What is the treatment approach for a patient with pulmonary embolism (PE) and gastrointestinal (GI) bleeding?

From the Guidelines

The management of a patient with pulmonary embolism (PE) and gastrointestinal (GI) bleeding should prioritize stabilization of both conditions, with careful consideration of anticoagulation therapy to balance the risks of thrombosis and hemorrhage. Initially, stabilize the patient by addressing hemodynamic status, providing oxygen support, and assessing the severity of both conditions. For the PE, therapeutic anticoagulation is typically required, but must be modified due to active GI bleeding. Consider placing an inferior vena cava (IVC) filter temporarily if the PE is life-threatening and GI bleeding precludes immediate anticoagulation. Once the GI bleeding is controlled, start with a lower intensity anticoagulation regimen such as unfractionated heparin at 12-15 units/kg/hour without a bolus, with close monitoring of aPTT (target 1.5-2 times normal) 1. Identify and treat the source of GI bleeding through endoscopy, and provide supportive care including blood transfusions if hemoglobin drops below 7-8 g/dL. After bleeding stabilizes for 48-72 hours, transition to therapeutic anticoagulation with either low molecular weight heparin (enoxaparin 1 mg/kg twice daily) or direct oral anticoagulants, but edoxaban should be considered as an alternative to weight-adjusted subcutaneous LMWH in patients without gastrointestinal cancer 1. The duration of anticoagulation typically ranges from 3-6 months depending on PE etiology, and for patients with PE and cancer, extended anticoagulation (beyond the first 6 months) should be considered for an indefinite period or until the cancer is cured 1. This approach balances the competing risks of thrombosis and hemorrhage while addressing both life-threatening conditions. Some studies suggest the use of apixaban or rivaroxaban as an alternative to LMWH for outpatient treatment of PE 1, but the most recent and highest quality study recommends the use of edoxaban in patients without gastrointestinal cancer 1. Key considerations in the management of these patients include:

• Stabilization of hemodynamic status
• Assessment of the severity of both PE and GI bleeding
• Temporary placement of an IVC filter if necessary
• Lower intensity anticoagulation regimen initially
• Transition to therapeutic anticoagulation after bleeding stabilizes
• Consideration of extended anticoagulation in patients with cancer.

From the FDA Drug Label

The recommended dose of apixaban tablets for the treatment of PE is 10 mg taken orally twice daily for the first 7 days of therapy. After 7 days, the recommended dose is 5 mg taken orally twice daily. The patient with pulmonary embolism should be treated with apixaban 10 mg orally twice daily for the first 7 days, then 5 mg orally twice daily.

• For a patient with GI bleeding, the treatment should be individualized, and the decision to continue or stop anticoagulation should be based on the risk of thromboembolic events versus the risk of bleeding.
• The patient's condition and the severity of the GI bleeding should be closely monitored, and the anticoagulation therapy should be adjusted accordingly 2.

From the Research

Treatment of Pulmonary Embolism with GI Bleeding

• The treatment of patients with pulmonary embolism (PE) and gastrointestinal (GI) bleeding is complex and requires careful consideration of the risks and benefits of anticoagulation therapy 3.
• In patients with nonmassive PE and a high risk of bleeding, such as those with GI bleeding, withholding treatment may be a possible strategy if serial noninvasive leg tests are negative and cardiopulmonary reserve is adequate 3.
• However, the use of anticoagulants, such as direct oral anticoagulants (DOACs), is generally recommended for the treatment of PE, as they have been shown to be effective in reducing the risk of recurrent PE and have a lower risk of bleeding compared to traditional anticoagulants 4, 5, 6.
• In patients with PE and GI bleeding, the use of DOACs may be preferred due to their lower risk of bleeding and practical advantages, such as fixed dosage and no need for routine monitoring 4, 6.
• Thrombolytic therapy may be considered in patients with hemodynamically unstable PE and a low bleeding risk, but its use is not recommended in patients with GI bleeding due to the high risk of bleeding complications 5, 7.

Management of GI Bleeding in Patients with PE

• The management of GI bleeding in patients with PE requires careful consideration of the underlying cause of the bleeding and the patient's overall clinical condition 3, 5.
• In patients with GI bleeding and PE, the use of endoscopy and other diagnostic tests may be necessary to determine the source of the bleeding and guide treatment 6.
• The treatment of GI bleeding in patients with PE may involve the use of medications, such as proton pump inhibitors, and/or endoscopic therapies, such as cauterization or clipping 5, 6.
• In some cases, surgical intervention may be necessary to control the bleeding and prevent further complications 5, 7.