Should anticoagulation be held before a colonoscopy or EGD in a patient on anticoagulant therapy?

Management of Anticoagulation Before Colonoscopy and EGD

For diagnostic colonoscopy or EGD with biopsies only, continue anticoagulation without interruption; for therapeutic procedures like polypectomy or sphincterotomy, hold warfarin for 5 days and DOACs for 48 hours (72 hours if CrCl 30-50 mL/min), checking INR <1.5 before high-risk procedures. 1

Risk Stratification by Procedure Type

The first critical step is determining whether your endoscopic procedure carries low or high bleeding risk:

Low-Risk Procedures (Continue Anticoagulation)

• Diagnostic EGD with standard forceps biopsies 1
• Diagnostic colonoscopy with standard forceps biopsies 1, 2
• ERCP with stent placement (without sphincterotomy) 1

For these procedures, continue warfarin and ensure INR remains within therapeutic range during the week before the procedure 1. No bridging is needed 1.

High-Risk Procedures (Hold Anticoagulation)

• Polypectomy 1
• Endoscopic sphincterotomy 1
• Endoscopic mucosal resection or submucosal dissection 1
• Dilation of strictures 1
• Treatment of varices 1
• PEG tube placement 1

Warfarin Management

For Low Thrombotic Risk Patients

• Stop warfarin 5 days before the procedure 1
• Check INR prior to procedure to ensure <1.5 1
• Resume warfarin the evening of the procedure with usual dose 1, 2
• No heparin bridging is recommended 1, 2

For High Thrombotic Risk Patients

High thrombotic risk includes: drug-eluting stents within 12 months, bare metal stents within 1 month, mechanical mitral valve, atrial fibrillation with CHADS-VASc >5, VTE within 3 months, or severe thrombophilia 1.

• Stop warfarin 5 days before procedure 1
• Start therapeutic-dose LMWH 2 days after stopping warfarin 1
• Give last LMWH dose at least 24 hours before procedure 1
• Check INR prior to procedure to ensure <1.5 1
• Resume warfarin evening of procedure 1
• Restart therapeutic LMWH the day after procedure 1
• Continue LMWH until therapeutic INR achieved 1

Direct Oral Anticoagulant (DOAC) Management

For Normal Renal Function

• Stop DOACs 48 hours before high-risk procedures 1, 3
• Resume DOACs 24-48 hours after procedure once hemostasis established 1, 3
• No heparin bridging is recommended 1, 3

For Moderate Renal Impairment (CrCl 30-50 mL/min)

• For dabigatran specifically: stop 72 hours before procedure 1, 3
• For apixaban with CrCl 30-50 mL/min: stop 72 hours before procedure 3
• Check renal function before determining discontinuation timeline 3
• Consult hematology if renal function rapidly deteriorating 1, 3

Antiplatelet Agent Management

Aspirin

• Continue aspirin for all elective procedures 1
• Only withhold aspirin for serious or life-threatening active bleeding 1

P2Y12 Inhibitors (Clopidogrel, Prasugrel, Ticagrelor)

For patients on dual antiplatelet therapy (DAPT) after coronary stenting:

Very High Risk (ACS or PCI <6 weeks):

• Defer elective procedure entirely 1

High Risk (ACS or PCI 6 weeks to 6 months):

• Continue aspirin 1
• Withhold P2Y12 inhibitor 5 days before procedure 1
• Resume P2Y12 inhibitor after adequate hemostasis 1
• Consult cardiology before stopping P2Y12 inhibitors 1

Moderate-Low Risk (>6 months post-PCI or stable CAD):

• Continue aspirin 1
• Withhold P2Y12 inhibitor 5 days before procedure 1

Critical Bleeding Risk Data

Recent evidence demonstrates specific bleeding rates that inform decision-making:

• Polypectomy on continued warfarin: 0.8% transfusion rate for polyps <1 cm 2
• Hot snare polypectomy in anticoagulated patients: 23% immediate bleeding, 14% delayed bleeding requiring intervention 2
• Cold snare polypectomy in anticoagulated patients: 5.7% immediate bleeding, 0% delayed bleeding 2
• Continuing anticoagulation during EMR: 4.7% major bleeding rate, lower than heparin bridging 4

Critical Pitfalls to Avoid

Never routinely bridge low thrombotic risk patients with LMWH - this increases bleeding risk without reducing thrombotic events 2, 3. The BRIDGE trial definitively showed bridging causes more harm than benefit in most patients 1.

Never use hot snare technique for polypectomy in anticoagulated patients - cold snare dramatically reduces bleeding (0% vs 14% delayed hemorrhage) 2.

Never give vitamin K for DOAC-associated bleeding - it is ineffective 1.

Monitor for delayed bleeding up to 14-15 days post-polypectomy - this can occur even with proper anticoagulation management 2.

Resumption of Anticoagulation

Resume anticoagulation 24-48 hours after procedure depending on bleeding risk and adequacy of hemostasis 1, 3. For warfarin, restart the usual evening dose on the day of procedure 1, 2. For DOACs, the rapid onset of action (within hours) means therapeutic anticoagulation is quickly re-established 1.