7 June - Anticoagulation in the Elderly

In which patients can warfarin be safely resumed after a major GI hemorrhage?  Multiple factors must be considered:  what is the risk of not anticoagulating?  Prosthetic mitral valves may not be forgiving, but a minor DVT several months ago may not pose much risk.  How many CHADS2 points does the A-fib patient have?  How significant was the bleed?  Did it occur at therapeutic INR levels or only at significantly elevated ones?  No simple algorithm for this, but these guidelines from the ACC/AHA give some pointers.

At least with regards to elderly patients with A-fib, physicians tend to overestimate the risk and clinical impact of gastrointestinal hemorrhage or hemorrhagic stroke and underestimate the benefit of anticoagulant therapy. Annals of Pharmacotherapy on Medscape reviews warfarin in the elderly in detail.

Here is a nice review of the literature that largely focuses on antiplatelet therapy in patients with a history of GI hemorrhage.  Key points:  Clopidogrel has lower bleeding risk than ASA, but not by much.  ASA plus PPI has significantly lower bleeding risk than clopidogrel.  Clopidogrel is not as active when given with omeprazole, but other PPIs do not seem to exhibit this effect.