The management of antithrombotic agents in patients undergoing urgent gastrointestinal (GI) endoscopy presents a common and complex clinical challenge. The use of anticoagulants and antiplatelet therapies, especially in older patients with significant comorbidities, has increased substantially in recent decades due to the rising prevalence of cardiovascular and thromboembolic diseases. Balancing the risk of ongoing hemorrhage against the potentially life-threatening consequences of thrombosis remains a delicate and critical clinical decision. This review provides a practical, evidence-based approach to the periprocedural management of antithrombotic therapy in urgent endoscopy, particularly in the context of acute GI bleeding. We summarize the indications, pharmacokinetics, and reversal strategies for commonly used agents, including warfarin, direct oral anticoagulants (DOACs), low-molecular-weight heparin, aspirin, and P2Y12 inhibitors. Risk stratification is discussed in detail, considering both the urgency and bleeding risk of endoscopic procedures, as well as the thromboembolic risk associated with temporary drug interruption. Special considerations are given to high-risk patients, such as those with recent coronary stents, mechanical heart valves, or atrial fibrillation with elevated stroke risk scores. Close consultation and collaboration with other specialties, including cardiology and hematology, is often essential to optimize patient outcomes. Recommendations based on real-world clinical experience alongside formal guideline directives aim to support safe and timely endoscopic intervention without compromising systemic thrombotic protection, especially in emergent situations.
The management of antithrombotic therapy in patients undergoing urgent gastrointestinal (GI) endoscopy is a common problem, but it also represents a significant challenge for clinicians. The use of antiplatelets and anticoagulants has increased significantly in recent decades due to aging of the population and the increased prevalence of cardiovascular and thromboembolic comorbidities. These medications are important for the treatment and prevention of diseases such as ischemic cerebrovascular events, myocardial infarction, and venous thromboembolism. On the other hand, they significantly increase the risk of bleeding episodes in different organs, including the GI tract.
Many patients who are under antithrombotic treatment often experience bleeding episodes. Urgent GI endoscopy is required either to achieve hemostasis or to exclude active bleeding, and cessation of these agents is usually required to improve the outcomes of the procedure and minimize the risk of rebleeding. However, inappropriate interruption of these agents can expose patients to acute thrombotic episodes that can even prove life-threatening. Therefore, a careful and evidence-based approach is required in these cases.
In this review, we address the pharmacology of commonly used antiplatelets and anticoagulants, patient risk stratification, and practical reversal protocols in everyday practice. Management recommendations for different clinical scenarios are discussed, with emphasis given to high-risk populations and the importance of the cooperation of different medical specialties to achieve optimal results. Through this comprehensive review, we aim to provide a structured, evidence-based approach to the periprocedural management of antithrombotic agents in patients who are in need of urgent GI endoscopy.
We conducted a literature search of peer-reviewed articles up to August 2025. Studies were identified through electronic databases including PubMed, Scopus, and Google Scholar, using combinations of the following keywords: gastrointestinal bleeding; endoscopy; antithrombotics; antiplatelets; anticoagulants; risk; thrombotic protection. All types of studies were potentially eligible for inclusion in this review. We excluded expert opinions, studies referring to child population, and animal studies. After deduplication, a two-step screening process was conducted independently by three authors (KP, CM, and DV). Original research articles, clinical trials, reviews, and formal guidelines focusing on the management of antithrombotic therapy in the context of urgent GI endoscopy were included in the study. Articles that were not written in English, were conference abstracts, or lacked relevance to antithrombotic medications and GI bleeding were excluded.
Antithrombotic agents are generally classified into antiplatelet drugs and anticoagulants. Understanding the pharmacokinetics, mechanisms of action, and reversal strategies of these medications is essential to plan their management in clinical practice.
Aspirin is an agent that has both anti-inflammatory and antiplatelet actions. By reducing the production of prostaglandins, it limits the severity of inflammatory components such as pain, edema, and fever. However, it is the inhibition of cyclooxygenase-1 (COX-1) and the prevention of thromboxane-A2-mediated platelet aggregation that makes aspirin a potent antithrombotic agent. Although aspirin has a short plasma half-life of 10–20 min, its effect on platelets lasts for approximately 10 days, due to reduced production of COX-1 during that period.
