How should I manage a patient with upper GI bleeding who is on anticoagulant therapy?

Management of a patient with upper gastrointestinal bleeding on anticoagulant therapy involves the following key steps:

• Immediately assess the severity of bleeding and resuscitate as needed, including transfusion of blood products according to local massive bleeding protocols.

• For patients actively bleeding and on warfarin, offer immediate prothrombin complex concentrate (PCC) to reverse anticoagulation, and monitor the international normalised ratio (INR) to confirm reversal. Consider further PCC if needed.

• For patients on direct oral anticoagulants (DOACs), refer to MHRA safety advice and NICE guidance on reversal agents such as andexanet alfa for apixaban or rivaroxaban.

• Do not use recombinant factor VIIa except as a last resort when all other methods have failed.

• Once bleeding has stopped, manage warfarin therapy according to local protocols.

• Discuss the risks and benefits of continuing antiplatelet agents such as clopidogrel with appropriate specialists and the patient.

• Offer endoscopy within 24 hours of admission for diagnosis and treatment, with urgent endoscopy immediately after resuscitation in unstable patients.

• Use appropriate endoscopic haemostatic techniques (mechanical clips, thermal coagulation, or fibrin/thrombin with adrenaline) but do not use adrenaline as monotherapy.

• Continue low-dose aspirin for secondary prevention if haemostasis is achieved.

This approach balances urgent reversal of anticoagulation to control bleeding with careful consideration of thrombotic risks and specialist input for ongoing anticoagulant or antiplatelet therapy management.

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