From the Guidelines
Management of upper gastrointestinal bleeding in a patient on Xarelto (rivaroxaban) requires immediate discontinuation of the anticoagulant and aggressive resuscitation, with Andexxa (andexanet alfa) being the preferred reversal agent if available, as supported by the 2024 study 1. The initial steps involve establishing two large-bore IV lines and beginning fluid resuscitation with crystalloids while assessing hemodynamic stability. Blood products should be administered as needed, with a target hemoglobin of at least 7-8 g/dL. For rivaroxaban reversal, the dose of Andexxa depends on the timing and amount of the last rivaroxaban dose, with a 400 mg bolus followed by a 480 mg infusion for rivaroxaban intake more than 7 hours before reversal, or an 800 mg bolus followed by a 960 mg infusion for rivaroxaban intake less than 7 hours before reversal or unknown recent intake, as indicated in the study 1. Urgent endoscopy should be performed within 24 hours, preferably within 12 hours after hemodynamic stabilization, as recommended by the 2024 update on nonvariceal upper gastrointestinal bleeding 1. Proton pump inhibitor therapy should be initiated immediately with an IV bolus of 80 mg pantoprazole or esomeprazole followed by continuous infusion at 8 mg/hour for 72 hours, then transitioning to oral therapy. Octreotide (50-100 mcg IV bolus followed by 25-50 mcg/hour infusion) may be beneficial if variceal bleeding is suspected. After bleeding is controlled and the patient is stable, reassess the risk-benefit ratio of restarting anticoagulation, potentially considering alternative anticoagulants or lower doses, with the timing of anticoagulation resumption typically ranging from 7-14 days after bleeding cessation, depending on the indication for anticoagulation and bleeding risk. Key considerations in managing UGIB include the high risk of rebleeding, massive hemorrhage, and death, emphasizing the need for prompt and effective intervention, as highlighted in the studies 1.
From the Research
Management of Upper Gastrointestinal Bleeding
The management of upper gastrointestinal bleeding (UGIB) in a patient on Xarelto (rivaroxaban) involves several steps:
- Resuscitation of the patient is the first and most important step in its management, followed by measures to localize and treat the exact source and site of bleeding 2
- Endoscopic therapy is the mainstay of treatment in patients with active bleeding, as it achieves hemostasis and improves patient outcomes 3
- Pharmacotherapy is an important adjunct to endoscopic hemostasis, with acid suppression after endoscopic hemostasis reducing rates of further bleeding and interventions 3
- The use of vasoactive agents and antibiotics have both been shown to reduce mortality in patients with variceal bleeding 3
- Tranexamic acid may reduce upper gastrointestinal bleeding and stabilize patients before endoscopic treatments, and may reduce all-cause mortality 4
Role of Endoscopy
- Endoscopy is the essential tool for the diagnosis and treatment of active upper GI hemorrhage 5
- Endoscopic therapy together with proton pump inhibitors and eradication of Helicobacter pylori significantly reduces rebleeding rates, mortality and number of emergency surgical interventions 5
- The amount of blood in the stomach at endoscopy reflects initial risk, and predicts rebleeding and surgery 6
Pharmacological Treatment
- Acid suppression therapy for peptic ulcer bleeds, vasoactive agents, and antibiotics for variceal bleeding are important components of pharmacological treatment 3
- Tranexamic acid and lansoprazole have been shown to reduce the amount of blood in the stomach at endoscopy, although there is no evidence of synergy between the two drugs 6