Post-polypectomy bleeding and thromboembolism risks associated with warfarin<i>vs</i>direct oral anticoagulants

Yanagisawa, Naohiro; Nagata, Naoyoshi; Watanabe, Kazuhiro; Iida, Tatsuhiro; Hamada, Mariko; Kobayashi, Shinzo; Shimbo, Takuro; Akiyama, Junichi; Uemura, Naomi

doi:10.3748/wjg.v24.i14.1540

Cited by 40 publications

(59 citation statements)

References 33 publications

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“…A 2012 study, which compared patients on dabigatran to patients on warfarin, found similar risks of peri-procedural bleeding and thromboembolic events between the two medications 16 . More recent studies have suggested DOACs may have a lower risk of post-polypectomy bleeding compared to warfarin 11,17,18 in line with our study findings. Similarly, clopidogrel use has also been associated with an increased risk of post-polypectomy bleeding 19,20 .…”

Section: Accepted Manuscript 14supporting

confidence: 92%

Patients Prescribed Direct-Acting Oral Anticoagulants Have Low Risk of Postpolypectomy Complications

Oliver

Lin

et al. 2019

Clinical Gastroenterology and Hepatology

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Background & Aims: Use of direct-acting oral anticoagulants (DOACs) is increasing, but little is known about the associated risks in patients undergoing colonoscopy with polypectomy. We aimed to determine the risk of post-polypectomy complications in patients prescribed DOACs. Methods: We performed a retrospective analysis using the Clinformatics Data Mart Database (a de-identified administrative database from a large national insurance provider) to identify adults who underwent colonoscopy with polypectomy or endoscopic mucosal resection (EMR) from January 1, 2011, through December 31, 2015. We collected data from 11,504 patients prescribed antithrombotic agents (1590 DOAC, 3471 warfarin, and 6443 clopidogrel) and 599,983 patients not prescribed antithrombotics of interest (controls). We compared 30-day post-polypectomy complications, including gastrointestinal bleeding (GIB), cerebrovascular accident (CVA), myocardial infarction (MI), and hospital admissions, of patients prescribed DOACs, warfarin, or clopidogrel vs controls. Results: Post-polypectomy complications were uncommon but occurred in a significantly higher proportion of patients receiving any antithrombotic vs controls (P<0.001). The percentage of patients in the DOAC group with GIB was 0.63% (95% CI, 0.3%-1.2%) vs 0.2% (95% CI, 0.2%-0.3%) in controls. The percentage of patients with CVA in the DOAC group was 0.06% (95% CI, 0.01%-0.35%) vs 0.04% (95% CI, 0.04%-0.05%) in controls. After we adjusted for bridge anticoagulation, EMR, Charlson comorbidity index (CCI), and CHADS 2 (congestive heart failure, hypertension, age over 75, diabetes, stroke [double weight]) score, patients prescribed DOACs no longer had a

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Section: Accepted Manuscript 14supporting

confidence: 92%

Patients Prescribed Direct-Acting Oral Anticoagulants Have Low Risk of Postpolypectomy Complications

Oliver

Lin

et al. 2019

Clinical Gastroenterology and Hepatology

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“…A study by Beppu et al has shown that edoxaban (a direct factor Xa inhibitor) had the lowest PPB rate among the four current DOACs on the market and the use of DOACs (interrupted 1 day before the treatment procedure and restarted within 24 h after the procedure in this study) carried a similar safety profile, decreased the rate of delayed PPB, and reduced the length of hospital stay, compared with heparin bridge therapy. 18 A similar study by Yanagisawa et al 19 showed comparable rates of delayed PPB between warfarin and all DOACs (no patients on edoxaban). Predictive models for PPB in patients receiving warfarin and DOACs, such as the Outcomes Registry for Better Informed Treatment score 20 and a risk-scoring model from China, 21 have been proposed but are yet to be validated for widespread use.…”

