In a patient with active gastrointestinal bleeding, a recent recurrent femoral deep vein thrombosis, who has stopped apixaban and is scheduled for urgent upper and lower endoscopy in two days, is it appropriate to continue a therapeutic heparin drip as bridge anticoagulation?

No, Stop the Heparin Drip Immediately

In a patient with active gastrointestinal bleeding who was on apixaban for recent recurrent DVT, starting a therapeutic heparin drip is contraindicated and should be discontinued immediately. 1, 2

Why Heparin Bridging is Not Indicated

DOACs Do Not Require Bridging

• Guidelines explicitly state: "We do not recommend bridging therapy in patients on DOACs" for periprocedural management, even in high-risk thrombotic situations. 1
• The patient was on apixaban (a DOAC), not warfarin—bridging is only considered for warfarin in specific high-risk scenarios. 1

Active GI Bleeding is a Contraindication to Heparin

• The FDA label for heparin warns: "Avoid using heparin in the presence of major bleeding, except when the benefits of heparin therapy outweigh the potential risks" and specifically lists gastrointestinal ulcerative lesions as conditions with increased hemorrhage risk. 2
• Active GI bleeding dramatically increases the risk of fatal hemorrhage with heparin therapy. 2

What Should Be Done Instead

Immediate Management

• Stop the heparin drip now. 2
• Withhold all anticoagulation until hemostasis is achieved through endoscopy. 1
• Proceed with urgent endoscopy as planned without anticoagulation on board. 1

Risk Stratification for This Patient

Your patient has high thromboembolic risk because the DVT is both recent AND recurrent:

• VTE <3 months qualifies as high thromboembolic risk requiring careful anticoagulation resumption planning. 1, 3
• Recurrent DVT further elevates this risk. 3

Timing of Anticoagulation Resumption After Hemostasis

Once endoscopy achieves hemostasis (stable hemoglobin for 12-24 hours, no transfusion requirement, no active bleeding):

1. Resume apixaban as soon as hemostasis is confirmed—guidelines recommend resumption within 3 days maximum for high thromboembolic risk patients. 1, 3, 4

2. If you need bridging anticoagulation (only if there will be a delay >48 hours before restarting apixaban):

   • Consider therapeutic LMWH starting 48 hours after hemostasis is achieved. 3, 4
   • This is NOT the same as starting heparin during active bleeding—timing is critical. 3

3. The optimal window is 24-48 hours after bleeding control; delays beyond 7 days significantly increase thrombotic risk including recurrent DVT, PE, and mortality. 3, 4

Key Evidence Points

Why Guidelines Reject DOAC Bridging

• Multiple guideline societies (APAGE, APSDE, BSG, ESGE) reached strong consensus that DOACs should be withheld before procedures and resumed after hemostasis WITHOUT heparin bridging. 1
• The pharmacokinetics of DOACs (rapid onset/offset) make bridging unnecessary and potentially harmful. 5, 6

The Mortality Trade-Off

• Resuming anticoagulation after GI bleed reduces thromboembolism by 66-70% but increases rebleeding by 65-91%—however, the net clinical benefit strongly favors resumption in high-risk patients like yours. 3
• Permanently discontinuing anticoagulation increases mortality far more than it reduces rebleeding. 3

Common Pitfalls to Avoid

1. Do not confuse warfarin bridging protocols with DOAC management—heparin bridging is only indicated for warfarin in specific high-risk scenarios (mechanical mitral valve, prosthetic valve with AF, CHADS-VASc >5, VTE <3 months, severe thrombophilia). 1

2. Do not bridge with heparin during active bleeding—this is explicitly contraindicated and increases fatal hemorrhage risk. 2

3. Do not delay anticoagulation resumption beyond 7 days once hemostasis is achieved—this increases thrombotic events including recurrent DVT. 3, 4

4. Do not use aspirin as a substitute—aspirin is inadequate for VTE prevention and only indicated for cardiovascular secondary prevention. 3, 4

Practical Next Steps

• Stop heparin immediately. 2
• Proceed with endoscopy without anticoagulation. 1
• Once hemostasis is documented (stable Hgb ×12-24h, no transfusions, endoscopic confirmation), restart apixaban at the original dose. 1, 3
• If apixaban resumption must be delayed >48 hours for clinical reasons, consider therapeutic LMWH as a bridge starting 48 hours post-hemostasis. 3, 4
• Document the thrombotic risk, bleeding risk, and shared decision-making discussion. 3