Management of colonic diverticular bleeding: A narrative review with literature search of current evidence and therapeutic strategies

Table 9 Framework for antithrombotic management after colonic diverticular bleeding

Agent/class	TE risk if stopped	Resumption timing	Clinical considerations
Anticoagulation (high TE risk)	High	7-14 days post-hemostasis	Earlier (< 7 days) for mechanical valves, recent stroke
Anticoagulation (AF)	High	≤ 7 days preferred	Lower MACE without significant increase in GI rebleeding in AF
Warfarin	Varies	After INR therapeutic	Use 4F-PCC (not FFP) for urgent reversal
Rivaroxaban	Moderate	Consider switch to apixaban	HR 1.53 higher LGIB risk vs apixaban; class switch reasonable
Aspirin (2° CV prevention)	High if stopped	Resume as soon as feasible	Discontinuation increases mortality; rebleeding risk outweighed
DAPT (recent PCI/ACS)	Very high if stopped	Continue aspirin; liaise cardiology re P2Y12	P2Y12 pause per stent age; never stop both without cardiology input
NSAIDs	Low (TE)	Substitute if possible	Replace with acetaminophen or COX-2 inhibitor where feasible
Andexanet alfa (factor Xa reversal)			Withdrawn from United States market; confirm availability with pharmacy/hematology

Resumption timing recommendations are based on observational data only; no randomized controlled trials exist. TE: Thromboembolic; AF: Atrial fibrillation; CV: Cardiovascular; DAPT: Dual antiplatelet therapy; PCI: Percutaneous coronary intervention; ACS: Acute coronary syndrome; NSAIDs: Non-steroidal anti-inflammatory drugs; INR: International normalized ratio; MACE: Major adverse cardiovascular events; GI: Gastrointestinal; 4F-PCC: Four-factor prothrombin complex concentrate; FFP: Fresh frozen plasma; HR: Hazard ratio; COX-2: Cyclooxygenase-2; LGIB: Lower gastrointestinal bleeding.