When to stop or restart antiplatelets and anticoagulation during GI bleed?

Let’s say one of your patients is an 80 year old male with a history of CAD, HTN, HLD, and CKD stage III presenting with nausea and abdominal pain. He also complains of a “choking” sensation for the past week. You notice that his hemoglobin is around 9 g/dL; a couple of months ago it was 13 g/dL. Given his symptoms, you consult GI and he undergoes EGD that shows LA grade C esophagitis and some gastritis that gets biopsied. He is started on a PPI BID, and as you are going through his discharge med list, you wonder if his aspirin, which was held on admission, is safe to be restarted–and if so, when?

Luckily, to this particular scenario, the answer is pretty clear. He doesn’t have a high bleeding risk otherwise, and in patients with CAD, as shown in two meta-analyses cited by this Hospitalist piece, it’s safer to restart aspirin immediately rather than hold it indefinitely. (Aspirin probably didn’t need to be held in the first place.)

Other scenarios are not so clear. What if this wasn’t just a baby aspirin, but warfarin or another agent like dabigatran or apixaban? What if the patient had an NSTEMI and got a stent 3 months ago? What if the bleeding were so severe he was getting daily blood transfusions? In the graphic below, I have tried to show that stopping and resuming antiplatelets and anticoagulation is about weighing benefits of stopping anticoagulation vs. risks of thrombosis for each individual patient–there is no blanket statement that can be made.

Generally speaking, for resuming antiplatelets and anticoagulation, you should do it as soon as hemostasis has been achieved, or when endoscopy shows no active bleeding. The ACC recommends restarting warfarin within 24 hours after hemostasis (on a bridge if needed). There’s no data to support restarting a DOAC within a certain amount of time, but, extrapolating, it’s probably fine to restart within a day.

For information about specific medications and specific endoscopic procedures, the ASGE has an excellent practice guideline published in 2016. Just to entice you, here’s an example of one of the tables:


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