When to restart a DOAC or warfarin (oral anticoagulation) after a major bleeding event (intracranial haemorrhage or GI bleed)

• available evidence favours resumption of anticoagulation therapy for gastrointestinal tract bleeding and intracranial hemorrhage survivors, and it is reasonable to begin postbleeding decision making with resuming anticoagulation therapy as the default plan
  
  
• advice in the context of restarting anticoagulation - either warfarin or DOAC anticoagulation - because "it seems reasonable to assume that the risks and benefits of resuming DOAC anticoagulation therapy will be largely similar to those associated with resuming warfarin therapy because these agents have shown similar if not superior efficacy and safety to warfarin in clinical trials" (1)
  
  
• after considering factors related to the index bleeding event, the underlying thromboembolic risk, and comorbid conditions, a decision to accept or modify the default plan can be made in collaboration with other care team members, the patient, and their caregivers
  • restarting oral anticoagulation after gastrointestinal bleeding
    • although additional information is needed regarding the optimal timing of anticoagulation resumption, available evidence indicates that waiting approximately 14 days may best balance the risk of recurrent bleeding, thromboembolism, and mortality after gastrointestinal tract bleeding (1)
      
      
  • when to resume anticoagulation after intracranial hemorrhage (ICH) is less clear, but most studies indicate that resumption within the first month of discharge is associated with better outcomes (1)
    • a review states (2):
      • anticoagulation resumption does not increase the risk of recurrent ICH and can also reduce the risk of all-cause mortality
      • anticoagulation cessation exposes patients to a significantly higher risk of thromboembolism, which could be reduced by resumption
      • optimal timing of anticoagulation resumption after ICH is still unknown
        • both early (< 2 weeks) and late (> 4 weeks) resumption should be reached only after very careful assessment of risks for ICH recurrence and thromboembolism
        • it has been suggested that “early resumption” (within 2 weeks) of oral anticoagulation (OAC) therapy in patients with a high risk of thromboembolism, and “late resumption” (after 4 weeks) in patients with a high risk of ICH
      • introduction of new oral anticoagulants and other interventions, such as left atrial appendage closure, has provided some patients with more alternatives
    • the European Heart Rhythm Association guidelines recommend that OAC may be restarted after 4–8 weeks after ICH, if the risk of thromboembolism is high and the risk of recurrent ICH is low (3)

Reference:

• Witt DM. What to do after the bleed: resuming anticoagulation after major bleeding.Hematology Am Soc Hematol Educ Program. 2016 Dec 2; 2016(1): 620–624.
• Li Y-g, Lip GYH. Anticoagulation Resumption After Intracerebral Hemorrhage Curr Atheroscler Rep. 2018; 20(7): 32.
• Steffel J, Verhamme P, Potpara TS, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39(16):1330–1393. doi:10.1093/eurheartj/ehy136