When to stop, how to reverse, and when to restart antithrombotic drugs periendoscopically in nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal (GI) (UGI) bleeding in patients taking antithrombotics including antiplatelet agents, vitamin K antagonists, and direct oral anticoagulants is challenging because of varying clinical presentations that include the severity of hemorrhage, the type and magnitude of anticoagulation, the patient׳s underlying thromboembolic risk, and the specific bleeding lesion with attendant ability to achieve successful endoscopic hemostasis. Interruption of antithrombotics for bleeding management exposes the patient to the underlying risk of thromboembolic events from the underlying cardiovascular state, whereas continuation or restarting antithrombotics subjects the patient to ongoing or recurrent bleeding. The balance between excessive bleeding vs thrombosis is the principle for deciding optimal management of these patients.This article focuses on the management of antithrombotic-associated nonvariceal UGI bleeding describing the approach to managing these patients from the gastroenterologist׳s perspective. The focus will include risk assessment for patients taking antithrombotics, determination of residual antithrombotic effect to guide selection and timing of reversal agents, and strategies for restarting antithrombotics once hemostasis has been achieved.