From the Guidelines
Coumadin (warfarin) should typically be held before an EGD, with the specific approach depending on the patient's thromboembolic risk and the type of procedure planned, as recommended by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update 1. For low-risk diagnostic EGDs without biopsies, warfarin can often be continued if the INR is within the therapeutic range. However, for therapeutic procedures or when biopsies are anticipated, warfarin should be held for 5 days before the procedure to allow the INR to normalize (below 1.5) 1. Patients at high risk for thromboembolism (such as those with mechanical heart valves, recent venous thromboembolism, or atrial fibrillation with prior stroke) may require bridging therapy with low molecular weight heparin while warfarin is held 1. After the procedure, warfarin can usually be resumed the same evening if there are no bleeding complications. The decision to hold warfarin balances bleeding risk during the procedure against the patient's thromboembolic risk while off anticoagulation, and should be made on an individual basis in consultation with the patient's cardiologist or primary physician managing their anticoagulation. Some key points to consider include:
- Checking INR prior to the procedure to ensure <1.5 1
- Advising patients of the increased risk of post-procedure bleeding compared to non-anticoagulated patients 1
- Considering bridging therapy with low molecular weight heparin for patients at high thrombotic risk 1
- Resuming warfarin the same evening after the procedure if there are no bleeding complications 1
From the Research
Management of Anticoagulation Therapy
- The management of anticoagulation therapy is crucial in patients undergoing procedures such as endoscopy 2.
- The risk of procedure-related bleeding while taking anticoagulants needs to be weighed against the risk of thromboembolism from discontinuing these drugs 2.
Coumadin and Endoscopy
- For patients on Coumadin, it is recommended to discontinue the medication 4-5 days before high-risk procedures such as polypectomy, endoscopic sphincterotomy, laser therapy, mucosal ablation, and treatment of varices [(2,3)].
- However, for low-risk procedures such as upper endoscopy with biopsy, colonoscopy with biopsy, or endoscopic retrograde cholangiopancreatography with stent insertion, it may not be necessary to adjust anticoagulation 2.
Bridge Therapy
- Bridge therapy with low-molecular-weight heparin (LMWH) or unfractionated heparin may be necessary for patients at high risk of thromboembolism [(4,2,3)].
- The decision to use bridge therapy should be based on the individual patient's risk of thromboembolism and bleeding [(4,2,3)].
Resuming Anticoagulation Therapy
- Anticoagulation therapy can be resumed after the procedure, and it is recommended to start with a low dose and adjust as needed [(2,3)].
- The timing of resuming anticoagulation therapy depends on the individual patient's risk of thromboembolism and bleeding [(2,3)].