Management of Prophylactic Enoxaparin Before Endoscopic Procedures
For routine diagnostic endoscopy (low-risk procedures), prophylactic enoxaparin does not need to be withheld and can be continued without interruption. 1
Risk Stratification of Endoscopic Procedures
The decision to withhold enoxaparin depends entirely on whether the procedure is classified as low-risk or high-risk:
Low-Risk Procedures (Continue Enoxaparin)
- Diagnostic endoscopy with or without biopsies 1, 2
- Biliary or pancreatic stenting 1
- Device-assisted enteroscopy without polypectomy 1
For all low-risk procedures, continue prophylactic enoxaparin without any dose adjustments or interruptions. 1
High-Risk Procedures (Consider Withholding)
- Polypectomy 1
- ERCP with sphincterotomy 1
- Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) 1
- Endoscopic dilation of strictures 1
- Endoscopic therapy of varices 1
- Percutaneous endoscopic gastrostomy (PEG) 1
- Endoscopic ultrasound with fine needle aspiration 1
- Esophageal, enteral, or colonic stenting 1
Management for High-Risk Procedures
Patients at Low Thrombotic Risk
For high-risk procedures in patients at low thrombotic risk, withhold the last dose of prophylactic enoxaparin at least 24 hours before the procedure. 1, 2
- No bridging therapy is required 1, 2
- Resume enoxaparin 24-72 hours after the procedure once adequate hemostasis is confirmed 1, 3
Patients at High Thrombotic Risk
High thrombotic risk conditions include: 1
- Drug-eluting coronary stents within 12 months 1, 3
- Bare metal coronary stents within 1 month 1, 3
- Prosthetic metal heart valve in mitral position 1, 2
- Atrial fibrillation with mitral stenosis 1, 2
- Less than 3 months after venous thromboembolism 1
For high-risk procedures in patients at high thrombotic risk, therapeutic-dose LMWH bridging should be used rather than simply withholding prophylactic enoxaparin. 1
The protocol involves: 1
- Stop warfarin (if applicable) 5 days before the procedure
- Start therapeutic-dose LMWH 2 days after stopping warfarin
- Administer the last dose of LMWH at least 24 hours before the procedure
- Resume therapeutic LMWH the day after the procedure until adequate anticoagulation is re-established
Critical Clinical Considerations
Missing prophylactic enoxaparin doses significantly increases VTE risk—nearly doubling the odds of thromboembolism in trauma patients. 4 This underscores that the decision to withhold enoxaparin should not be made lightly, as most doses are held for procedures rather than actual bleeding events. 4
The bleeding risk from continuing prophylactic enoxaparin during low-risk endoscopy is minimal and does not outweigh the thrombotic risk of withholding it. 1
Common Pitfall to Avoid
Do not reflexively hold all anticoagulation for "scopes"—the vast majority of diagnostic endoscopies are low-risk procedures where prophylactic enoxaparin can and should be continued. 1, 2 Only therapeutic interventions during endoscopy warrant consideration of withholding enoxaparin. 1