Management of Antithrombotic Agents for Patients Undergoing GI Endoscopy

Publication Date: January 1, 2016
Last Updated: March 14, 2022

RECOMMENDATIONS

Elective endoscopic procedures

Patients receiving anticoagulant therapy

We recommend that elective endoscopic procedures be deferred until short-term anticoagulation therapy (eg, warfarin for VTE) is completed. (, ⊕⊕⊕o)
312101
We suggest discontinuing anticoagulation (ie, warfarin [Coumadin], NOACs) for the appropriate drug-specific interval in the periendoscopic period if high-risk endoscopic procedures are planned in a patient at low risk for thromboembolic events. (, ⊕⊕oo)
312101
We suggest continuing warfarin and NOAC in the periendoscopic period in patients undergoing low-risk endoscopic procedures. (, ⊕⊕oo)
312101
We suggest bridge therapy for patients undergoing high-risk endoscopic procedures who are at high risk for thromboembolic events. (, ⊕⊕oo)
312101
We suggest that warfarin (Coumadin) be restarted on the same day as the procedure in all patients who do not have ongoing bleeding. (, ⊕⊕oo)
312101
We suggest that the reinitiation of NOACs after high-risk endoscopic procedures be delayed until adequate hemostasis is ensured, given their rapid onset of action and lack of reversal agents. If therapeutic doses of NOACs cannot be restarted within 12 to 24 hours after a high-risk endoscopic procedure, thromboprophylaxis (ie, UFH bridge) should be considered to decrease risk of thromboembolism, given the short half-life of the NOAC agent, in those with a high risk for thromboembolism. (, ⊕⊕oo)
312101

Patients receiving APA therapy

We suggest that continuation of low doses of ASA and nonsteroidal anti-inflammatory drugs may be continued safely in the periendoscopic period. (, ⊕⊕⊕o)
312101
We recommend that thienopyridines be continued for all low-risk endoscopic procedures. (, ⊕⊕⊕o)
312101
We recommend discontinuation of thienopyridines at least 5 to 7 days before high-risk endoscopic procedure or switching to ASA monotherapy and continuing until the thienopyridine can be safely resumed. (, ⊕⊕⊕o)
312101
We recommend that elective endoscopic procedures be deferred in patients with recently placed intracoronary stents and/or ACS until the patient has received antithrombotic therapy for the minimum recommended duration. (, ⊕⊕⊕o)
312101
We suggest that thienopyridines be withheld for at least 5 to 7 days (ticagrelor 3-5 days) before high-risk endoscopic procedures and that ASA be continued for patients requiring dual APA. (, ⊕⊕⊕o)
312101

Urgent and emergent endoscopic procedures

Patients receiving anticoagulant therapy

We recommend patients with acute GI bleeding on anticoagulation therapy have anticoagulant agents held to facilitate achievement of hemostasis.

(, ⊕⊕⊕o)
312101
We recommend either:

(1) 4-factor PCC and vitamin K or
(2) fresh frozen plasma be given for life-threatening GI bleeding in patients on warfarin anticoagulant therapy.

Please note the ACCP advocates only option 1. The AHA/ACC supports option 1 or 2. (, ⊕⊕⊕o)
312101
We suggest endoscopic therapy not be delayed in patients with serious GI bleeding and an INR < 2.5. (, ⊕⊕oo)
312101
We suggest patients who require anticoagulation receive UFH because of its relatively short half-life after successful endoscopic hemostasis for high-risk stigmata. (, ⊕⊕oo)
312101

Patients receiving APA therapy

We recommend consultation with the prescribing specialist (or their colleague) before stopping APAs in situations of significant GI bleeding in patients

(1) with recently (<1 year) placed drug eluting intracoronary stents,
(2) within 30 days after insertion of a bare metal intracoronary stent, or
(3) within 90 days of ACS. The risk of an adverse cardiac event associated with cessation of the APA therapy likely exceeds the benefit of decreasing postendoscopic bleeding.

(, ⊕⊕⊕o)
312101
We recommend patients on APAs with life-threatening or serious GI bleeding should have these agents held after discussion with their cardiologist. (, ⊕⊕⊕o)
312101

Recommendation Grading

Overview

Title

Management of Antithrombotic Agents for Patients Undergoing GI Endoscopy

Authoring Organization

American Society for Gastrointestinal Endoscopy

Publication Month/Year

January 1, 2016

Last Updated Month/Year

May 31, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Laboratory services, Operating and recovery room, Outpatient

Intended Users

Laboratory technician, nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D001778 - Blood Coagulation Disorders, D016099 - Endoscopy, Gastrointestinal

Keywords

antiplatelet, Antithrombotic Agents, GI endoscopy

Source Citation

Acosta, R. D., Abraham, N. S., Chandrasekhara, V., Chathadi, K. V., Early, D. S., Eloubeidi, M. A., … DeWitt, J. M. (2016). The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointestinal Endoscopy, 83(1), 3–16. doi:10.1016/j.gie.2015.09.035