Anticoagulants and Antiplatelets During Acute GI Bleeding Clinical Practice Guidelines (ACG/CAG, 2022)

American College of Gastroenterology, Canadian Association of Gastroenterology

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

April 29, 2022

Guidelines on the management of anticoagulants and antiplatelets during acute gastrointestinal bleeding (GIB) and the periendoscopic period were published in April 2022 by the American College of Gastroenterology and the Canadian Association of Gastroenterology (ACG/CAG) in The American Journal of Gastroenterology .[1,2] The guidelines provide recommendations, algorithms, and a dissemination tool to address acute GIB and elective endoscopy as well as indicate when to continue, hold, and resume antithrombotic agents.

Antithrombotic Agents in the Setting of Acute GIB

Vitamin K antagonist reversal

For hospitalized patients or persons under observation with acute GIB who are taking warfarin, the ACG/CAG:

  • Suggest against giving fresh frozen plasma (FFP) or vitamin K

  • Were unable to make a recommendation for or against giving prothrombin complex concentrate (PCC) but suggest administering PCC compared with FFP administration

Direct thrombin inhibitor reversal (dabigatran)

It is suggested against giving idarucizumab to hospitalized patients or persons under observation with acute GIB who are taking dabigatran.

Other agent reversals for inpatients or those being observed with acute GIB

  • Rivaroxaban/apixaban: It is suggested against giving andexanet alfa.

  • Direct oral anticoagulants (DOACs): PCC administration is not suggested.

  • Antiplatelets: It is suggested against giving platelet transfusions.

Acetylsalicylic acid (ASA): Holding versus continuing

For patients with GIB receiving cardiac ASA for secondary prevention whose ASA was held, the ACG/CAG suggest resumption on the day hemostasis is endoscopically confirmed.

Antithrombotic Agents in the Setting of Elective Endoscopy

Anticoagulants: Interrupt or continue

For patients on warfarin who are undergoing elective/planned endoscopic GI procedures, continuing warfarin is suggested, rather than a temporary interruption of 1-7 days. Bridging anticoagulation is suggested against in patients taking warfarin whose warfarin was withheld in the periprocedural period.

For patients taking DOACs who are undergoing elective/planned endoscopic GI procedures, temporary interruption of DOACs is suggested.

Antiplatelets: Interrupt or continue

Those who are on dual antiplatelet therapy for secondary prevention and undergoing elective endoscopic GI procedures are suggested to temporarily interrupt their PGY12 receptor inhibitor while continuing ASA.

No recommendation could be made for or against temporary interruption of the PGY12 receptor inhibitor for those taking single antiplatelet therapy with a PGY12 receptor inhibitor and undergoing elective endoscopic GI procedures.

Patients on cardiac ASA monotherapy (ASA 81-325 mg/day) for secondary prevention are suggested against ASA interruption.

Resuming anticoagulants or P2Y12 receptor inhibitors post endoscopy

No recommendations could be made as to whether interrupted warfarin or DOACs should be resumed on the same day as an elective endoscopy or to wait 1-7 days post procedure.


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