From the Guidelines
The decision to withhold anticoagulation and anti-platelet medications before an endoscopy procedure depends on the specific procedure risk and the patient's thrombotic risk, with a general recommendation to continue these medications for low-risk procedures and temporarily discontinue them for high-risk procedures, as guided by the most recent evidence from the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update 1.
Procedure Risk and Medication Management
For low-risk endoscopic procedures, such as diagnostic upper endoscopy or colonoscopy without biopsies, anticoagulation and anti-platelet medications can typically be continued, with the exception of specific cases where the risk of thrombosis versus hemorrhage needs to be individually assessed 1.
- For patients on warfarin, the medication should be continued for low-risk procedures, ensuring the INR does not exceed the therapeutic range in the week prior to the procedure 1.
- Aspirin can usually be continued for most procedures, including low-risk endoscopic procedures, due to its low risk of bleeding complications 1.
High-Risk Procedures
For high-risk procedures, such as polypectomy, endoscopic mucosal resection, or sphincterotomy, the management of anticoagulation and anti-platelet therapy is more nuanced:
- Warfarin should be discontinued 5 days before the procedure for patients at low thrombotic risk, with an INR check prior to the procedure to ensure it is <1.5 1.
- For patients at high thrombotic risk, warfarin may need to be temporarily discontinued and substituted with low molecular weight heparin (LMWH) 1.
- P2Y12 receptor antagonists (e.g., clopidogrel) may need to be discontinued 5-7 days before high-risk procedures in patients at low thrombotic risk, while aspirin can usually be continued 1.
Patient-Specific Considerations
The decision to withhold or continue anticoagulation and anti-platelet medications must be tailored to the individual patient's risk factors, including the presence of recent coronary stents, stroke, or high thrombotic risk, which may necessitate bridging therapy with heparin or consultation with specialists 1.
- The timing of medication resumption after the procedure varies based on bleeding risk but typically ranges from immediately after the procedure to 2-3 days later, aiming to balance the risks of procedure-related bleeding against thrombotic events from medication discontinuation 1.
From the Research
Anticoagulation and Anti-Platelet Medications in Endoscopy
- The decision to withhold anticoagulation and anti-platelet medications for an endoscopy procedure depends on the type of procedure, the patient's risk of bleeding, and their thrombotic risk 2, 3, 4, 5, 6.
- For low-risk endoscopic procedures, such as diagnostic endoscopy and biopsy, there is no need to discontinue or adjust anticoagulation 2, 6.
- For high-risk endoscopic procedures, such as polypectomy and biliary sphincterotomy, an individual approach is required, which may include stopping oral anticoagulant therapy with or without the administration of unfractionated heparin or low-molecular-weight heparin 2, 5.
- Antiplatelet drugs, such as aspirin, clopidogrel, and ticlopidine, may increase the risk of bleeding induced by gastrointestinal endoscopic procedures, but there is no indication to stop therapy before esophagogastroduodenoscopy 2.
- Discontinuation of aspirin 4-7 days before other endoscopic procedures is recommended, depending on the cardiovascular risk 2.
- For patients on dual antiplatelet therapy for secondary prevention, temporary interruption of the P2Y12 receptor inhibitor while continuing aspirin is suggested 4, 6.
- The use of heparin bridging therapy during warfarin cessation is not recommended due to the associated risk of increased bleeding 3, 5.
Specific Medication Management
- Warfarin: continuation as opposed to temporary interruption is suggested for low-risk procedures, but if held for high-risk procedures, bridging anticoagulation is not recommended unless the patient has a mechanical heart valve 4.
- Direct Oral Anticoagulants (DOACs): temporary interruption rather than continuation is suggested for high-risk procedures 4, 6.
- P2Y12 receptor antagonists: continuation as single or dual antiplatelet therapy is recommended for low-risk procedures, but discontinuation 5 days before high-risk procedures is recommended for patients at low thrombotic risk 6.