How to manage anticoagulation in patients with Atrial Fibrillation (Afib) who have experienced a Gastrointestinal (GI) bleed?

From the Guidelines

Anticoagulation in patients with Atrial Fibrillation (Afib) who have experienced a Gastrointestinal (GI) bleed should be managed by interrupting direct oral anticoagulant therapy at presentation and considering restarting treatment at a maximum of 7 days after haemorrhage. When managing anticoagulation in Afib patients after a GI bleed, it is crucial to balance the risk of thromboembolic events against the risk of recurrent bleeding.

• The initial step involves interrupting anticoagulation until hemostasis is achieved, which can typically take 7-14 days depending on the severity of the bleed 1.
• Direct oral anticoagulants (DOACs) are preferred over warfarin due to their lower GI bleeding risk, with apixaban and dabigatran being common first choices, and their doses should be adjusted based on renal function and age.
• Adding a proton pump inhibitor like pantoprazole for gastric protection is also recommended.
• The decision to restart anticoagulation should be made after careful consideration of the patient's stroke risk (using CHA₂DS₂-VASc score) and bleeding risk (using HAS-BLED score), and patient engagement in this decision is vital, including discussions about the risks and implications of resuming anticoagulation 1.
• Close monitoring after restarting therapy is essential, with follow-up within 2-4 weeks to assess for recurrent bleeding. This approach prioritizes minimizing morbidity, mortality, and improving quality of life by carefully managing the risks associated with anticoagulation in Afib patients who have experienced a GI bleed.

From the Research

Management of Anticoagulation in Afib with GI Bleed

• The management of anticoagulation in patients with Atrial Fibrillation (Afib) who have experienced a Gastrointestinal (GI) bleed is a complex issue, with limited high-quality evidence and no guidelines to guide physicians 2.
• When a patient presents with bleeding manifestations or hemodynamic instability, it is essential to perform endoscopy to determine the bleed location and severity of bleeding, and then perform initial resuscitation 2.
• Administration of all anticoagulants and antiplatelets should be stopped, and bleeding allowed to resolve with time; however, anticoagulant reversal should be considered for patients who have life-threatening bleeding or when the bleeding is not controlled by the initial resuscitation 2.

Resumption of Anticoagulation

• Anticoagulation needs to be timely resumed, considering that bleeding risk outweighs thrombotic risk when anticoagulation is resumed early after the bleeding event 2.
• To prevent further bleeding, physicians should prescribe anticoagulant therapy with the lowest risk of GI bleeding, avoid medications with GI toxicity, and consider the effect of concomitant medications on potentiating the bleeding risk 2.

Choice of Anticoagulant

• The choice of anticoagulant can affect the risk of GI bleeding, with rivaroxaban increasing the risk of GI bleeding compared to warfarin 3.
• Apixaban has been shown to have a lower risk of GI bleeding compared to rivaroxaban, dabigatran, and warfarin 4.
• Proton pump inhibitor (PPI) co-therapy can reduce the risk of GI bleeding in patients treated with oral anticoagulants, particularly in those with a prior history of upper GI bleeding 5, 4.

Risk Factors for GI Bleeding

• Independent clinical factors most strongly associated with GI bleeding include baseline anemia, history of GI bleeding, and long-term aspirin use 3.
• A history of GI bleeding in patients with Afib may impact decisions about anticoagulation treatment, and prior GI bleeding has been associated with an increased risk of subsequent major GI bleeding 6.