Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines

Dig Dis Sci. 2021 Nov;66(11):3698-3714. doi: 10.1007/s10620-020-06728-y. Epub 2021 Jan 6.

Abstract

Background: Patients receiving anticoagulant therapies, such as vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), commonly experience gastrointestinal (GI) bleeding as a complication and may require anticoagulant reversal prior to endoscopic treatment. Anticoagulant reversal agents include prothrombin complex concentrates (PCCs; including 3 or 4 coagulation factors), plasma, vitamin K, and target-specific DOAC reversal agents (e.g., idarucizumab and andexanet alfa).

Aim: To review current US, as well as international, guidelines for anticoagulant reversal agents in patients on VKAs or DOACs presenting with GI bleeding prior to endoscopy, guideline-based management of coagulation defects, timing of endoscopy, and recommendations for resumption of anticoagulant therapy following hemostasis. Supporting clinical data were also reviewed.

Methods: This is a narrative review, based on PubMed and Internet searches reporting GI guidelines and supporting clinical data.

Results: GI-specific guidelines state that use of reversal agents should be considered in patients with life-threatening GI bleeding. For VKA patients presenting with an international normalized ratio > 2.5, guidelines recommend PCCs (specifically 4F-PCC), as they may exhibit greater efficacy/safety compared with fresh frozen plasma in reversal of VKA-associated GI bleeding. For DOAC patients, most guidelines recommend targeted specific reversal agents in the setting of GI bleeding; however, PCCs (primarily 4F-PCC) are often listed as another option. Resumption of anticoagulant therapy following cessation of GI bleeding is also recommended to reduce risks of future thromboembolic complications.

Conclusions: The utility of anticoagulant reversal agents in GI bleeding is recognized in guidelines; however, such agents should be reserved for use in truly life-threatening scenarios.

Keywords: Andexanet alfa; Anticoagulants; Idarucizumab; Prothrombin complex concentrates.

Publication types

  • Review

MeSH terms

  • Anticoagulants / adverse effects*
  • Blood Coagulation Factors / therapeutic use*
  • Gastrointestinal Hemorrhage / chemically induced*
  • Gastrointestinal Hemorrhage / drug therapy*
  • Humans
  • Practice Guidelines as Topic*
  • Vitamin K / therapeutic use*

Substances

  • Anticoagulants
  • Blood Coagulation Factors
  • Vitamin K