Which Direct Oral Anticoagulants (DOACs) are contraindicated with high-risk gastric procedures?

DOACs Contraindicated with High-Risk Gastric Procedures

Dabigatran is contraindicated in patients with creatinine clearance <15-30 mL/min undergoing high-risk gastric procedures, while all DOACs should be temporarily discontinued before high-risk gastric procedures according to specific timing guidelines. 1

Contraindications Based on Renal Function and Procedure Risk

• Dabigatran is specifically contraindicated in patients with creatinine clearance <30 mL/min undergoing high-risk gastric procedures 1
• All DOACs (apixaban, rivaroxaban, edoxaban) are not recommended in patients with creatinine clearance <15 mL/min undergoing high-risk gastric procedures 1
• High-risk gastric procedures include endoscopic submucosal dissection (ESD), which has shown a post-procedure bleeding rate of 19.6% in patients taking DOACs 2

Timing of DOAC Discontinuation Before High-Risk Gastric Procedures

For Dabigatran:

• Creatinine clearance >80 mL/min: Discontinue 2 days before procedure 1
• Creatinine clearance 50-80 mL/min: Discontinue 3 days before procedure 1
• Creatinine clearance 30-50 mL/min: Discontinue 4 days before procedure 1
• Creatinine clearance 15-30 mL/min: Contraindicated 1

For Apixaban, Rivaroxaban, and Edoxaban:

• All creatinine clearance levels >15 mL/min: Discontinue 2 days before high-risk gastric procedures 1
• Creatinine clearance <15 mL/min: Not recommended 1

Specific Gastric Procedures and DOAC Considerations

• ERCP with sphincterotomy: All DOACs should be delayed for at least 48 hours after the procedure due to increased risk of post-procedural bleeding 3
• Gastric ESD: Rivaroxaban appears to have higher post-procedure bleeding risk compared to dabigatran (21.4% vs. 0%) 2
• Patients with gastrointestinal malignancies should avoid DOACs due to significantly increased bleeding risk, particularly with intact intraluminal tumors 4

Resumption of DOACs After High-Risk Gastric Procedures

• For high-risk endoscopic procedures, DOACs should be resumed up to 48 hours after the procedure, depending on the perceived bleeding and thrombotic risks 1, 3
• The decision to restart anticoagulation should balance the risk of post-procedural bleeding against the risk of thromboembolism 3
• For patients at high thrombotic risk requiring immediate anticoagulation, consider bridging with low molecular weight heparin rather than immediate DOAC resumption 3

Management of Bleeding During Gastric Procedures in Patients on DOACs

• For severe bleeding during gastric procedures, temporary drug withdrawal may be sufficient due to the short half-lives of DOACs 1
• For life-threatening bleeding, specific reversal agents may be considered: idarucizumab for dabigatran and andexanet alfa for factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) 1
• The effect of rivaroxaban on coagulation can be reversed by prothrombin complex concentrate (50 IU/kg of 4-factor concentrate), but this does not work for dabigatran 1

Pitfalls and Caveats

• Bridging therapy with heparin when interrupting DOACs is generally not recommended as it may increase bleeding risk without reducing thromboembolism 1
• The Dresden DOAC registry showed heparin bridging for patients on rivaroxaban led to significantly higher rates of major bleeding compared to no bridging (2.7% vs. 0.5%, p=0.01) 1
• DOACs should be avoided in patients who have undergone major gastric resections or bypass procedures due to potential altered absorption 5
• Rivaroxaban therapy should be avoided in patients undergoing gastrectomy due to concerns about efficacy 5
• Despite the higher frequency of gastrointestinal bleeding in patients on DOACs compared to warfarin, the severity of bleeding appears to be less severe, with fewer hospitalizations and transfusions required 6