The ACG and Canadian Association of Gastroenterology have developed recommendations for the management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the elective periendoscopic period.

“We aimed to bring together clinical content and methodological experts in gastrointestinal endoscopy and GI bleeding, hematology, and cardiology to create pragmatic, principle-based guidance related to managing antiplatelet and anticoagulant drugs before endoscopy and in the setting of gastrointestinal bleeding,” Neena S. Abraham, MD, MSc (Epi), FACG, of the Mayo Clinic in Scottsdale, Arizona, told Healio. “In this important update, we critically evaluated the published literature related to temporary interruption and resumption of these agents and the use of reversal agents. Clinicians can have confidence in our recommendations based on the unprecedented rigor used in evaluating the literature and the multidisciplinary perspective addressing common clinical scenarios.”

Guidelines for the management of antithrombotic agents in the setting of acute GI bleed include:

• Fresh frozen plasma (FFP) administration should not be used in patients on warfarin who are either hospitalized or under observation with acute GI bleeding.
• Prothrombin complex concentrate (PCC) administration is neither recommended nor not recommended.
• PCC administration is recommended in patients on warfarin who are hospitalized or under observation for a GI bleed, compared with FFP administration.
• Vitamin K is not recommended in these patients.
• Idarucizumab should not be administered in patients on dabigatran.
• Andexanet alfa should not be administered in patients on rivaroxaban or apixaban.
• PCCs should not be administered in patients on direct oral anticoagulants (DOACs).
• Platelet transfusions are not recommended in patients on antiplatelet agents.
• In patients with GI bleeding on cardiac acetylsalicylic acid (ASA) for secondary prevention, ASA should not be held; however, in patients whose ASA was held, ASA should be resumed on the day hemostasis is endoscopically confirmed.

Guidelines for the management of antithrombotic agents in the elective endoscopic setting include:

• Warfarin should be continued rather than temporarily interrupted.
• In patients who held warfarin in the periendoscopic period, bridging anticoagulation is not recommended.
• DOACs should temporarily be interrupted rather than continued.
• P2Y12 receptor inhibitor should be temporarily interrupted while continuing ASA in patients on dual antiplatelet therapy for secondary prevention.
• ASA should not be interrupted in patients on ASA 81–325 mg/d for secondary prevention.