Section: Risk Factorsmentioning

confidence: 75%

Endoscopic Management of Post-Polypectomy Bleeding

Gutta

Gromski

2020

Clin Endosc

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Post-polypectomy bleeding (PPB) is one of the most common complications of endoscopic polypectomy. There are multiple risk factors related to patient and polyp characteristics that should be considered. In most cases, immediate PPB can be effectively managed endoscopically when recognized and managed promptly. Delayed PPB can manifest in a myriad of ways. In severe delayed PPB, resuscitation for hemodynamic stabilization should be prioritized, followed by endoscopic evaluation and therapy once the patient is stabilized. Future areas of research in PPB include the risks of direct oral anticoagulants and of specific electrosurgical settings for hot-snare polypectomy vs. cold-snare polypectomy, benefits of closure of post-polypectomy mucosal defects using through-the-scope clips, and prospective comparative evaluation of newer hemostasis agents such as hemostatic spray powder and over-the-scope clips.Clin Endosc 2020;53:302-310

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“…In this regard, also the role of bridging need to be better assessed, as recent data suggest that patients undergoing bridging with LMWH are at higher risk of procedural-related bleeding compared to patients not undergoing bridging with LMWH or continuing warfarin therapy[ 40 , 41 ]. On the same line, a recent study showed as patients discontinuing anticoagulant with LMWH bridging, as suggested by guidelines, had a higher PPB rate compared to patients continuing anticoagulants (19.6% vs 10.8%, P = 0.087)[ 42 ]. Based on these observations, recommendation on bridging therapy should be revised, and the choice should be individualized, taking into account the hemorrhagic and thromboembolic risk of each patient.…”

Section: Risk Of Bleeding Associated With Endoscopic Proceduresmentioning

confidence: 99%

“…With regard to DOACs, the risk of PPB is not well known. The aforementioned study, comparing post-polypectomy complication rates in 218 patients receiving oral anticoagulants (73 DOACs, 145 warfarin) and 218 patients not receiving anticoagulant therapy, showed that the PPB was similar between DOACs and warfarin and higher for both compared with controls (13.7% vs 13.7% vs 0.9%, P < 0.001)[ 42 ].…”

Section: Risk Of Bleeding Associated With Endoscopic Proceduresmentioning

confidence: 99%

Management of antiplatelet or anticoagulant therapy in endoscopy: A review of literature

Maida¹,

Sferrazza

Maida

et al. 2020

WJGE

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Endoscopic procedures hold a basal risk of bleeding that depends on the type of procedure and patients’ comorbidities. Moreover, they are often performed in patients taking antiplatelet and anticoagulants agents, increasing the potential risk of intraprocedural and delayed bleeding. Even if the interruption of antithrombotic therapies is undoubtful effective in reducing the risk of bleeding, the thromboembolic risk that follows their suspension should not be underestimated. Therefore, it is fundamental for each endoscopist to be aware of the bleeding risk for every procedure, in order to measure the risk-benefit ratio for each patient. Moreover, knowledge of the proper management of antithrombotic agents before endoscopy, as well as the adequate timing for their resumption is essential. This review aims to analyze current evidence from literature assessing, for each procedure, the basal risk of bleeding and the risk of bleeding in patients taking antithrombotic therapy, as well as to review the recommendation of American society for gastrointestinal endoscopy, European society of gastrointestinal endoscopy, British society of gastroenterology, Asian pacific association of gastroenterology and Asian pacific society for digestive endoscopy guidelines for the management of antithrombotic agents in urgent and elective endoscopic procedures.

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Post-polypectomy bleeding and thromboembolism risks associated with warfarinvsdirect oral anticoagulants

Cited by 40 publications

References 33 publications

Patients Prescribed Direct-Acting Oral Anticoagulants Have Low Risk of Postpolypectomy Complications

Patients Prescribed Direct-Acting Oral Anticoagulants Have Low Risk of Postpolypectomy Complications

Endoscopic Management of Post-Polypectomy Bleeding

Management of antiplatelet or anticoagulant therapy in endoscopy: A review of literature

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