Management of Upper GI Bleeding

Initial Assessment and Resuscitation

• Arrange for urgent upper GI endoscopy (within 12 hours) for patients with upper GI bleeding, particularly those with high-risk features such as hemodynamic instability, in-hospital bloody emesis/nasogastric aspirate, or contraindication to interruption of antiplatelet therapy, as recommended by the European Society of Cardiology 1

Medical Therapy

• The American Heart Association recommends using PPIs, which are more effective than H2-receptor antagonists in preventing recurrent bleeding, for patients with upper GI bleeding on antiplatelet therapy 2
• Continue PPI therapy indefinitely in patients with a history of GI bleeding on antiplatelet therapy, as recommended by the American Heart Association 2
• Patients with multiple risk factors for GI bleeding should receive prophylactic PPI therapy, according to the American Heart Association 2

Antiplatelet Regimen Adjustment

• For patients who completed the initial 21-30 days of DAPT after stroke, transition to monotherapy as recommended by the European Stroke Organisation 3
• If continued DAPT is necessary, maintain PPI co-therapy, as recommended by the American Heart Association 2
• DAPT with aspirin and clopidogrel should continue for only 21-30 days after minor stroke or high-risk TIA, then transition to monotherapy, according to the European Stroke Organisation 3
• The optimal antiplatelet strategy for patients requiring an antiplatelet switch is clopidogrel 75mg daily + PPI, which is the preferred option 2, 4

Prevention of Recurrent Bleeding

• Consider testing for and treating H. pylori infection in patients with a history of peptic ulcer disease, as recommended by the American Heart Association 2
• Be aware of the potential interaction between PPIs and clopidogrel, although clinical significance remains uncertain, as noted by the American Heart Association 2
• The addition of a PPI to clopidogrel decreases the risk of upper GI bleeding by 81% in clopidogrel users, providing greater protection than H2-receptor antagonists 5, 2
• Alternative antiplatelet agents such as prasugrel or ticagrelor may be considered, but note that these may have a higher bleeding risk than clopidogrel 2

Special Considerations

• For patients using aspirin for primary prevention, switching to clopidogrel with PPI is an appropriate alternative 4
• The American College of Cardiology and the European Society of Cardiology suggest that the cardiovascular protection benefit of aspirin outweighs the slightly increased risk of rebleeding in patients with GI bleeding, and aspirin should be continued without interruption if used for secondary cardiovascular prevention 6, 4
• P2Y12 inhibitors like clopidogrel should be temporarily discontinued during active GI bleeding and resumed within 3-5 days after endoscopic hemostasis is achieved, with ticagrelor resuming within 2-3 days and clopidogrel/prasugrel resuming within 5 days 6, 2
• The American Heart Association recommends never discontinuing both aspirin and P2Y12 inhibitors simultaneously in patients with coronary stents, as the risk of stent thrombosis increases dramatically 6
• Cardiology consultation is recommended before any changes to antiplatelet therapy, particularly for patients with acute coronary syndrome within 6 months, recent coronary stent placement, or high risk of stent thrombosis 6, 7
• Platelet transfusions should be avoided in patients with GI bleeding who are on antiplatelet therapy, as evidence shows they do not reduce rebleeding risk and may be associated with higher mortality 6
• Antiplatelet therapy should be restarted as soon as hemostasis is achieved, with the FDA label for clopidogrel specifically stating: "If clopidogrel must be temporarily discontinued, restart it as soon as possible" 6

Patient Population Recommendations