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A 58-year-old woman is admitted to the hospital for hematemesis of 2 days' duration; she has also been experiencing weakness and dyspnea on exertion for 1 day. Medical history is significant for recurrent deep venous thrombosis, for which she receives chronic anticoagulation. Her only medication is warfarin to maintain an INR of 2-3, although she has not taken this medication since the onset of her symptoms because of vomiting.

On physical examination, temperature is 36.7°C (98.0°F), blood pressure is 115/62 mm Hg, pulse rate is 102/min and regular, and respiration rate is 14/min. The patient appears pale. Cardiac examination reveals mild tachycardia. The abdomen is soft, and bowel sounds are present.

Laboratory studies:

Hematocrit

23%

Hemoglobin

7.8 g/dL (78 g/L)

Platelet count

256,000/μL (256 x 109/L)

INR

1.3

Serum creatinine

1.0 mg/dL (88.4 μmol/L)

Serum aminotransferases

Normal

A fecal occult blood test is guaiac positive. Esophagogastroduodenoscopy shows a single duodenal ulcer with a clot and without active bleeding.

Warfarin is held. An intravenous proton pump inhibitor is started.

Q.

Which of the following is the most appropriate management option for this patient's anticoagulation following resolution of her gastrointestinal bleeding?

The most appropriate management for this patient is to restart warfarin after discharge when her acute gastrointestinal (GI) bleeding has resolved, but without waiting for a specified time period. The patient has a solitary ulcer as a source of bleeding, although the ulcer was no longer bleeding under direct visualization. Warfarin is used to manage recurrent thromboembolism, and patients who take anticoagulation therapy have a clearly increased risk for GI bleeding. A recent retrospective study involving 442 patients examined outcomes with different anticoagulation strategies in patients taking chronic warfarin therapy for prevention of recurrent thromboembolism who experienced GI bleeding. Approximately half of this group resumed warfarin within 90 days of GI bleeding, while the other half had warfarin therapy withheld for at least 90 days following bleeding. A statistically significant increase in thrombotic complications was seen in the group in whom warfarin was withheld for 90 days following GI bleeding, but no significant increase in bleeding risk was noted in those who resumed warfarin therapy within 90 days of GI bleeding. Based on this information, it appears reasonable to restart anticoagulation with warfarin after the bleeding event has been stabilized and treated. Although the exact timing for restarting anticoagulation after a recent bleeding episode is not well defined, this decision is typically made by balancing the circumstances of the bleed and the overall risk associated with anticoagulation. This study suggests holding anticoagulation for a specified time period following a bleed does not lead to improved outcomes. Because this patient has a known and treatable cause of bleeding and a clearly defined risk for thrombosis owing to multiple thromboembolic events, anticoagulation with warfarin should not be withheld for a prolonged time upon discharge and should be restarted when she has been stabilized.

Discontinuing anticoagulation would not be an acceptable management strategy because of this patient's recurrent episodes of thromboembolism.

Dabigatran is an oral thrombin inhibitor indicated for the prevention of stroke accompanying atrial fibrillation, for the prevention of deep venous thrombosis, and for preventing postoperative thrombosis in patients undergoing orthopedic procedures. Because dabigatran has not been studied in patients with previous GI bleeding events and because no established reversal agent or therapy is available for overdose, dabigatran would not be an appropriate therapy option for this patient.

Key Point

  • Resuming warfarin following a gastrointestinal bleeding event is associated with lower risks of thrombosis and death than withholding anticoagulation therapy and does not significantly increase the risk for recurrent gastrointestinal bleeding.
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