The American College of Gastroenterology and their corresponding Canadian group recently published a new guideline for the management of anticoagulants and antiplatelets during acute GI bleed.
Their recommendations in the setting of ACUTE GI BLEED are as follows:
· For patients on warfarin, they suggest AGAINST giving FFP or Vitamin K; if needed, they suggest PCC compared with FFP. Their review of the data suggests PCC resulted in a quicker resolution of supratherapeutic INR, but no direct comparison of mortality or hemostasis, against FFP or even placebo.
· For patients on DOACs (Apixaban (Eliuquis) Dabigatran (Pradaxa), Rivoraxaban (Xarelto)), they suggest AGAINST PCC administration; they suggest AGAINST direct reversal with idarucizumab in the case of Pradaxa, or andexanet alfa in the case of Eliquis or Xarelto. (Their is a paucity of data regarding their use and thrombotic potential. There appears to be a trend towards improvement of hemostasis, and they do open the door for conditional use in life threatening GI bleed where the DOAC has been taken within 24 hours.
· They suggest AGAINST platelet transfusions for those on platelet inhibitors. (data suggests harm and increased thrombotic events)
· For patients on ASA, they suggest AGAINST holding it; if it has been held, they suggest resumption on the day hemostasis has been endoscopically confirmed.
NOTABLY, all of these recommendations are CONDITIONAL, with LOW TO VERY LOW CERTAINTIES of EVIDENCE.
The guidelines were developed by a working group from the ACG and GAC, including gastroenterologists, cardiologists, and hematologists, who attempted to make an evidenced based approach to these clinical questions, reviewing relevant literature and RCTs.
As an overall summation of the data, there is poor evidence that in ACUTE GI bleed, administration of reversal agents resulted in less bleeding, and have a risk of thromboembolic events. The cited RCTs are mostly with very small n-values (most less than 200), are often manufacturer funded, and mortality and outcomes based data is incredibly limited.
This is obviously a very gross overview. A more detailed discussion can be found in their paper below:
https://pubmed.ncbi.nlm.nih.gov/35368325/