Bleeding Prophylaxis in Bleeding Disorder Patients Undergoing GI Endoscopy
Recommendations
For All Bleeding Disorder Patients
Advise pre-treatment with antifibrinolytic therapy,* continue for 5 days if forceps biopsy or polypectomy for polyp <8 mm, up to 10 days if larger polyp or endoscopic mucosal resection or endoscopic variceal ligation or ERCP with sphincterotomy or hemorrhoidectomy.
* antifibrinolytic therapy-tranexamic acid 1.3 g PO tid or epsilon aminocaproic acid 50–100mg/kg PO q6h beginning 1–24 hrs pre-procedure.
For Moderate or Severe Hemophilia or Severe VWD on Prophylaxis
Advise moving the prophylactic factor dose to the day of the procedure adjusting to goal of 80–100% 1 hr pre-procedure and repeat same dose 24 hrs later if forceps biopsy or polypectomy done. If polyp >7 mm or endoscopic mucosal resection or ERCP with sphincterotomy, continue for up to 7 days and up to 10 days if bleeding.
For the Non-inhibitor Hemophilia a Patient on Emicizumab
Advise infusing with FVIII to goal 80–100% pre-procedure and repeat same dose 24 hrs later as above and possibly longer pending type and size of lesion as above.
For the Inhibitor Hemophilia a Patient on Emicizumab
Infuse rVIIa pre-procedure 90–120 mcg/kg and repeat the same dose q2h × 2 doses on the day of procedure and consider weaning dose to every 8–12 hours for several more days pending the type and size of lesion as above.
For the Known DDAVP Responsive Type 1 VWD, Low VWF or Mild Hemophilia Patient
Administer IN or IV DDAVP 60–90 min pre-procedure and consider repeat dose based on bleeding phenotype and likelihood of adequate fluid restriction 24 hrs later if forceps biopsy or polypectomy. If polyp >7 mm or endoscopic mucosal resection, consider repeat dose post-procedure day #7–9.
For Endoscopic Variceal Ligation or Hemorrhoidectomy
Infuse 100% pre-dose and continue to infuse daily × 7 days.
For Mild Platelet Function Disorders
Pre-administer IN/IV DDAVP 60–90 min pre-procedure and repeat dose 24 hrs later if forceps biopsy or polypectomy. If polyp >7 mm or endoscopic mucosal resection, consider repeat dose DDAVP post-procedure day #7–9.
For Severe Platelet Function Disorders (Glanzmann Thrombasthenia, Bernard Soulier Syndrome)
Pre-administer rVIIa 90–120 mcg/kg then q2h × 2 more doses (minimum) and repeat dose 24 hrs later if forceps biopsy or polypectomy. If polyp >7 mm or endoscopic mucosal resection, consider platelet transfusion (HLA matched, leuco-reduced) pre-procedure based on bleeding phenotype and consider repeat dose of rVIIa post-procedure day #7–9.
Recommendation Grading
Overview
Title
Bleeding Prophylaxis in Bleeding Disorder Patients Undergoing GI Endoscopy
Authoring Organization
National Hemophilia Foundation
Publication Month/Year
March 16, 2020
Last Updated Month/Year
February 19, 2024
Document Type
Consensus
External Publication Status
Published
Country of Publication
US
Document Objectives
The need for prophylaxis in persons with hemophilia (PWH) due to the relatively frequent use of endoscopy in general medical care of patients with gastrointestinal signs and symptoms and the implementation of population‐based colorectal cancer screening with surveillance colonoscopies
Target Patient Population
Patients with hemophilia undergo colonoscopies
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Laboratory services, Outpatient, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management, Prevention
Diseases/Conditions (MeSH)
D003113 - Colonoscopy, D004724 - Endoscopy, D006467 - Hemophilia A, D002836 - Hemophilia B
Keywords
prophylaxis, hemophilia