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Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines

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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.

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Funding

Editorial assistance was provided by Hanna Mourad-Agha of Fishawack Communications Ltd, funded by CSL Behring.

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Authors and Affiliations

  1. Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX, USA

    Truman J. Milling

  2. Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA

    Majed A. Refaai

  3. Section of Gastroenterology Hepatology and Nutrition, The University of Chicago, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA

    Neil Sengupta

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TJM has received consulting fees and/or research funding from CSL Behring, Portola, Boehringer Ingelheim, Genentech, and Octapharma, and has received speaking fees from Janssen. His institutional salary is supported by a grant from the National Heart, Lung and Blood Institute. He serves on the executive committee for the ANNEXA4 and ANNEXA-I trials, the steering committee for the Lex-209 trial, and the publications committee for the Kcentra trials. MAR has received consulting fees and/or research funding from CSL Behring, Portola, Boehringer Ingelheim, Octapharma, Bayer, Instrumentation Laboratory, and iLine microsystems, and has received speaking fees from CSL Behring. NS has received consulting fees from Portola.

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Milling, T.J., Refaai, M.A. & Sengupta, N. Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines. Dig Dis Sci 66, 3698–3714 (2021). https://doi.org/10.1007/s10620-020-06728-y

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