P2Y12 inhibitors are a class of antiplatelets that inhibit the P2Y12 platelet receptor and stop adenosine diphosphate (ADP)-mediated platelet activation. Clopidogrel, prasugrel, and ticagrelor are the most widely used agents in this class. The first two are thienopyridines that irreversibly inhibit platelet action, while the latter is a triazolopyrimidine with a reversible action. Prasugrel has a rapid onset of action but also a longer washout period compared to clopidogrel. Ticagrelor also has a fast onset of action and reaches its peak concentration in the bloodstream in less than 3 h, while its reversible action allows a faster recovery of platelet action compared to clopidogrel. However, patients must receive ticagrelor twice daily due to its short duration of action.
Rapid reversal of antiplatelet action is often required due to bleeding events or for urgent surgical procedures. Platelet transfusion should be considered in patients with active bleeding and recent intake of these agents, but evidence regarding their effect on patient outcomes remains poor. Moreover, clinicians should be aware of possible complications such as volume overload and hemolytic adverse reactions. Other agents such as desmopressin and tranexamic acid have also shown promising results in reversing antiplatelet action; however, their effects are still not adequately studied and their use in clinical practice is not yet established. Bentracimab, a monoclonal antibody with high affinity for ticagrelor and its metabolites, has shown promise as a reversal agent in clinical trials, but has not yet received approval for clinical use.
Vitamin K antagonists (VKAs) inhibit the production of vitamin K-dependent clotting factors (II, VII, IX, X) and cause elevation of the international normalized ratio (INR). Warfarin is the most commonly used agent of this class. Close monitoring of INR values is essential to monitor therapeutic effectiveness and reduce adverse events. Warfarin’s long half-life (20–60 h) and narrow therapeutic window make its management in cases of acute bleeding challenging.
Exogenous vitamin K is effective at reversing VKA effects through both the oral and intravenous (IV) routes. Moreover, a lack of thromboembolic risk after its administration makes it a safe option for patients with acute events. Prothrombin complexes (PCCs) and fresh frozen plasma (FFP) can also be used as reversal agents. PCCs contain vitamin K-dependent clotting factors in an inactivated or partially activated form, and can achieve rapid reversal of warfarin effects. Therefore, they are preferred when available in cases of major bleeding, because they have a better efficacy and safety profile compared to FFPs.
Direct oral anticoagulants (DOACs) are newer oral agents that have a more specific mechanism of action. Apixaban, ribaroxaban, and edoxaban inhibit clotting factor Xa, while dabigatran is a direct thrombin inhibitor. These agents have a rapid onset of action (2–4 h) and shorter half-lives (8–14 h with preserved renal function) compared to warfarin. Routine monitoring of coagulation is not required, although specific anti-Xa and thrombin assays can be useful when available. These capabilities have established DOACs as the preferred type of anticoagulants for the treatment and prevention of many types of thromboembolic events. Their use has increased in recent years, especially in older patients with severe comorbidities.
In cases of acute bleeding, PCCs can be used to limit the effects of DOACs and rapidly improve coagulation. Active charcoal can also have an effect if the last oral intake was within 2–3 h. However, the use of targeted reversal agents is considered a more effective option. Idarucizumab is a monoclonal antibody that binds dabigatran with high specificity, while Andexanet A is a modified form of human factor Xa protein, which reverses the effects of apixaban and rivaroxaban. Both these antidotes have been approved for use in patients with acute bleeding episodes who require rapid reversal of anticoagulant treatment, but their high cost and limited availability limit their widespread use in clinical practice.
Unfractioned heparin (UFH) is a potent anticoagulant that has been used in clinical practice for decades. It basically acts by activating antithrombin and reducing factor Xa activity and thrombin formation, while it also aids downregulation of the exogenous coagulation pathway by activating the tissue factor pathway inhibitor. Despite the rapid onset of UFH action, its short half-life and the need for close monitoring and IV administration led to the development of newer agents. Low-molecular-weight heparins (LMWHs) such as enoxaparin are compounds produced after depolymerization of UFH. They are available as injectable therapy, have longer half-lives, and a better safety profile, while their increased bioavailability also makes them better suited for clinical practice. Moreover, fondaparinux is a synthetic inhibitor of coagulation factor Xa, which is an injectable agent with 100% bioavailability, long half-life, and few adverse events. Its use in different clinical scenarios has been increasing in recent years.
Protamine sulfate is an established antidote of UFH, because it reverses its action entirely. However, it does not completely reverse LMWH effects and does not neutralize fondaparinux. In cases of severe acute bleeding, PCCs and recombinant factor VIIa (rFVIIa) can be used to reverse the effects of fondaparinux; however, data supporting their protective effect are limited.
Periprocedural management of antithrombotic agents in patients undergoing GI endoscopy relies on a clear understanding of bleeding risk associated with different procedures. The most recent guidelines from the American Society of Gastroenterology
