Gastrointestinal endoscopy in patients on anticoagulant therapy and antiplatelet agents

Abstract

Periprocedural management of antithrombotics for gastrointestinal endoscopy is a common clinical issue, given the widespread use of these drugs for primary and secondary cardiovascular prevention. For diagnostic procedures, with or without biopsy, no adjustments in antithrombotics are usually needed. For operative procedures, balancing the risk of periprocedural hemorrhage with the continuation of antithrombotics against the chance of recurrent thromboembolic events with their discontinuation may be challenging. Oral anticoagulants need to be temporarily withheld, and consideration must be given to whether a periendoscopic “bridge” therapy, typically a low-molecular-weight heparin, should be used in order to minimize the risk of thromboembolic events. Although some emerging evidence has shown that patients receiving heparin bridging appear to be at increased risk of overall and major bleeding and at similar risk of thromboembolic events compared to controls, bridging therapy is still recommended for patients on vitamin K antagonists who are at high thrombotic risk. Conversely, bridging therapy is usually not needed for patients taking new oral agents, which are characterized by shorter half-lives, and a rapid offset and onset of action. Management of antiplatelet therapy requires special care in patients on secondary prevention, especially those with coronary stents. This review is intended to summarize the recommendations of updated International Guidelines designed to help the decision-making process in such an intricate field.

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

“…The findings support the recommendation that aspirin discontinuation in this patient population should be advocated only under circumstances where the risk of adverse outcomes caused by bleeding risk clearly outweighs that of catastrophic atherothrombotic events. These findings have been confirmed in later studies (70)(71)(72)(73)(74)(75)(76)(77)(78)150). Conversely, recently published large-scale evidence (15)(16)(17)(18)(19) shows lack of benefit of aspirin for primary prevention of cardiovascular events, but aspirin therapy is associated with increased bleeding episodes.…”

“…Therefore, overlap between chronic persistent pain and cardiovascular disease has a synergistic impact on physical and psychological health, affecting performance of social responsibilities, including work and family life. Antithrombotic therapy has a clear evidence-based foundation with a favorable risk-benefit profile for prevention and management of cardiovascular disease, including limiting the present and future burden of cardiac or cerebrovascular infarcts (4,5,(15)(16)(17)(18)(19)(55)(56)(57)(58)(67)(68)(69)(70)(71)(72)(73)(74)(75)(76)(77)(78)(79)(80)(81). Of note, a significant proportion of patients with established cerebrovascular, cardiovascular or peripheral vascular disease who are receiving antithrombotic therapy, are commonly in need of interventions including surgery and interventional pain management techniques, despite the debate regarding their safety, clinical and cost effectiveness, and indications with numerous regulations (1,(22)(23)(24)(25)(26)(27)(28)(29)(30).…”

Biopsy in emergency gastroscopy does not increase the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding combined with suspected malignant gastric ulcer: a multicenter retrospective cohort study

“…operation procedure: Proportion → Two Independent Proportions → Test (Inequality) → Tests for Two Proportions (Ratios). According to guidelines, the rebleeding rate of Forrest I ANVUGIB is 55%, and we hypothesized that a biopsy has a low risk effect (RR = 1.2) at increasing rebleeding compared with no biopsy [ 9 , 13 ]. To detect this difference with 80% power and a significance level of 0.05, 307 patients were considered necessary for each group.…”

Gastrointestinal Endoscopy in Patients on Direct Oral Anticoagulants. A Consensus Paper of the Romanian Society of Gastroenterology and Hepatology

“…The endoscopic procedure should be performed when the DOAC level is at its lowest, so the anticoagulant effect. In general, because of their short half-life, DOACs can be continued until shortly before the procedure, and because of their rapid onset of action, the anticoagulation effect is achieved within a few hours after reinitiating the treatment [43]. These DOACs properties proved that bridging therapy with parenteral unfractionated or low molecular weight heparin is unnecessary, obviating the inconveniences of heparin therapy and of laboratory testing of coagulation parameters [44,45].…”

“…For high-risk elective endoscopic procedures the general recommendation is to take the last DOAC dose at least 48 hours before the procedure (4 to 5 half-lives). For patients with a CrCl 30-50 mL/min on dabigatran the last dose should be taken at least 72 hours before the procedure (very low quality evidence, weak recommendation) [33,34,36,43].…”