Is it necessary to stop prophylactic enoxaparin (Clexane) before undergoing upper and lower endoscopy?

From the Guidelines

For upper and lower endoscopy, prophylactic clexane (low molecular weight heparin) typically needs to be temporarily discontinued to reduce bleeding risk, with the most recent guidelines suggesting that it should be stopped at least 24 hours before high-risk procedures 1. The decision to discontinue clexane should be made on a case-by-case basis, taking into account the patient's thrombotic risk and the type of endoscopic procedure being performed.

• For standard diagnostic endoscopy without planned biopsies, clexane can be held on the morning of the procedure.
• For therapeutic endoscopy or procedures with planned biopsies, clexane should be stopped 24 hours before the procedure. The timing of resumption depends on the procedure performed and bleeding risk, but generally can be restarted 24-48 hours after therapeutic procedures if hemostasis is adequate 1. Patients with high thrombotic risk (such as recent venous thromboembolism, mechanical heart valves, or recent coronary stents) may require bridging with unfractionated heparin or individualized management plans 1. Always consult with both the endoscopist and the prescribing physician before stopping clexane, as the decision requires balancing bleeding risk against thrombotic risk for each individual patient. The temporary discontinuation is necessary because clexane inhibits factor Xa in the coagulation cascade, which increases bleeding risk during procedures where tissue is cut or sampled. Key considerations include:
• The patient's underlying thrombotic risk
• The type of endoscopic procedure being performed
• The need for bridging anticoagulation in high-risk patients
• The timing of clexane resumption after the procedure. It is essential to follow the most recent guidelines and consult with relevant specialists to ensure the best possible outcome for the patient 1.

From the Research

Prophylactic Clexane and Endoscopy

• The management of anticoagulants before and after endoscopy is crucial to weigh the risk of procedure-related bleeding against the risk of thromboembolism from discontinuing these drugs 2.
• For low-risk procedures such as upper endoscopy with biopsy, colonoscopy with biopsy, or endoscopic retrograde cholangiopancreatography with stent insertion, it is not necessary to adjust anticoagulation 2.
• However, procedures that incur a high risk of bleeding, such as polypectomy, endoscopic sphincterotomy, laser therapy, mucosal ablation, and treatment of varices, may require discontinuation of warfarin four to five days beforehand 2.
• Low molecular weight heparin, such as clexane, can be an alternative to unfractionated heparin for select cases with a high risk of thromboembolism 2.
• There is no direct evidence on the necessity of stopping prophylactic clexane before upper and lower endoscopy, but the management of anticoagulants should be individualized based on the patient's risk of thromboembolism and the type of procedure being performed 2, 3.

Risk of Bleeding and Thromboembolism

• The risk of bleeding and thromboembolism should be carefully evaluated in patients undergoing endoscopy, particularly in those with a history of anticoagulant use 2, 4.
• Patient selection for prophylactic intubation prior to endoscopy is critical, and factors such as illness severity, planned upper endoscopy, and hematemesis 24 hours prior should be considered 4.
• The use of anticoagulants, including low molecular weight heparin, should be carefully managed to minimize the risk of bleeding and thromboembolism 2, 3.

Safety of Endoscopy in High-Risk Patients

• Upper and lower gastrointestinal endoscopy can be safely performed in patients over 85 years of age, with a high rate of immediate diagnosis and significant modifications of therapeutics 5.
• However, the risk-benefit ratio of endoscopy should be carefully evaluated in high-risk patients, including those with a history of anticoagulant use or bleeding disorders 2, 5.