In patients on DAPT, continue aspirin only during periendoscopic period, states ACG/ CAG guideline
USA: A recent study published in the Journal of the Canadian Association of Gastroenterology has reported clinical practice guidelines on the management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. The guideline was developed by the American College of Gastroenterology (ACG) in association with the Canadian Association of Gastroenterology (CAG).
Antithrombotic drugs including vitamin K antagonists, direct oral anticoagulants, antiplatelet drugs such as the P2Y12 receptor inhibitors, and acetylsalicylic acid (ASA) are used in the management of patients with ischemic heart disease, atrial fibrillation, venous thromboembolism, and valvular heart disease. But the use of these drugs also increases the risk of gastrointestinal (GI) bleeding from luminal sources such as ulcers or diverticula and after endoscopic procedures. There is a dearth of standardized, evidence-based protocols to inform best practices before and after endoscopic procedures in urgent and elective settings. Furthermore, uncertainty regarding best practice recommendations and associated levels of evidence has led to significant variation in adherence to guideline-directed practices.
Against the above backdrop, Neena S Abraham and colleagues proposed an evidence-based approach to periprocedural antithrombotic drug management in common emergent and elective settings addressing clinical questions related to (i) temporary interruption of anticoagulant and antiplatelet drugs; (ii) reversal of anticoagulant and antiplatelet drugs; (iii) periprocedural heparin bridging; and (iv) postprocedural resumption of anticoagulant and antiplatelet drugs.
To develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute GI bleeding and the elective endoscopic setting, the authors conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development, and Evaluations approach.
Based on the systematic review, the following recommendations were developed:
Management of antithrombotic agents in the setting of acute GI bleed
- For patients on warfarin who are hospitalized or under observation with acute GI bleeding, the authors suggest against FFP administration.
- For patients on warfarin who are hospitalized or under observation with acute GIB, a recommendation for or against PCC administration could not be reached.
- For patients on warfarin who are hospitalized or under observation with acute GIB, the authors suggest PCC administration compared with FFP administration.
- For patients on warfarin who are hospitalized or under observation with acute GIB (upper and/or lower), the authors suggest against the use of vitamin K.
- For patients on dabigatran who are hospitalized or under observation with acute GIB, the authors suggest against the administration of idarucizumab.
- For patients on rivaroxaban or apixaban who are hospitalized or under observation with acute GIB, the authors suggest against andexanet alfa administration.
- For patients on DOACs who are hospitalized or under observation with acute GIB, the authors suggest against PCC administration.
- For patients on antiplatelet agents who are hospitalized or under observation with acute GIB, the authors suggest against platelet transfusions.
- For patientswithGIbleeding oncardiacASAfor secondary prevention, the authors suggest against holding the ASA.
- For patients with GI bleeding on ASA for secondary cardiovascular prevention whose ASA was held, the authors suggest the ASA be resumed on the day hemostasis is endoscopically confirmed.
Management of antithrombotic agents in the elective endoscopy setting
- For patients on warfarin undergoing elective/planned endoscopic GI procedures, the authors suggest warfarin be continued, as opposed to temporarily interrupted (1–7 d).
- For patients on warfarin, who hold warfarin in the periprocedural period for elective/planned endoscopic GI procedures, the authors suggest against bridging anticoagulation.
- For patients on DOACs who are undergoing elective/planned endoscopic GI procedures, the authors suggest temporarily interrupting DOACs rather than continuing DOACs.
- For patients on dual antiplatelet therapy for secondary prevention who are undergoing elective endoscopic GI procedures, the authors suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA.
- For patients on single antiplatelet therapy with a P2Y12 receptor inhibitor who are undergoing elective endoscopic GI procedures, the authors could not reach a recommendation for or against temporary interruption of the P2Y12 receptor inhibitor.
- For patients on ASA 81–325 mg/d (i.e., cardiac ASA monotherapy) for secondary prevention, the authors suggest against interruption of ASA.
- In patients who are undergoing elective endoscopic GI procedures whose warfarin was interrupted, a recommendation for or against resuming warfarin the same day vs 1–7 d after the procedure could not be reached.
- In patients who are undergoing elective endoscopic GI procedures whose DOAC was interrupted, a recommendation for or against resuming the DOAC on the same day of the procedure vs 1–7 d after the procedure could not be reached.
- In patients who are undergoing elective endoscopic GI procedures whose P2Y12 inhibitor was interrupted, a recommendation for or against resuming P2Y12 inhibitor on the same day of the procedure vs 1–7 d after the procedure could not be reached.
"We did not identify a study comparing the timing of DOAC resumption proposed in this recommendation. Hence, the panel was unable to make a recommendation," wrote the authors.
"Decisions regarding resumption of DOAC therapy should consider the rapid onset of action, achievement of adequate hemostasis at the time of the procedure, the risk of delayed bleeding for the endoscopic procedure performed, the patient's risk of thrombosis, and patient preferences in consultation with a cardiologist and hematologist."
Reference:
Neena S Abraham, MD, MSc (Epi), FACG, Alan N Barkun, MD, MSc (Epi), FACG, CAGF, Bryan G Sauer, MD, MSc (Clin Res), FACG, James Douketis, MD, Loren Laine, MD, FACG, Peter A Noseworthy, MD, Jennifer J Telford, MD, MPH, FACG, CAGF, Grigorios I Leontiadis, MD, PhD, CAGF, American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period, Journal of the Canadian Association of Gastroenterology, 2022;, gwac010, https://doi.org/10.1093/jcag/gwac010
KEYWORDS: Journal of the Canadian Association of Gastroenterology, anticoagulants, antiplatelets, gastrointestinal bleeding, periendoscopic period, vitamin K antagonists, direct oral anticoagulants, Neena S Abraham, American College of Gastroenterology, Canadian Association of Gastroenterology, DOAC, warfarin, DAPT, aspirin
