Which anticoagulants (blood thinners) and antiplatelet agents should be held in a patient with a gastrointestinal (GI) bleed?

Management of Anticoagulants and Antiplatelets During GI Bleeding

All anticoagulants and antiplatelet agents should be temporarily withheld during active gastrointestinal bleeding, with specific timing for resumption based on the indication, thrombotic risk, and success of endoscopic hemostasis. 1

Initial Management of Antiplatelet Therapy

• For patients on aspirin for primary prevention of cardiovascular events, permanently discontinue aspirin as the bleeding risk outweighs cardiovascular benefit 1
• For patients on aspirin for secondary prevention, temporarily withhold aspirin only during active serious or life-threatening bleeding, and restart as soon as hemostasis is achieved 2, 1
• For patients on dual antiplatelet therapy (DAPT), never withhold both agents simultaneously due to high risk of stent thrombosis 2, 1
• In patients on DAPT with aspirin and clopidogrel, continue aspirin and temporarily withhold clopidogrel during active bleeding 2, 1

Management of Anticoagulants

• For patients on direct oral anticoagulants (DOACs), interrupt therapy at presentation with GI bleeding 1, 3
• For patients on warfarin with serious bleeding, use prothrombin complex concentrate (PCC) and low-dose vitamin K (<5 mg) for urgent reversal rather than fresh frozen plasma 2, 4
• For patients on DOACs with life-threatening bleeding, specific reversal agents may be considered, though evidence for routine use is limited 5, 4

Timing of Resumption After Hemostasis

• For aspirin used for secondary prevention, restart as soon as hemostasis is achieved 1
• For P2Y12 receptor inhibitors (clopidogrel, prasugrel):
  • Resume within 5 days after endoscopic hemostasis 1
  • For ticagrelor, consider earlier resumption within 2-3 days due to its reversible binding 2, 1
• For patients on warfarin:
  • High thrombotic risk: Consider low molecular weight heparin bridging at 48 hours after hemostasis 3
  • Low thrombotic risk: Restart warfarin at 7 days after bleeding has stopped 3
• For DOACs, consider restarting treatment at a maximum of 7 days after bleeding has stopped 1

Risk Stratification for Resumption

• High thrombotic risk factors requiring earlier antiplatelet resumption:
  • Recent coronary stent placement (especially within 30 days) 2
  • Left main coronary artery stenting 2
  • Proximal left anterior descending (LAD) artery stenting 2
  • Last remaining patent coronary artery 2
  • Multiple stents or long stent length (>60 mm) 2
  • History of stent thrombosis 2

Protective Strategies

• Initiate high-dose proton pump inhibitor (PPI) therapy for all patients with GI bleeding on antithrombotic therapy 2, 1
• Continue PPI therapy for the duration of combined antithrombotic therapy 2
• Consider PPI therapy even when a single antithrombotic agent is used, based on individual GI bleeding risk 2

Important Considerations and Pitfalls

• Discontinuation of aspirin for secondary prevention is associated with a nearly sevenfold increase in risk for death or acute cardiovascular events 1, 6
• All-cause mortality is significantly lower in patients who resume aspirin immediately after endoscopic hemostasis 1
• Avoid unnecessarily prolonged discontinuation of antiplatelet therapy, especially aspirin for secondary prevention 1, 3
• Be aware of potential drug-drug interactions between PPIs and clopidogrel, particularly in Asian populations with high prevalence of CYP2C19 slow metabolizers (25% vs <5% in Western populations) 2, 1
• Platelet transfusions for patients on antiplatelet therapy with GI bleeding have not been shown to reduce rebleeding and may be associated with higher mortality 1, 5

Specific Recommendations for Periendoscopic Management

• For elective procedures with high bleeding risk:
  • For patients on warfarin, consider temporary interruption without bridging unless the patient has a mechanical heart valve 5
  • For patients on DOACs, temporarily interrupt rather than continuing these agents 5
  • For patients on DAPT for secondary prevention, temporarily interrupt the P2Y12 receptor inhibitor while continuing aspirin 5
  • If on cardiac aspirin monotherapy for secondary prevention, do not interrupt aspirin 5