GI bleeding on antiplatelet or anticoagulant therapy

Red Flags

Haemodynamic instability with active GI bleeding on anticoagulation — resuscitate, transfuse, urgent endoscopy; reverse anticoagulation per agent^[1]
Major life-threatening bleed on warfarin (intracranial, ongoing massive haemorrhage) — give 4-factor PCC plus IV vitamin K; do NOT give FFP first-line^[1]
DOAC-associated major bleeding — specific reversal: idarucizumab for dabigatran, andexanet alfa or 4F-PCC for factor Xa inhibitors^[1]
Recent (within 30 days) coronary stent on dual antiplatelet — interrupting P2Y12 risks stent thrombosis; involve cardiology before stopping^[1]

First-line treatment

Interventions

Endoscopic haemostasis^[1]
Within 24 h of presentation. Modalities: clips, thermal coagulation, sclerosant or adrenaline injection, banding for varices. Combination therapy preferred over monotherapy
Restart anticoagulation early^[1]
Resume warfarin or DOAC within 7 days of haemostasis (often within 48–72 h) to balance re-bleeding vs thromboembolism. AF without mechanical valve does not need bridging

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Aspirin (continue)^[1]	Antiplatelet (secondary prevention)	Continue 75–100 mg PO daily during acute bleed if used for secondary CV prevention; if interrupted, resume on day haemostasis is confirmed at endoscopy	—	ACG-CAG suggests AGAINST routine interruption of cardiac aspirin during acute GI bleed; benefits exceed re-bleed risk
Clopidogrel or ticagrelor (interrupt selectively)^[1]	P2Y12 inhibitor	Hold during acute bleed if dual antiplatelet not protecting recent stent; involve cardiology if stent <30 days	—	Resume as soon as haemostasis achieved; bridge with aspirin alone if P2Y12 must be paused after recent stent
4-factor prothrombin complex concentrate (4F-PCC)^[1]	Coagulation factor concentrate	25–50 IU/kg IV (max 5000 IU); INR-guided per local protocol	—	Preferred over FFP for warfarin reversal in major bleeding; rapid INR correction. Co-administer IV vitamin K 10 mg
Idarucizumab^[1]	Dabigatran-specific reversal antibody fragment	5 g IV (two 2.5 g doses given <15 min apart)	—	Use for dabigatran-associated life-threatening bleeding only
Pantoprazole IV^[1]	Proton pump inhibitor	80 mg IV bolus then 8 mg/h infusion for 72 h post high-risk endoscopic stigmata; oral 40 mg BD if low-risk lesion	—	Empirical PPI before endoscopy in upper GI bleed; reduces re-bleed in high-risk ulcers post-endoscopic therapy

Aspirin (continue)^[1]

Antiplatelet (secondary prevention)

Adult: Continue 75–100 mg PO daily during acute bleed if used for secondary CV prevention; if interrupted, resume on day haemostasis is confirmed at endoscopy
Paediatric: —

ACG-CAG suggests AGAINST routine interruption of cardiac aspirin during acute GI bleed; benefits exceed re-bleed risk

Clopidogrel or ticagrelor (interrupt selectively)^[1]

P2Y12 inhibitor

Adult: Hold during acute bleed if dual antiplatelet not protecting recent stent; involve cardiology if stent <30 days
Paediatric: —

Resume as soon as haemostasis achieved; bridge with aspirin alone if P2Y12 must be paused after recent stent

4-factor prothrombin complex concentrate (4F-PCC)^[1]

Coagulation factor concentrate

Adult: 25–50 IU/kg IV (max 5000 IU); INR-guided per local protocol
Paediatric: —

Preferred over FFP for warfarin reversal in major bleeding; rapid INR correction. Co-administer IV vitamin K 10 mg

Idarucizumab^[1]

Dabigatran-specific reversal antibody fragment

Adult: 5 g IV (two 2.5 g doses given <15 min apart)
Paediatric: —

Use for dabigatran-associated life-threatening bleeding only

Pantoprazole IV^[1]

Proton pump inhibitor

Adult: 80 mg IV bolus then 8 mg/h infusion for 72 h post high-risk endoscopic stigmata; oral 40 mg BD if low-risk lesion
Paediatric: —

Empirical PPI before endoscopy in upper GI bleed; reduces re-bleed in high-risk ulcers post-endoscopic therapy

Safety-net

Black tarry stools, vomiting fresh blood or coffee grounds, sudden weakness or fainting — call emergency services immediately^[1]
Do not stop your blood thinner (aspirin, clopidogrel, warfarin, DOAC) on your own — sudden interruption can cause stroke or stent clot. Always talk to your clinician first^[1]
After a GI bleed, you will likely restart blood thinners within a week — the risk of clotting from holding them is generally higher than the risk of re-bleeding^[1]

Referral criteria

Haemodynamic instability or massive haemorrhageEmergency department; activate massive transfusion protocol; urgent endoscopy^[1]
Major bleed on DOAC requiring specific reversalEmergency department for idarucizumab (dabigatran) or andexanet alfa / 4F-PCC (Xa inhibitors)^[1]
GI bleed within 30 days of coronary stent placementCardiology AND gastroenterology joint decision before any antiplatelet interruption^[1]
Recurrent or refractory GI bleeding despite endoscopy and PPIInterventional radiology for arterial embolisation or surgery^[1]

Clinical summary

Management of acute GI bleeding and peri-endoscopic care for patients on antiplatelets or anticoagulants — when to hold, when to reverse, when to resume.

References

1.ACG-CAG Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period (2022); ISG/CSI/IAN/VSI joint position statement (2022) (2022)