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Updated Guideline on Endoscopy and Antiplatelet or Anticoagulant Therapy From British and European Gastroenterology Organizations

Douglas K. Rex, MD, MASGE reviewing Veitch AM, et al. Gut 2021 Aug 6.

This guideline from the British Society of Gastroenterology and the European Society of Gastrointestinal Endoscopy relies on the traditional division of procedures into low risk and high risk for bleeding and risk for thromboembolism into high and low. 

The guideline includes recommendations for antiplatelet or anticoagulant therapy with low-risk endoscopic procedures, including diagnostic procedures with or without biopsy, and biliary, pancreatic, and lumenal stent placement. High-risk procedures include polypectomy, sphincterotomy, EMR, ESD, dilation, variceal therapy, PEG, EUS-guided sampling or intervention, and radiofrequency ablation. The low-risk conditions for thromboembolism include a xenograft heart valve, atrial fibrillation with a CHADS2 score of ≤4, and venous thromboembolism that occurred at least 3 months prior. High-risk conditions include nearly all other risk conditions for thromboembolism. 

Most of the recommendations are familiar. 

  • Low-risk procedures in patients on clopidogrel, prasugrel, and ticagrelor: Continue medications.
  • Low-risk procedures in patients on warfarin: Check the INR 1 week beforehand, and adjust the dose as needed to be within the therapeutic range at procedure time.
  • Low-risk procedures in patients treated with direct oral anticoagulants (DOACs): Omit the DOAC the morning of the procedure.
  • High-risk procedures in patients on clopidogrel, prasugrel, and ticagrelor: Stop medications for 7 days (okay to continue aspirin), unless the patient underwent drug-eluting coronary stent placement less than 6 to 12 months ago or bare metal stent placement within the past month.
  • High-risk procedures in patients at low risk for thromboembolism: Stop warfarin 5 days beforehand, check the INR prior to the procedure to confirm it is <1.5. In patients on DOACs, restart the DOAC 2 to 3 days after the procedure.
  • High-risk procedures in patients at high risk for thromboembolism: Stop warfarin 5 days before the procedure, and bridge anticoagulant therapy before and after the procedure with low-molecular-weight heparin. 
  • High-risk procedures in patients treated with DOACs who are at high risk of thromboembolism: Take the last dose 3 days before the endoscopy (except with dabigatran with a glomerular filtration rate of 30 to 50 ml/min, in which case the last dose should be taken 5 days before the procedure), and restart DOAC 2 to 3 days after the procedure.

Comment:

This seems like a good set of recommendations. However, there is only the briefest mention that colonoscopy is the most commonly performed procedure in many Western countries and polypectomy is the most commonly performed treatment during colonoscopy, and we generally have no knowledge beforehand of whether polypectomy will be needed when we start the procedure. Therefore, as we generally do in the U.S., it is reasonable to continue to treat all colonoscopies as high-risk procedures.


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Douglas K. Rex, MD, MASGE

Bio and Disclosures

Citation(s):

Veitch AM, Radaelli F, Alikhan R, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021;70:1611-1628. (http://dx.doi.org/10.1136/gutjnl-2021-325184)
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