From the Guidelines
The recommended duration for withholding anticoagulation therapy prior to endoscopic evaluation depends on the specific medication, procedure bleeding risk, and the patient's renal function, with warfarin typically requiring 5 days of discontinuation and INR confirmation <1.5 before high-risk procedures, as recommended by the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guidelines 1.
Key Considerations
- For low-risk procedures, anticoagulants may be continued, but high-risk procedures require temporary discontinuation.
- Direct oral anticoagulants (DOACs) should be held for 3 days before high-risk procedures in patients with normal renal function, as stated in the 2021 guideline update 1.
- For dabigatran specifically, patients with decreased renal function require longer discontinuation periods: 5 days if GFR is 30-50 ml/min, as recommended by the 2021 guideline update 1.
- Apixaban, rivaroxaban, and edoxaban should be held for 3 days before high-risk procedures, with consideration for longer discontinuation in patients with impaired renal function.
- Warfarin requires 5 days of discontinuation with INR confirmation <1.5 before high-risk procedures, as recommended by the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guidelines 1.
- Low molecular weight heparins should be held for 24 hours, while unfractionated heparin can be stopped 4-6 hours before procedures due to its short half-life.
Impaired Renal Function Considerations
- Decreased GFR leads to drug accumulation and prolonged anticoagulant effects, increasing bleeding risk during endoscopic procedures.
- Patients with rapidly deteriorating renal function should have their renal function checked before the procedure, and a haematologist should be consulted if necessary, as recommended by the 2021 guideline update 1.
- Bridging therapy with heparin may be needed for patients at high thrombotic risk during the anticoagulation pause.
Procedure-Specific Considerations
- High-risk procedures, such as polypectomy, require longer discontinuation periods for anticoagulants compared to low-risk procedures, such as diagnostic GI endoscopy.
- The PAUSE trial demonstrated the safety of omitting DOACs for 1 day before a low-risk endoscopic procedure, but this may not be applicable to all patients or procedures, as noted in the 2021 guideline update 1.
From the Research
Recommended Duration for Withholding Anticoagulation Therapy
- The recommended duration for withholding anticoagulation therapy prior to endoscopic evaluation depends on the type of anticoagulant and the patient's condition 2.
- For patients on warfarin, the advice is fundamentally unchanged from previous guidance, but the specific duration is not specified in the provided studies.
- For patients on Direct Oral Anticoagulants (DOACs), the last dose should be taken ≥ 48 hours before the procedure for high-risk endoscopic procedures (very low quality evidence, strong recommendation) 2.
- For patients on dabigatran with a creatinine clearance (CrCl) or estimated glomerular filtration rate (eGFR) of 30 - 50 mL/min, the last dose of DOAC should be taken 72 hours before the procedure (very low quality evidence, strong recommendation) 2.
Influence of Impaired Renal Function on Withholding Anticoagulation Therapy
- Impaired renal function, specifically a Glomerular Filtration Rate (GFR) of 30 - 50 mL/min, influences the duration of withholding anticoagulation therapy for patients on dabigatran, requiring the last dose to be taken 72 hours before the procedure 2.
- In patients with rapidly deteriorating renal function, a haematologist should be consulted (low quality evidence, strong recommendation) 2.
- The studies do not provide specific guidance on the management of anticoagulation therapy in patients with impaired renal function for other types of anticoagulants 3, 4, 5, 6.
General Recommendations for Antithrombotic Management
- The management of antithrombotic therapy in patients undergoing endoscopic procedures should consider the risk of bleeding and thromboembolic events 3, 4, 5, 6.
- Guidelines from various societies, including the European Society of Gastrointestinal Endoscopy (ESGE), British Society of Gastroenterology (BSG), American Society of Gastrointestinal Endoscopy (ASGE), Asian Pacific Association of Gastroenterology (APAGE), and Asian Pacific Society for Digestive Endoscopy (APSDE), provide recommendations for the management of antithrombotic therapy in patients undergoing endoscopic procedures 3, 6.