ISSN: 2008-2258
Vol 13, (2020): Supplement1- Winter
An algorithmic approach to gastrointestinal bleeding in patients receiving antithrombotic agents
Gastroenterology and Hepatology from Bed to Bench,
,
,
Page S8-S17
https://doi.org/10.22037/ghfbb.v13i1.2189
Abstract
Gastrointestinal bleeding is an overwhelming complication of patients taking antithrombotic agents. These drugs pose a challenge to physicians in the management of bleeding to establish hemostasis without putting these patients at a higher risk for thromboembolism. This study aims to propose an algorithmic approach to four major groups of patients receiving antithrombotic agents (single antiplatelet agents, dual antiplatelet agents, anticoagulants and direct oral anticoagulants) to decide when and how these drugs should be held or restarted to offset between the risk of re-bleeding and thromboembolism. Four case-based algorithms are proposed in this article based on some relevant articles. Having designed four case-based algorithms, we are hoping to guide physicians who face a dilemma on the management of patients receiving antithrombotics when gastrointestinal bleeding occurs. Patients using antithrombotics referred for gastrointestinal bleeding were stratified into four groups based on the medication which is used as an antithrombotic agent and four algorithms were designed which are presented here. We have made an attempt to have a stepwise approach to four cases relevant to the study and have an evaluation on the management of their antithrombotic agents during an episode of gastrointestinal bleeding. It is widely accepted that antithrombotic agents should be restarted as soon as possible after the establishment of hemostasis in a patient taking antithrombotics referring for gastrointestinal bleeding. The time for resuming these drugs is different based on the severity of bleeding, the probability of thromboembolic events, and the nature of the antithrombotic medication which is used by the patient.
Keywords: Algorithms, Gastrointestinal bleeding, Thromboembolic events, Antithrombotic agents.
(Please cite as: Sadeghi A, Zali MR, Mohaghegh Shalmani H, Ketabi Moghadam P, Rajabnia Chenari M, Karimi MA, et al. An algorithmic approach to gastrointestinal bleeding in patients receiving antithrombotic agents. Gastroenterol Hepatol Bed Bench 2020;13(Suppl.1):S8-S17).
- Algorithms, Gastrointestinal bleeding; Thromboembolic events; Antithrombotic agents
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References
Scott MJ, Veitch A, Thachil J. Reintroduction of anti-thrombotic therapy after a gastrointestinal haemorrhage: if and when? Br J Haematol 2017;177:185-97.
Gimbel ME, Minderhoud SCS, Ten Berg JM. A practical guide on how to handle patients with bleeding events while on oral antithrombotic treatment. Neth Heart J 2018;26:341-51.
Patsias I, Mittal C, Elbatta M, Elbatta M, Garikapati K, Bradley P, et al. Optimal duration to restart warfarin after discontinuation of therapy in atrial fibrillation patients that developed gastrointestinal bleeding. J Am Coll Cardiol 2013;61:E342.
Masoodi M, Zali MR, Ehsani-Ardakani MJ, Mohammad-Alizadeh AH, Aiassofi K, Aghazadeh R, et al. Abdominal pain due to lead-contaminated opium: a new source of inorganic lead poisoning in Iran. Arch Iran Med 2006;9:72-5.
Lee JK, Kang HW, Kim SG, Kim JS, Jung HC. Risks related with withholding and resuming anticoagulation in patients with non-variceal upper gastrointestinal bleeding while on warfarin therapy. Int J Clin Pract 2012;66:64-8.
Valgimigli M, Bueno H, Byrne RA, Byrne RA, Collet JP, Costa F, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2017;39:213-60.
Acosta RD, Abraham NS, Chandrasekhara V, Chathadi KV, Early DS, Eloubeidi MA, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016;83:3-16.
Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015;47:a1-46.
Chan FKL, Goh KL, Reddy N, Fujimoto K, Ho KY, Hokimoto S, et al. Management of patients on antithrombotic agents undergoing emergency and elective endoscopy: Joint Asian Pacific Association of gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines. GUT 2018;67:405-17.
Baghaei K, Shokrzadeh L, Jafari F, Dabiri H, Yamaoka Y, Bolfion M, et al. Determination of Helicobacter pylori virulence by analysis of the cag pathogenicity island isolated from Iranian patients. Dig Liver Dis 2009;41:634-8.
Sung JJ, Lau JY, Ching JY, Wu JC, Lee YT, Chiu PW, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding a randomized trial. Ann Intern Med 2010;152:1-9.
Halvorsen S, Storey RF, Rocca B, Sibbing D, Ten Berg J, Grove EL, et al. Management of antithrombotic therapy after bleeding in patients with coronary artery disease and/or atrial fibrillation: expert consensus paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J 2017;38:1455-62.
Strate LL, Gralnek IM. ACG clinical guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol 2016;111:459-74.
Saito Y, Okada S, Ogawa H, Soejima H, Sakuma M, Nakayama M, et al. Low-dose aspirin for primary prevention of cardiovascular events in patients with type 2 diabetes mellitus: 10-year follow up of a randomized controlled trial. Circulation 2017;135:659-70.
Souk KM, Tamim HM, Abu Daya HA, Rockey DC, Barada KA. Aspirin use for primary prophylaxis: Adverse outcomes in non-variceal upper gastrointestinal bleeding. World J Gastrointest Surg 2016;8:501-7.
Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. GUT 2016;65:374-89.
