Management of GI Bleed in Patients on Anticoagulation for Pulmonary Embolism

Introduction to PPI Therapy

• The American College of Cardiology recommends continuing PPI therapy for 6-8 weeks following endoscopic hemostasis to allow mucosal healing, then continuing indefinitely as long-term gastroprotection while the patient remains on anticoagulation 1, 2

Acute Phase Management

• Initiate high-dose PPI therapy immediately upon presentation with GI bleeding, ideally before endoscopy 2
• After successful endoscopic hemostasis, administer high-dose PPI as continuous infusion for 72 hours 2

Short-Term Continuation

• Continue PPI therapy for 6-8 weeks following endoscopic treatment to ensure complete mucosal healing 1, 2
• During this period, the patient should remain on standard-dose PPI 2

Long-Term Gastroprotection

• Patients with a history of prior GI bleeding require ongoing PPI therapy 3, 4
• Ongoing anticoagulation therapy significantly increases GI bleeding risk, necessitating long-term PPI use 3, 4, 5
• The American Heart Association suggests that patients on anticoagulation for pulmonary embolism should continue PPI therapy indefinitely 3, 4

Anticoagulation Management

• For unprovoked PE, anticoagulation should continue indefinitely with periodic reassessment 6, 7
• PPI therapy should continue for the entire duration of anticoagulation 4, 5

Practical Management

• Transition to oral PPI once tolerating oral intake, and continue standard-dose PPI once daily 2
• Continue full-dose Eliquis (5 mg twice daily, or 2.5 mg twice daily if dose-reduction criteria met) 6

Monitoring and Reassessment

• Reassess anticoagulation need periodically (e.g., annually) as recommended for extended-phase therapy 6, 7
• Document the ongoing indication for PPI therapy in the medical record 5
• Test and treat for H. pylori if not already done, as eradication reduces rebleeding risk 1, 2
• Avoid NSAIDs, which would further increase bleeding risk 3, 4