Should I hold the prophylactic dose of enoxaparin (Lovenox) before my elective esophagogastroduodenoscopy (EGD) scheduled for tomorrow?

Management of Prophylactic Enoxaparin Before EGD

For a diagnostic EGD (low-risk procedure), you should NOT hold prophylactic enoxaparin—continue it through the procedure. 1

Risk Stratification of Your EGD

The critical first step is determining whether your EGD is low-risk or high-risk for bleeding:

• Low-risk EGD includes diagnostic endoscopy with or without biopsies, which represents the vast majority of routine upper endoscopies 2, 1
• High-risk EGD includes therapeutic interventions such as polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), dilation of strictures, variceal therapy, or PEG placement 2, 1

A common pitfall is unnecessarily holding prophylactic anticoagulation for routine diagnostic procedures—this increases thrombotic risk without meaningful bleeding risk reduction. 1

Management for Low-Risk Diagnostic EGD

Continue prophylactic enoxaparin without any dose adjustment or timing changes. 1 The BSG/ESGE guidelines support continuing anticoagulation for low-risk endoscopic procedures, as the bleeding risk does not meaningfully increase while the thrombotic risk of interruption can be significant 2

Management for High-Risk Therapeutic EGD

If your EGD involves therapeutic interventions, the approach depends on your thrombotic risk:

For Patients at Low Thrombotic Risk:

• Omit the last prophylactic enoxaparin dose at least 24 hours before the procedure 1, 3
• No bridging anticoagulation is required 1
• Resume prophylactic enoxaparin 24-72 hours after the procedure once adequate hemostasis is confirmed 1

For Patients at High Thrombotic Risk:

High thrombotic risk conditions include: 1

• Drug-eluting coronary stent placed within the past 12 months
• Bare-metal coronary stent placed within the past 1 month
• Prosthetic mechanical mitral valve
• Atrial fibrillation with mitral stenosis
• Venous thromboembolism within the past 3 months

For these patients, therapeutic-dose LMWH bridging is recommended rather than simple omission: 1

• If on warfarin, stop it 5 days before the procedure 2
• Start therapeutic-dose LMWH 2 days after warfarin cessation 2
• Give the final LMWH dose at least 24 hours before the procedure 1
• Resume therapeutic LMWH the day after the procedure until target anticoagulation is re-established 1

Key Clinical Considerations

The evidence strongly supports that continuing prophylactic enoxaparin during low-risk endoscopy does not meaningfully increase bleeding risk and therefore outweighs the thrombotic risk associated with omission 1. This represents a shift from older, more conservative practices that routinely held all anticoagulation.

For therapeutic-dose enoxaparin (not prophylactic), the timing is more critical—hold for 12-24 hours before high-risk procedures 3. However, your question specifically asks about prophylactic dosing, where the 24-hour window is appropriate 1.

The most important action is to clarify with your endoscopist whether any therapeutic interventions are planned. If this is purely diagnostic, continue your prophylactic enoxaparin without interruption 1.