Ray WA, Chung CP, Murray KT, Smalley WE, Daugherty JR, Dupont WD, et al. Association of proton pump inhibitors with reduced risk of warfarin-related serious upper gastrointestinal bleeding. Gastroenterology 2016;151:1105-12.
Yusuf S, Zhao F, Mehta S. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001;345:494-502.
Zakko L, Rustagi T, Douglas M, and Laine L. No benefit from platelet transfusion for gastrointestinal bleeding in patients taking antiplatelete agents. Clin Gastroenterol Hepatol 2017;15:46-52.
Witt DM, Delate T, Garcia DA, Clark NP, Hylek EM, Ageno W, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med 2012;172:1484-91.
Qureshi W, Mittal C, Patsias I, Garikapati K, Kuchipudi A, Cheema G, et al. Restarting anticoagulation and outcomes after major gastrointestinal bleeding in atrial fibrillation. Am J Cardiol 2014;113:662-68.
Tapaskar N, Pang A, Werner D. A, Sengupta N. Resuming anticoagulation following hospitalization for gastrointestinal bleeding is associated with reduced thromboembolic events and improved mortality: results from a systematic review and meta-analysis. Dig Dis Sci 2020.
Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. apixaban versus warfarin in patients with atrial fibrillation. The N Engl J Med 2011;365:981-92.
Nagata N, Sakurai T, Moriyasu S, Shimbo T, Okubo H, Watanabe K. Impact of INR monitoring, reversal agent use, heparin bridging, and anticoagulant interruption on re-bleeding and thromboembolism in acute gastrointestinal bleeding. PLoS One 2017;12:e0183423.
Giugliano RP, Ruff CT, Braunwald E, Murphy SA, Wiviott SD, Halperin JL. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013;369:2093-104.
Alizadeh AH, Ranjbar M, Ansari S, MirArab A, Alavian SM, Mohammad K, et al. Seroprevalence of hepatitis B in Nahavand, Islamic Republic of Iran. East Mediterr Health J. 2006;12:528-37.
Abraham NS, Singh S, Alexander GC, Heien H, Haas LR, Crown W, et al. Comparative risk of gastrointestinal bleeding with dabigatran, rivaroxaban, and warfarin: population based cohort study. BMJ 2015;350:h1857.
Shokrzadeh L, Baghaei K, Yamaoka Y, Dabiri H, Jafari F, Sahebekhtiari N, et al. Analysis of 3'-end variable region of the cagA gene in Helicobacter pylori isolated from Iranian population. J Gastroenterol Hepatol 2010;25:172-7.
Desai J, Kolb JM, Weitz JI, Aisenberg J. Gastrointestinal bleeding with the new oral anticoagulants defining the issues and the management strategies. Thromb Haemost 2013;110:205-12.
Diep R, Garcia D. Should we monitor the direct oral anticoagulants? J thromb thrombolysis 2020;50:30-2.
Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139-51.
Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365:883-91.
Xu X, Liang Q. Dabigatran monitoring was influencec by thrombin time reagent with different thrombin concentrations. Clin Appl Thromb Hemost 2019;25:1076029619867137.
Halvorsen S, Atar D, Yang H, De Caterina R, Erol C, Garcia D, et al. Efficacy and safety of apixaban compared with warfarin according to age for stroke prevention in atrial fibrillation: observations from the ARISTOTLE trial. Eur Heart J 20014;35:1864-72.
Ikeda K, Tachibana H. Clinical implication of monitoring rivaroxaban and apixaban by using anti-factor Xa assay in patients with non-valvular atrial fibrillation. J Arrhythm 2016;32:42-50.
Erenberg ES, Kamphuisen PW, Sijpkens MK, Meijers JC, Buller HR ,Levi M. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, cross over study in healthy subjects. Circulation 2011;124:1573-79.
Pollack CV Jr, Reilly PA, van Ryn J, Eikelboom JW, Glund S, Bernstein RA, et al. Idarucizumab for dabigatran reversal-full cohort analysis. N Engl J Med 2017;377:431-41.
Marano G, Vaglio S, Pupella S, Liumbruno GM, Franchini M. How we treat bleeding associated with direct oral anticoagulants. Blood Transfus 2016;14:465-73.
Khadzhynov D, Wagner F, Formella S, Wiegert E, Moschetti V, Slowinski T, et al. Effective elimination of dabigatran by hemodialysis. A phase I single-center study in patients with end stage renal disease. Thromb Haemost 2013;109:596-605.
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;37:2893-962.
Rottenstreich A, Zacks N, Kleinstern G, Raccah BH, Roth B, Da'as N, et al. Direct-acting oral anticoagulant drug level monitoring in clinical patient management. J Thromb Thrombolysis 2018;45:543-9.
Martin K, Beyer-Westendorf J, Davidson BL, Huisman MV, Sandset PM, Moll S. Use of the direct oral anticoagulants in obese patients: guidance from the SSC of the ISTH. J Thromb Haemost 2016;14:1308-13.
Moll S, Martin KA. Anticoagulant drug choice in patients who have had bariatric surgery presently, DOACs are not the preferred choice. Thromb Res 2018; 163:196-9.
Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, et al. Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. EP Europace 2013;15:625-51.
Elhosseiny S, Moussawi HA, Chalhoub JM, Lafferty J, and Deeb L. Direct oral anticoagulants in cirrhotic patients: current evidence and clinical observations. Can J Gastroenterol Hepatol 2019;4383269.
Sharifian A, Tavakoli E, Ashtari S, Zali MR. Endoscopic findings in upper gastrointestinal bleeding patients at Tehran’s Taleghani Hospital, Iran. Govaresh 2016;21:260-65.
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