Abraham Neena S, Barkun Alan N, Sauer Bryan G, Douketis James, Laine Loren, Noseworthy Peter A, Telford Jennifer J, Leontiadis Grigorios I
Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, USA.
Division of Gastroenterology, Department of Medicine, McGill University, Montreal, Quebec, Canada.
J Can Assoc Gastroenterol. 2022 Mar 17;5(2):100-101. doi: 10.1093/jcag/gwac010. eCollection 2022 Apr.
We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleeding: For patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy setting: For patients on warfarin, we suggest continuation as opposed to temporary interruption (1-7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y receptor inhibitor for patients on a single P2Y inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1-7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y receptor inhibitor drugs because of insufficient evidence.
我们对预先定义的临床问题进行了系统评价，并采用推荐分级、评估、制定与评价方法，针对急性胃肠道（GI）出血和择期内镜检查时抗凝药及抗血小板药物的围内镜管理制定推荐意见。以下推荐意见针对急性GI出血患者：对于服用华法林的患者，我们建议不要给予新鲜冰冻血浆或维生素K；如有需要，与给予新鲜冰冻血浆相比，我们建议给予凝血酶原复合物浓缩剂（PCC）；对于服用直接口服抗凝剂（DOACs）的患者，我们建议不要给予PCC；如果服用达比加群，我们建议不要给予依达赛珠单抗，如果服用利伐沙班或阿哌沙班，我们建议不要给予安多明；对于服用抗血小板药物的患者，我们建议不要进行血小板输注；对于因二级预防而服用心脏用阿司匹林（ASA）的患者，我们建议不要停用，但如果ASA已经中断，我们建议在通过内镜确认止血的当天恢复用药。以下推荐意见针对择期（计划好的）内镜检查患者：对于服用华法林的患者，我们建议继续用药而非临时中断（1 - 7天），但如果因GI出血风险高的操作而停药，除非患者有机械心脏瓣膜，否则我们建议不要进行桥接抗凝；对于服用DOACs的患者，我们建议临时中断而非继续用药；对于因二级预防而接受双联抗血小板治疗的患者，我们建议临时中断P2Y受体抑制剂，同时继续服用ASA；如果因二级预防而接受心脏用ASA单药治疗，我们建议不要中断用药。在以下情况下证据不足，无法给出推荐意见。对于服用华法林且发生急性GI出血的患者，与安慰剂相比，我们无法推荐是否给予PCC。在择期围手术期内镜检查情况下，对于服用单一P2Y抑制剂的患者，我们无法推荐是否临时中断P2Y受体抑制剂。由于证据不足，我们也无法就服用抗凝药（华法林或DOACs）或P2Y受体抑制剂药物的患者在术后当天恢复用药与术后1 - 7天恢复用药之间给出推荐意见。
