What medications, including anticoagulants (e.g. warfarin), antiplatelet agents (e.g. aspirin, clopidogrel), nonsteroidal anti-inflammatory drugs (NSAIDs), and selective serotonin reuptake inhibitors (SSRIs), should be held prior to endoscopy in patients with various medical histories, such as diabetes and high blood pressure?

Management of Medications Prior to Endoscopy

The decision to hold medications before endoscopy depends on two critical factors: the bleeding risk of the procedure (low-risk vs. high-risk) and the patient's thrombotic risk, with most medications continued for low-risk procedures and selectively held for high-risk procedures. 1, 2

Procedure Risk Stratification

Low-Risk Procedures (Continue All Medications)

• Diagnostic procedures with or without biopsies 1, 2
• Biliary or pancreatic stenting 1
• Device-assisted enteroscopy without polypectomy 1
• Oesophageal, enteral, or colonic stenting 1
• Endoscopic ultrasound without sampling or interventional therapy 1

High-Risk Procedures (Selective Medication Holding)

• Endoscopic polypectomy 1, 2
• ERCP with sphincterotomy 1
• Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) 1, 2
• Endoscopic dilatation of strictures 1
• Endoscopic therapy of varices 1
• Percutaneous endoscopic gastrostomy (PEG) 1
• EUS-guided sampling or interventional therapy 1
• Oesophageal or gastric radiofrequency ablation 1

Aspirin Management

Continue aspirin for ALL procedures, regardless of bleeding risk, especially for secondary prevention. 1, 2

• For secondary prevention (history of MI, stroke, coronary stents): Never stop aspirin 1, 2
• For primary prevention: Consider permanent discontinuation only in the setting of acute GI hemorrhage 1
• The risk of thrombotic events from stopping aspirin outweighs the minimal increase in bleeding risk 1, 2
• NSAIDs can be continued similarly to aspirin for low-risk procedures 3

Clopidogrel and P2Y12 Inhibitors (Plavix, Prasugrel, Ticagrelor)

Low-Risk Procedures

• Continue clopidogrel without interruption 1, 2
• Continue dual antiplatelet therapy (DAPT) if prescribed 1, 2

High-Risk Procedures

• Stop clopidogrel 5 days before the procedure 1, 2, 4
• Continue aspirin throughout 1, 2
• Exception: Patients with coronary stents require cardiology consultation before stopping any antiplatelet agent 1, 2
• For patients with recent coronary stents (especially <6 months), consider them high thrombotic risk and manage in liaison with interventional cardiology 1
• In major hemorrhage with DAPT, continue aspirin if the P2Y12 inhibitor must be interrupted 1

Warfarin Management

Low-Risk Procedures

• Continue warfarin without interruption 1, 5, 2
• Check INR one week before endoscopy to ensure it is within therapeutic range 1, 5
• If INR is above therapeutic range but <5, reduce daily dose until INR returns to therapeutic range 1
• Proceed with procedure if INR is therapeutic 5

High-Risk Procedures with LOW Thrombotic Risk

• Stop warfarin 5 days before the procedure 1, 2
• Check INR prior to procedure to ensure INR <1.5 1
• No heparin bridging required 2
• Restart warfarin evening of procedure with usual daily dose 1
• Check INR one week later to ensure adequate anticoagulation 1

High-Risk Procedures with HIGH Thrombotic Risk

• Stop warfarin 5 days before the procedure 1, 2
• Start LMWH bridge 2 days after stopping warfarin 2
• Stop LMWH 24 hours before procedure 2
• Check INR prior to procedure to ensure INR <1.5 1
• Restart warfarin evening of procedure 1
• Resume LMWH bridging until INR is therapeutic 2

High Thrombotic Risk Conditions (Requiring Bridging)

• Prosthetic metal heart valve 1
• Atrial fibrillation with mitral stenosis 1
• Atrial fibrillation with previous stroke/TIA 1
• Recent VTE (within 3 months) 1
• Previous VTE on anticoagulation with target INR 3.5 1

Low Thrombotic Risk Conditions (No Bridging Needed)

• Xenograft heart valve 1
• Atrial fibrillation without high-risk factors (CHADS₂ <4) 1

Direct Oral Anticoagulants (DOACs: Apixaban, Rivaroxaban, Edoxaban, Dabigatran)

Low-Risk Procedures

• Omit only the morning dose on the day of the procedure 1, 2
• Resume DOAC after procedure once hemostasis confirmed 2

High-Risk Procedures with Normal Renal Function

• Stop DOACs 48 hours before the procedure 2
• No bridging therapy required 2
• Resume 24-72 hours after procedure based on bleeding risk 2

High-Risk Procedures with Decreased Renal Function (CrCl 30-50 mL/min)

• Stop dabigatran 72 hours before the procedure 2
• Consider prolonging interval for other DOACs 2
• Adjust timing based on renal function 2

SSRIs and Other Medications

SSRIs do not need to be held prior to endoscopy. 6

• SSRIs may have antiplatelet effects but are not routinely discontinued 6
• Warfarin drug label notes SSRIs may increase bleeding risk when combined with anticoagulants, but this does not mandate discontinuation 6
• Consider the psychiatric risk of stopping SSRIs versus the minimal incremental bleeding risk 6

Diabetes and blood pressure medications should be continued with standard perioperative adjustments (hold morning insulin dose, continue antihypertensives). 1

Common Pitfalls to Avoid

• Never stop both antiplatelet agents simultaneously in patients with coronary stents - this dramatically increases stent thrombosis risk 1, 2
• Do not routinely bridge all patients on warfarin - bridging is only for high thrombotic risk patients undergoing high-risk procedures 2
• Do not give high-dose vitamin K (>2.5 mg) for warfarin reversal - this causes prolonged warfarin resistance 7
• Do not forget to check renal function when managing DOACs - clearance is significantly affected by renal impairment, especially for dabigatran 2
• Do not restart anticoagulation too early after polypectomy - wait 24-72 hours based on perceived bleeding risk 2
• Do not unnecessarily withhold warfarin before low-risk procedures - this increases thromboembolic risk without benefit 5