabigatran in patients requiring anticoagulation after Roux-en-Y gastric bypass 3.
• The study advised avoidance of rivaroxaban therapy in patients undergoing gastrectomy 3.
• A systematic review and network meta-analysis compared the efficacy and safety of NOACs for the initial and long-term treatment of venous thromboembolism (VTE) and found that apixaban had the most favorable safety profile 4.
• Another systematic review and network meta-analysis compared the efficacy and safety of anticoagulants for the extended treatment of VTE and found that apixaban had a significantly reduced risk of major or clinically relevant non-major bleed compared with other NOACs and warfarin 5.
• A review of gastrointestinal bleeding in patients on NOACs found that high-dose dabigatran, rivaroxaban, and high-dose edoxaban were associated with a higher risk of gastrointestinal bleeding (GIB) compared with warfarin 6.
• The review also noted that prevention of NOAC-related GIB includes proper patient selection, using a lower dose of certain NOACs, and correction of modifiable risk factors 6.

Risk Factors and Prevention

• Risk factors for NOAC-related GIB include concomitant use of ulcerogenic agents, older age, renal impairment, Helicobacter pylori infection, and a past history of GIB 6.
• Prevention of NOAC-related GIB includes proper patient selection, using a lower dose of certain NOACs, and correction of modifiable risk factors 6.
• Gastroprotective agents may also be prescribed to prevent GIB in patients on NOACs 6.

Management of Gastrointestinal Bleeding

• Overt GIB can be managed by withholding NOACs followed by delayed endoscopic treatment 6.
• In severe bleeding, additional measures include administration of activated charcoal, use of specific reversal agents, and urgent endoscopic management 6.