Anticoagulant‐associated gastrointestinal bleeding: Framework for decisions about whether, when and how to resume anticoagulants

Abstract

Gastrointestinal (GI) bleeding is the most frequent single site of oral anticoagulant (OAC)‐associated major bleeding. Patients with major GI bleeding experience morbidity and a substantial risk of short‐term all‐cause mortality up to 10%. While OACs are frequently discontinued during acute bleeding, there is substantial uncertainty about whether, when, and how OACs should be resumed after bleeding has resolved. Limited evidence suggests a lower risk of thromboembolism and death, and a higher risk of recurrent bleeding with OAC resumption. However, the absolute risks and optimal timing of anticoagulation remain uncertain based on these observational studies at risk of bias, particularly due to baseline confounding. In addition to an individualized approach to determining the benefits and harms of treatment decisions informed by the best available evidence about thrombosis and recurrent bleeding, discussions should meaningfully incorporate patient values and preferences. The objective of this review is to provide a framework for decision‐making by summarizing the epidemiology and clinical outcomes of OAC‐associated GI bleeding, providing an approach for assessment and risk stratification for OAC resumption and its timing, and outlining strategies for the prevention of recurrent GI bleeding.

Resumption of anticoagulant therapy after major bleeding and the risk of negative events in patients with atrial fibrillation (based on REGistry of Long-term AnTithrombotic TherApy-2 – REGATA)

“…Важно понимать, что риск повторного кровотечения не нивелируется в случае отказа от АКТ, так, обсервационные исследования свидетельствуют о риске рецидива кровотечений с частотой 3-5% в течение 90 дней после желудочно-кишечного кровотечения у этой категории больных [14]. В нашем исследовании у больных, которым не возобновили АКТ, рецидивов кровотечений не было, что, вероятно, связано с небольшим объемом выборки.…”

All-cause mortality after major gastrointestinal bleeding among patients receiving direct oral anticoagulants: a protocol for a systematic review and meta-analysis

“…Clinical discussions around the risks and benefits of anticoagulation focus on both prevention of vascular and bleeding risks. Bleeding related risk remains understudied, and a true understanding of mortality associated with GI bleeding would be of utility in clinical decision making [ 26 ]. In addition to discussions of anticoagulation initiation, restarting anticoagulation after a GI bleed is an area of ongoing study with substantial practice variation [ 27 ].…”

DOAC — not for everyone, and sometimes at different dose

“…As a rule, re-initiation of treatment is associated with expected lower risk of thrombosis and death, but at the same time with the higher risk of recurrent bleeding. Careful consideration of the benefits and risks is crucial [20].…”