title: Reintroduction of anti-thrombotic therapy after a gastrointestinal haemorrhage: if and when?
abstract: Gastrointestinal haemorrhage is a common clinical scenario and, in those using antithrombotic agents, the risk is significantly increased. Management of these patients, in terms of initial resuscitation is well established and numerous guidelines exist in this area. However, few studies have addressed the subsequent dilemma of if and when antithrombotic agents should be reintroduced. Consequently, practice is variable and not necessarily evidenced-based. Overall, for patients that are either anticoagulated or using antiplatelet drugs for secondary prophylaxis, there is a clear benefit to restarting these agents. However, there is limited data to guide when this should occur. For individuals at low risk of re-bleeding, current guidelines suggest single agent aspirin can be continued without interruption, assuming haemostatic control has been confirmed endoscopically. For those at higher bleeding risk, aspirin should be withheld, but reintroduced early (within 3 days of index endoscopy). However, randomised evidence is lacking, as are studies including more modern agents or combined anticoagulant/ antiplatelet regimens. As such, guidance statements are limited and management suggestions must be extrapolated from clinical trials, retrospective studies and data relating specifically to warfarin and aspirin. The intention of this review is to summarise what evidence is available and, where this is lacking, suggest pragmatic management options based on a risk-benefit assessment of thromboembolism and recurrent bleeding.
authors.affiliation: Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
authors.forename: Martin J
authors.identifier: 0000-0002-0854-1309
authors.initials: MJ
authors.lastname: Scott
authors.affiliation: Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Veitch
authors.affiliation: Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
authors.forename: Jecko
authors.initials: J
authors.lastname: Thachil
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D006471:Gastrointestinal Hemorrhage / Q000188:drug therapy*; D006801:Humans; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors
keywords: anticoagulants; antiplatelet agents; antithrombotics; gastrointestinal haemorrhage