Bridging DOACs Prior to Colonoscopy is Not Recommended
Bridging therapy is not recommended for patients on Direct Oral Anticoagulants (DOACs) prior to colonoscopy, as it increases bleeding risk without providing additional thrombotic protection. 1
DOAC Management for Colonoscopy
Temporary Interruption Protocol
- For standard-risk patients:
No Need for Bridging
- The Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) strongly recommend against bridging therapy in patients on DOACs 2
- The British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines similarly do not recommend bridging for DOACs 2
- The American College of Gastroenterology notes that bridging increases bleeding risk without reducing thrombotic events 1
Risk Considerations
Bleeding Risk
- DOACs have a short half-life and rapid onset/offset of action, making bridging unnecessary 3
- Patients on DOACs have low risk of post-polypectomy complications (0.63% GI bleeding vs 0.2% in controls) 4
- Bridging therapy is associated with higher rates of major hemorrhage (6.5% vs 1.8%) with no reduction in thromboembolism 1
Thrombotic Risk
- Continuing anticoagulant therapy during endoscopic mucosal resection was associated with a low major bleeding rate (4.7%) and minimal thrombotic events (0.9%) 5
- For truly high-risk patients (mechanical mitral valves, recent VTE <3 months, severe thrombophilia), consultation with a hematologist is recommended 1
Special Considerations
Renal Function
- For patients on dabigatran with CrCl 30-50 mL/min, the last dose should be taken 72 hours prior to the procedure 2
- In patients with rapidly deteriorating renal function, a hematologist should be consulted 2
Post-Procedure Management
- Resume DOACs after adequate hemostasis is achieved 2
- For high bleeding risk procedures, consider delaying DOAC resumption for 48-72 hours 1
- For apixaban specifically, the FDA label recommends restarting as soon as adequate hemostasis has been established 6
Common Pitfalls to Avoid
- Unnecessarily bridging DOAC patients, which increases bleeding risk without benefit 1
- Restarting DOACs too soon after high bleeding risk procedures 1
- Overlooking renal function when determining the timing of DOAC interruption 2
- Failing to recognize that DOACs have a rapid onset and offset of action, making bridging generally unnecessary 3
In summary, the evidence consistently shows that bridging therapy is not necessary for patients on DOACs undergoing colonoscopy. The short half-life of these medications allows for simple temporary interruption without the need for bridging anticoagulation.