Management of Warfarin in Gastrointestinal Bleeding
Interrupt warfarin immediately at presentation for all patients with GI bleeding, and reverse with prothrombin complex concentrate (PCC) plus vitamin K only in cases of unstable or severe hemorrhage. 1
Acute Management Based on Bleeding Severity
Low-Risk or Stable Hemorrhage
- Simply discontinue warfarin without active reversal, as its anticoagulant effect will naturally dissipate over 3-5 days 1
- Do not routinely normalize INR in stable patients, as INR at presentation does not predict rebleeding risk and reversal may delay necessary endoscopy 1
- Endoscopic hemostasis success rates exceed 95% even with INR between 1.5-2.5 1
Unstable or Life-Threatening Hemorrhage
- Administer 4-factor prothrombin complex concentrate (PCC) plus low-dose vitamin K (<5 mg) for immediate reversal 1
- PCC is superior to fresh frozen plasma: no ABO matching required, faster onset, minimal fluid overload risk 1
- Use low-dose vitamin K (<5 mg rather than 5-10 mg) to reduce hypercoagulability risk, especially when early re-anticoagulation is anticipated 1
- The optimal vitamin K dose for INR normalization is 1-2.5 mg based on randomized trial evidence 1
Critical pitfall: Fresh frozen plasma is inferior and should be avoided—it requires ABO matching, has slower onset, and carries higher infection transmission and fluid overload risks 1
Resumption of Anticoagulation: Risk-Stratified Approach
Low Thrombotic Risk Patients
Restart warfarin at day 7 after hemorrhage stops 1
- Starting between days 7-15 reduces thromboembolic events and mortality without increasing rebleeding 1
- Starting before day 7 causes a twofold increase in rebleeding with no significant thromboembolism reduction 1
- Low thrombotic risk includes: standard atrial fibrillation without high-risk features 2
High Thrombotic Risk Patients
Consider low molecular weight heparin (LMWH) bridging at 48 hours after hemostasis 1, 2
High thrombotic risk criteria include: 1
- Prosthetic metal heart valve in mitral position
- Atrial fibrillation with prosthetic heart valve or mitral stenosis
- <3 months after venous thromboembolism
Important nuance: For emergency bleeding situations requiring bridging, use unfractionated heparin rather than LMWH because its shorter half-life (1-2 hours) allows rapid reversal if rebleeding occurs 1
Critical evidence: Resuming anticoagulation provides a mortality benefit—patients who never resume warfarin have significantly increased risk of thrombosis and death 1, 3
Transfusion Thresholds
- Hemoglobin trigger of 70 g/L with target 70-90 g/L for clinically stable patients 1
- Hemoglobin trigger of 80 g/L with target 100 g/L for patients with cardiovascular disease history 1
- Over 80% of transfusions in GI bleeding may be inappropriate or unnecessary 1
Key Clinical Pitfalls to Avoid
Do not give fresh frozen plasma—the 2022 American College of Gastroenterology guidelines suggest against FFP administration in favor of PCC when reversal is needed 4
Do not routinely reverse all elevated INRs—reversal is only indicated for unstable/severe hemorrhage, not mild bleeding with therapeutic INR 1
Do not delay warfarin resumption indefinitely—failure to resume anticoagulation increases mortality from thromboembolism more than the risk of rebleeding 3