ACG Weighs In on Antithrombotic Use During GI Bleeds, Endoscopy

New practice guidelines from the American College of Gastroenterology and Canadian Association of Gastroenterology (ACG-CAG) offer evidence-based recommendations to manage patients on antithrombotics experiencing acute gastrointestinal (GI) bleeding or who are undergoing elective endoscopy.

Published in the American Journal of Gastroenterology, the guideline focuses on four key aspects in common emergent and elective settings:

• Temporary interruption of anticoagulants and antiplatelets
• Reversal of anticoagulants and antiplatelets
• Periprocedural heparin bridging
• Postprocedural resumption of anticoagulants and antiplatelets

Antithrombotic drugs — such as vitamin K antagonists or warfarin, direct-oral anticoagulants (DOACs), antiplatelet drugs, and acetylsalicylic acid (ASA) — are commonly used to manage atrial fibrillation and ischemic heart disease, among other conditions, but can increase the risk for GI bleeding, according to guideline authors led by Neena Abraham, MD, MSc, of the Mayo Clinic in Scottsdale, Arizona.

“Our aim was to create a focused, pragmatic guideline distilling the published literature to inform clinical practice for the care of patients whose antithrombotic medications put them at risk for acute bleeding and life-threatening hemorrhage or who require routine endoscopic procedures,” said Abraham in a press release.

“Patients are increasingly taking anticoagulants and antiplatelet agents for both treatment and prevention of disease, and with approximately 15 million endoscopic procedures done in the U.S. annually, physicians and patients all need to have clear guidance on the proper management of these medications around the time of endoscopy,” ACG President David Greenwald, MD, of Mount Sinai Hospital in New York City, told MedPage Today.

“All physicians should be familiar with these recommendations, and the summary statements should be on the wall in every office for easy reference,” said Greenwald.

Acute GI Bleeds

The first batch of statements address the management of patients hospitalized or under observation for acute GI bleeding — such as those with overt bleeding manifesting as melena, hematochezia, or hematemesis.

For patients on warfarin, prothrombin complex concentrate (PCC) is suggested if needed, rather than fresh frozen plasma or vitamin K.

Patients on DOACs should not be administered PCC, and those on the direct thrombin inhibitor dabigatran (Pradaxa) should not be administered idarucizumab (Praxbind) — though “selective use” of idarucizumab may be warranted for patients with a life-threatening bleed who took dabigatran within the past day.

Similarly, patients on inhibitors of factor Xa, rivaroxaban (Xarelto) or apixaban (Eliquis), should not receive andexanet alfa (Andexxa). And finally, patients on antiplatelet agents should not receive platelet transfusions.

For GI bleeding patients on cardiac ASA as a secondary prevention, it is not recommended that ASA be held. If ASA was held, however, it should be resumed on the same day of endoscopically confirmed hemostasis.

Elective Endoscopy

Additional statements target patients on antithrombotic agents in the elective endoscopy setting, but who are not at high risk of thromboembolic events.

For those on warfarin, treatment should be continued without any temporary interruption (1 to 7 days).

Bridging anticoagulation is not recommended for patients who have their warfarin held in the periendoscopic period. But “periprocedural bridging may be appropriate in the subset of patients with mechanical valves, atrial fibrillation with CHADS₂ score >5, patients with previous thromboembolism during temporary interruption of [vitamin K antagonists], or those patients undergoing certain types of surgery (e.g., cardiac valve replacement, carotid endarterectomy, and major vascular surgery),” the group noted. “Consultation with a cardiologist and hematologist is recommended in these high-risk thromboembolic patients.”

Patients on DOACs should have their treatment temporarily interrupted prior to endoscopy.

For patients receiving dual antiplatelet therapy as a secondary prevention, P2Y12 receptor inhibitors should be interrupted while ASA should be continued prior to procedures. Insufficient evidence was available for those on a P2Y12 receptor alone. The group also reached no consensus on how soon warfarin, DOACs, or P2Y12 inhibitors should be resumed following interruptions.

For those on cardiac ASA monotherapy (81-325 mg/dL) for secondary prevention, ASA should not be interrupted prior to an elective endoscopy.

Authors incorporated the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to derive their recommendations, though most were conditional due to low certainty of the evidence.

“These guidelines are established to support clinical practice and suggest preferable approaches to a typical patient with a particular medical problem based on the currently available published literature,” wrote Abraham and colleagues. “When exercising clinical judgment, particularly when treatments pose significant risks, healthcare providers should incorporate this guideline in addition to patient-specific medical comorbidities, health status, and preferences to arrive at a patient-centered care approach.”