Management of Antithrombotic Agents for Patients Undergoing GI Endoscopy
Publication Date: January 1, 2016
Last Updated: March 14, 2022
RECOMMENDATIONS
Elective endoscopic procedures
Patients receiving anticoagulant therapy
We recommend that elective endoscopic procedures be deferred until short-term anticoagulation therapy (eg, warfarin for VTE) is completed. (, ⊕⊕⊕o)
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We suggest discontinuing anticoagulation (ie, warfarin [Coumadin], NOACs) for the appropriate drug-specific interval in the periendoscopic period if high-risk endoscopic procedures are planned in a patient at low risk for thromboembolic events. (, ⊕⊕oo)
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We suggest continuing warfarin and NOAC in the periendoscopic period in patients undergoing low-risk endoscopic procedures. (, ⊕⊕oo)
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We suggest bridge therapy for patients undergoing high-risk endoscopic procedures who are at high risk for thromboembolic events. (, ⊕⊕oo)
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We suggest that warfarin (Coumadin) be restarted on the same day as the procedure in all patients who do not have ongoing bleeding. (, ⊕⊕oo)
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We suggest that the reinitiation of NOACs after high-risk endoscopic procedures be delayed until adequate hemostasis is ensured, given their rapid onset of action and lack of reversal agents. If therapeutic doses of NOACs cannot be restarted within 12 to 24 hours after a high-risk endoscopic procedure, thromboprophylaxis (ie, UFH bridge) should be considered to decrease risk of thromboembolism, given the short half-life of the NOAC agent, in those with a high risk for thromboembolism. (, ⊕⊕oo)
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Patients receiving APA therapy
We suggest that continuation of low doses of ASA and nonsteroidal anti-inflammatory drugs may be continued safely in the periendoscopic period. (, ⊕⊕⊕o)
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We recommend that thienopyridines be continued for all low-risk endoscopic procedures. (, ⊕⊕⊕o)
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We recommend discontinuation of thienopyridines at least 5 to 7 days before high-risk endoscopic procedure or switching to ASA monotherapy and continuing until the thienopyridine can be safely resumed. (, ⊕⊕⊕o)
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We recommend that elective endoscopic procedures be deferred in patients with recently placed intracoronary stents and/or ACS until the patient has received antithrombotic therapy for the minimum recommended duration. (, ⊕⊕⊕o)
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We suggest that thienopyridines be withheld for at least 5 to 7 days (ticagrelor 3-5 days) before high-risk endoscopic procedures and that ASA be continued for patients requiring dual APA. (, ⊕⊕⊕o)
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Urgent and emergent endoscopic procedures
Patients receiving anticoagulant therapy
We recommend patients with acute GI bleeding on anticoagulation therapy have anticoagulant agents held to facilitate achievement of hemostasis.
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We recommend either:
(1) 4-factor PCC and vitamin K or
(2) fresh frozen plasma be given for life-threatening GI bleeding in patients on warfarin anticoagulant therapy.
Please note the ACCP advocates only option 1. The AHA/ACC supports option 1 or 2.
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We suggest endoscopic therapy not be delayed in patients with serious GI bleeding and an INR < 2.5. (, ⊕⊕oo)
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We suggest patients who require anticoagulation receive UFH because of its relatively short half-life after successful endoscopic hemostasis for high-risk stigmata. (, ⊕⊕oo)
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Patients receiving APA therapy
We recommend consultation with the prescribing specialist (or their colleague) before stopping APAs in situations of significant GI bleeding in patients
(1) with recently (<1 year) placed drug eluting intracoronary stents,
(2) within 30 days after insertion of a bare metal intracoronary stent, or
(3) within 90 days of ACS. The risk of an adverse cardiac event associated with cessation of the APA therapy likely exceeds the benefit of decreasing postendoscopic bleeding.
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We recommend patients on APAs with life-threatening or serious GI bleeding should have these agents held after discussion with their cardiologist. (, ⊕⊕⊕o)
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Title
Management of Antithrombotic Agents for Patients Undergoing GI Endoscopy
Authoring Organization
American Society for Gastrointestinal Endoscopy
Publication Month/Year
January 1, 2016
Last Updated Month/Year
May 31, 2023
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Emergency care, Hospital, Laboratory services, Operating and recovery room, Outpatient
Intended Users
Laboratory technician, nurse, nurse practitioner, physician, physician assistant
Diseases/Conditions (MeSH)
D001778 - Blood Coagulation Disorders, D016099 - Endoscopy, Gastrointestinal
Keywords
antiplatelet, Antithrombotic Agents, GI endoscopy
Source Citation
Acosta, R. D., Abraham, N. S., Chandrasekhara, V., Chathadi, K. V., Early, D. S., Eloubeidi, M. A., … DeWitt, J. M. (2016). The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointestinal Endoscopy, 83(1), 3–16. doi:10.1016/j.gie.2015.09.035