Optimal timing of vitamin K antagonist resumption after upper gastrointestinal bleeding

Abstract

The optimal timing of vitamin K antagonists (VKAs) resumption after an upper gastrointestinal (GI) bleeding, in patients with continued indication for oral anticoagulation, is uncertain. We included consecutive cases of VKA-associated upper GI bleeding from three hospitals retrospectively. Data on the bleeding location, timing of VKA resumption, recurrent GI bleeding and thromboembolic events were collected. A model was constructed to evaluate the 'total risk', based on the sum of the cumulative rates of recurrent GI bleeding and thromboembolic events, depending on the timing of VKA resumption. A total of 121 (58 %) of 207 patients with VKA-associated upper GI bleeding were restarted on anticoagulation after a median (interquartile range) of one (0.2-3.4) week after the index bleeding. Restarting VKAs was associated with a reduced risk of thromboembolism (HR 0.19; 95 % CI, 0.07-0.55) and death (HR 0.61; 95 % CI, 0.39-0.94), but with an increased risk of recurrent GI bleeding (HR 2.5; 95 % CI, 1.4-4.5). The composite risk obtained from the combined statistical model of recurrent GI bleeding, and thromboembolism decreased if VKAs were resumed after three weeks and reached a nadir at six weeks after the index GI bleeding. On this background we will discuss how the disutility of the outcomes may influence the decision regarding timing of resumption. In conclusion, the optimal timing of VKA resumption after VKA-associated upper GI bleeding appears to be between 3-6 weeks after the index bleeding event but has to take into account the degree of thromboembolic risk, patient values and preferences.

The effects of anticoagulant therapy re‐initiation after gastrointestinal bleeding: A systematic review and meta‐analysis

“…We evaluated the incidences of different gastrointestinal bleeding levels in six studies. [25][26][27][28]33,34 We found a pooled odds ratio of 2.4…”

“…However, since the publication of these reviews, several high-quality cohort studies have been published. 27,28,33,34 As a result, an updated knowledge synthesis in terms of a systematic review and meta-analysis is strongly warranted. Therefore, with this systematic review and meta-analysis, we want to compare the evidence on the effects of continuation and discontinuation of anticoagulant/antithrombotic drugs after gastrointestinal bleeding on the overall incidences of gastrointestinal bleeding, thromboembolic events and mortality events.…”

Restarting oral anticoagulant therapy after major bleeding in atrial fibrillation: A systematic review and meta-analysis

“…weeks [27]. Currently, our meta-analysis does not provide evidence to specifically support a time frame for restarting OAC, and any decision making on restarting OAC needs to balance the risks of adverse outcomes.…”

“…Other two studies by the same group tried to investigate in two heterogeneous cohorts, the optimal timing of OAC resumption after ICH and GIB [26,27]. In the first paper, enrolling 234 patients with an ICH (58% with AF as indication for OAC), the authors found out that the combined risk of a recurrent ICH and an ischemic event reached a nadir when OAC was restarted between 10 and 30 weeks [26]; in the second paper, a risk modelling analysis based on 207 patients (63%) with a GIB event, found that the nadir between the recurrent bleeding and thromboembolic occurrence risk was reached restarting the OAC between 3 and 6…”

Bleeding Complications and Management on anticoagulant therapy

“…In a multicenter, retrospective study of 207 cases with warfarinassociated upper gastrointestinal bleeding, 121 patients resumed anticoagulation. 52 For equal disutility of gastrointestinal bleeding and stroke, the optimal timing would be between 3 and 6 weeks after the index event. For a disutility 2.1 to 3.1 times higher for stroke than for gastrointestinal bleeding, as concluded from a systematic review of values and preferences, 53 the optimal timing could be between 1 and 3 weeks, but earlier resumption will result in more recurrences of gastrointestinal bleeding with renewed interruption of anticoagulation.…”