When to restart anticoagulation (blood thinner) and antiplatelet therapy after a colonoscopy or Esophagogastroduodenoscopy (EGD)?

When to Restart Anticoagulation and Antiplatelet Therapy After Colonoscopy or EGD

Restart anticoagulants and antiplatelets within 24-72 hours after colonoscopy or EGD, with the specific timing determined by whether the procedure was low-risk (diagnostic only) versus high-risk (polypectomy, therapeutic intervention) and the patient's thrombotic risk. 1

Risk Stratification Framework

Low-Risk Procedures (Diagnostic EGD/Colonoscopy ± Biopsies)

• Resume anticoagulants the same day after diagnostic procedures without therapeutic intervention 2
• DOACs can be restarted immediately once hemostasis is confirmed, as they achieve anticoagulant effect within hours 1
• Aspirin for secondary prevention should be resumed within 24 hours 1, 3

High-Risk Procedures (Polypectomy, EMR/ESD, Sphincterotomy)

• Resume anticoagulants 24-72 hours post-procedure depending on bleeding and thrombotic risk 1, 2
• The BSG/ESGE guidelines provide a strong recommendation to restart within 2-3 days after high-risk procedures, balancing hemorrhagic versus thrombotic risk 1
• P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) should be restarted 1-2 days after the procedure 1

Specific Agent Recommendations

Aspirin Monotherapy

• For secondary prevention: Resume within 24 hours after uncomplicated procedures with good hemostasis 1, 3
• Critical mortality data shows all-cause mortality is 10 times lower (1.3% vs 12.9%) when aspirin is resumed immediately after endoscopic hemostasis compared to discontinuation 3
• For primary prevention only, permanent discontinuation should be considered 1

P2Y12 Inhibitors (Clopidogrel, Prasugrel, Ticagrelor)

• Restart 1-2 days after high-risk procedures 1
• In patients with coronary stents, these must be restarted within a maximum of 5 days due to high stent thrombosis risk 1
• Never withhold both antiplatelet agents simultaneously in patients on dual antiplatelet therapy (DAPT) 3

Direct Oral Anticoagulants (DOACs)

• For low-risk procedures: Resume same day 2
• For high-risk procedures: Resume 24-72 hours post-procedure 2
• Data from the PAUSE study indicates restarting DOACs 2-3 days after high-risk procedures has low thromboembolic risk 1
• DOACs exert anticoagulant effect within hours, unlike warfarin which takes days 1

Warfarin

• Resume the evening of the procedure for most cases 1
• May be supplemented with heparin bridging in high thrombotic risk patients 4
• Check INR one week later to ensure adequate anticoagulation 1

Thrombotic Risk Stratification

High Thrombotic Risk (Earlier Resumption Required)

• Drug-eluting coronary stents within 12 months 1
• Bare metal coronary stents within 1 month 1
• Mechanical heart valves (especially mitral position) 2
• Atrial fibrillation with mitral stenosis 2
• Recent stroke/TIA 1

For high thrombotic risk patients: Resume anticoagulation with heparin bridging within 3 days 1

Low Thrombotic Risk (Can Delay Resumption)

• Ischemic heart disease without stents 1
• Cerebrovascular disease (remote) 1
• Peripheral vascular disease 1
• Atrial fibrillation without high-risk features 1

For low thrombotic risk patients: Resume anticoagulation as soon as possible after 7 days of interruption 1

Critical Pitfalls to Avoid

Delayed Resumption Risks

• Discontinuation of aspirin for secondary prevention increases risk of death or acute cardiovascular events nearly sevenfold (HR 6.9; 95% CI 1.4 to 34.8) 3
• A retrospective study showed permanent discontinuation of antithrombotics resulted in HR 5.77 for thrombotic events and HR 3.32 for mortality compared to restarting 1

Premature Resumption Risks

• Restarting DOACs immediately after polypectomy (rather than 24-48 hour delay) nearly doubles delayed bleeding risk without reducing thrombosis 1
• For very high-risk procedures like ESD, consider delaying restart beyond standard intervals—resumption within 1 week after ESD significantly increases post-ESD bleeding 1

Special Considerations for DAPT

• In patients with coronary stents presenting with GI bleeding, continue DAPT if possible in liaison with interventional cardiology 1
• If temporary cessation necessary, limit discontinuation to the P2Y12 inhibitor only and continue aspirin 1
• Maximum interruption of P2Y12 inhibitors should not exceed 5 days in stented patients 1

Practical Algorithm

1. Classify procedure risk: Diagnostic ± biopsy = low-risk; polypectomy/therapeutic = high-risk 1

2. Assess thrombotic risk: Recent stents, mechanical valves, recent stroke = high-risk 1

3. Low-risk procedure + any thrombotic risk: Resume same day 2

4. High-risk procedure + low thrombotic risk: Resume 48-72 hours post-procedure 1, 2

5. High-risk procedure + high thrombotic risk: Resume 24-48 hours with consideration for heparin bridging 1

6. Aspirin for secondary prevention: Resume within 24 hours regardless of procedure risk if hemostasis adequate 1, 3