Gastroenterologists Can Do Better at Managing Antithrombotics

David A. Johnson, MD


April 14, 2022

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Kudos to Dr Neena Abraham and her expert panel, who worked on recent guidelines published by the American College of Gastroenterology and the Canadian Association of Gastroenterology on the management of anticoagulation and antiplatelet therapy during acute gastrointestinal (GI) bleeding and the periendoscopic period.

This is something that's incredibly pertinent to day-to-day practice, where we frequently encounter patients with an acute GI bleed. This may even bring us in direct conflict with cardiologists or neurovascular prescribers of these agents. We might say that, given the GI bleed, we need to stop these therapies. They, in turn, would say we can't stop these therapies because the risks are too high.

I think the evidence has really evolved in favor of the latter approach. As gastroenterologists and interventional endoscopists, we need to embrace this change. To do so, let me put these guidelines in perspective.

Managing Antithrombotics and GI Bleeds

One of the first points noted in these guidelines represents a reversal of sorts. The authors recommend that if patients on warfarin present with an acute GI bleed, fresh frozen plasma should not be administered. This is something we've talked about previously in patients with cirrhosis, in whom evidence suggests that fresh frozen plasma is never really going to be helpful.

In the case of patients who are noncirrhotic, the recommendation here is against reversal with fresh frozen plasma or the administration of prothrombin complex concentrate. This is due to the downstream risk of thromboembolic events, which the guidelines review.

Although the recommendation was relatively weak, it was nonetheless offered. The exception is when there is an active, life-threatening–type bleed.

The same is true as it relates to the antiplatelet agents, direct thrombin inhibitors, or factor Xa inhibitors.

When it comes to these new treatments that allow us to reverse such things, or even traditional means whereby we may give platelet transfusions, the recommendation was not to do that. Again, the downstream risk was felt to be too high.

The same was true of patients taking aspirin. Stopping aspirin in the setting of a secondary prevention risk was not felt to be necessary. Although certainly, early restart of this is important.

Considerations During Endoscopic Procedures

Regarding continued prophylaxis in patients undergoing endoscopic procedures, I think the recommendations pretty much reflect current practice.

The exception is around the use of warfarin, which they recommended not stopping unless, perhaps, a patient has a mechanical heart valve. They suggest not using bridge therapy if you decide to stop the warfarin in any other circumstance than that reason. Those patients would be referred to their primary prescriber.

When it comes to antiplatelet interruption vs continuation, the recommendation was that a brief interruption of these therapies a day before is reasonable. It's not inferior but should be started again in concert with the prescriber and never interrupted without the prescriber's agreement.

The authors didn't give us great guidance about the timing of restarting treatment, suggesting that it take place from 1 day to 7 days. I typically tell my patients to restart it the day of or the day after, depending on when they take it and what the level of intervention was.

These things always come back to our first rule, which is to do no harm. So, if there is an acute GI bleed, the patient's thromboembolic risk needs to be weighed against their continued bleed risk, and the same as it relates to the intervention for an endoscopy.

Risks for Stent Thrombosis

We're learning more about the thromboembolic risk in these circumstances, particularly in patients who have primary coronary intervention. The most recent data suggest that if a patient comes in within 30 days of an acute stent thrombosis, the relative mortality is approximately 75%. And that's for mortality, not just stent thrombosis.

So, when we start to do acute GI bleeding interventions in our patients with acute stents, we need to understand this. Our cardiologist colleagues used to beat us over the head about this, warning us that we can't just stop these agents, to which we'd respond that we just had an acute GI bleed.

We, as gastroenterologists, need to control hemostasis and do as definitive an intervention as we can. However, we also must recognize that we really can't stop these antithrombotic therapies for stent occlusion. This is important. That 30-day mortality rate we just talked about is inordinately high for an acute coronary thrombosis for stent occlusion. And it's the same as it relates to anticoagulation. We need to know what the relative risks are.

Getting Comfortable With Interventions on Therapy

We also need to understand that we can do a lot of these interventions, particularly endoscopic interventions, [with patients] on therapy. I find that patients are kept in the hospital for a period of time because they need a Plavix or a clopidogrel washout, or they're not adequately cleaned by their platelet in aggregation.

That's just ridiculous. They need to be done as quickly as they can. They can always come back. If you have a large polyp, you need to bring them back. I always tell my patients upfront, "If we find something, we have to bring you back."

I think we need to step up and be more appropriately aggressive in treating these patients on therapy. There are emerging data relating to discontinuation of the dual anticoagulation therapy the day of treatment, which comes from endoscopic treatments performed in Japan. I think that data are strong, albeit still preliminary.

With cold snare polypectomy, I'm very confident that we can treat such patients more aggressively for diminutive lesions while on therapy. They don't really miss a beat. If there's a mild acute GI bleed, it can be recognized, and flushing or clipping it precludes most of the ongoing bleed in these patients in the absence of a significant additional intervention. I think that there's virtually zero risk for delayed hemorrhage in these patients if you use cold snare polypectomy.

We Need to Do Better

As gastroenterologists, we need to do better. We need to understand that these direct interventions are a problem.

A few years ago, in collaboration with several national experts, we looked at the downstream consequences of 30-day admission/readmission or emergency room evaluation for patients undergoing endoscopic procedures. We found that if they were on antiplatelet or anticoagulation therapy, there was an approximately 11 times increase in the odds ratio that they would have to come back within 30 days.

As gastroenterologists, we would frequently not see these patients, as they'd come back to a cardiologist, pulmonologist, or hospitalist. We wouldn't see them as a GI complication, but they really are because we interrupted the therapy.

We have a significant risk associated with our interventions. We need to be more aware that the interruption of anticoagulation and antiplatelet therapy may be a more consequent risk. We need to be better stewards of the risk-benefit assessments for these patients.

Please talk to your prescribers. Don't stop these therapies without their specific input and direction. Hopefully, this leads to better outcomes for patients.

I'm Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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