Since their launch in 2008, the new direct oral anticoagulants (DOACs) have been increasingly prescribed in clinical practice, gradually replacing anti-vitamin K (warfarin) agents in the prevention of thromboembolic events in non-valvular atrial fibrillation, and in the treatment and prevention of deep thrombophlebitis. Their efficacy has been supported by several clinical trials [1].

These anticoagulants are factor Xa or anti-Xa inhibitors, and therefore inhibit the main coagulation pathway. They have the advantage of a rapid and powerful action compared with warfarin therapy. They also do not require biological monitoring of anticoagulation levels.

A meta-analysis concluded that DOACs cause as much serious bleeding as warfarin therapy. However, they are more associated than warfarin with gastrointestinal bleeding, particularly gastroduodenal bleeding [1]. This bleeding remains a frequent cause of admission to emergency departments.

The occurrence of gastrointestinal bleeding on anticoagulants should prompt discussion of temporary discontinuation of the anticoagulant and correction of the coagulopathy, depending on the severity of the bleeding and the patient's thrombotic risk. This management must be coordinated between the emergency physician, cardiologist and gastroenterologist. It is important to note the time of the last DOACs dose, as DOACs generally lose their anticoagulant activity within 12 to 24 hours, given their relatively short half-life. Thus, most gastrointestinal bleeding can be managed by stopping the DOACs and waiting for the anticoagulant effects to wear off. Severe gastrointestinal bleeding may require plasma residual levels of DOACs, transfusion of haemostatic concentrates and, in certain situations, administration of specific antidotes or even haemodialysis. It should be noted that the DOACs antagonist, used in cases of severe acute gastrointestinal bleeding, may increase the risk of thromboembolism. To date, few scientific data are available to assess this risk.

In all cases, the correction of coagulopathy should not delay digestive endoscopy, or endoscopic or radiological hemostasis.

Digestive endoscopy has made progress in the management of gastrointestinal bleeding.

In the case of upper gastrointestinal bleeding, endoscopy enables lesion diagnosis, endoscopic haemostasis and assessment of the risk of haemorrhagic recurrence. However, despite advances in medical and endoscopic management, morbidity and mortality remain high. This is particularly true of associated comorbidities and treatments, notably anticoagulants in the elderly [2].

Once gastrointestinal bleeding has been controlled, the timing of resumption of anticoagulant therapy with DOACs - within 7 days or sooner - depends largely on the patient's thromboembolic risk [3].

The difficulty in managing gastrointestinal bleeding associated with DOACs lies in assessing the risk of bleeding (or recurrence of bleeding) and thromboembolism. These are two life-threatening events on which the morbidity and mortality of gastrointestinal bleeding in these patients largely depend. The widespread use of these new anticoagulants is prompting clinicians to be vigilant in prescribing them, to avoid complications such as gastrointestinal bleeding. Studies on the management of gastrointestinal bleeding associated with DOACs are still to come, with the development of antidotes.

References :

 [1] Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, and al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383:955-62.

[2] Abrignani MG, Gatta L, Gabrielli D, Milazzo G, De Francesco V, De Luca L, and al. Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO). Eur J Intern Med. 2021 Mar;85:1-13. doi: 10.1016/j.ejim.2020.11.014.

[3] Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, and al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy. 2021.