Oral anti-thrombotic therapy-management in patients requiring endoscopy Management of anti-thrombotic therapy in patients requiring endoscopy This guideline suggests appropriate management of patients undergoing endoscopic s who are on oral anti-coagulation therapy, aspirin, nonsteroidal antiinflammatory drugs (NSAIDS) or antiplatelets. When preparing a patient on anti-thrombotic agents for endoscopy considerations should include 1. The risk of complications of the underlying gastrointestinal disorder related directly to anti-thrombotic therapy 2. Bleeding related to an endoscopic and 3. A thromboembolic event related to interruption of anti-thrombotic therapy. The decision to reverse anticoagulation/anti-platelets, risking thromboembolic consequences, must be weighed against the risk of continued bleeding by maintaining the anti-thrombotic state. When anticoagulation therapy is temporary, such as for DVT, elective s should be delayed, if possible, until anticoagulation is no longer indicated. Patients should be advised that there is an increased risk of post bleeding compared with non-anticoagulated patients. In order to use this guideline effectively, identify the endoscopy procedural risk from the list below and then select the oral anti-thrombotic agent from the list in Appendix 1. Follow the flow chart accordingly. Endoscopy Procedural Risks Low risk s Gastroscopy +/- biopsy Flexible sigmoidoscopy +/- biopsy Colonoscopy* +/- biopsy Biliary or pancreatic stenting Oesophageal stent insertion Diagnostic EUS (endoscopic ultrasound) High risk s Gastric and colonoscopic polypectomy Dilatation of strictures Percutaneous endoscopic gastrostomy (PEG) Therapy of varices, Argon plasma coagulation (APC) Endoscopic mucosal resection (EMR) EUS and fine needle aspiration (FNA) ERCP +/- sphincterotomy. *NB It is reasonable to manage elective colonoscopy as a high risk as it is impossible to predict if polypectomy will be required. Page 1 of 5
Additional considerations Aspirin and NSAIDs should continue for all elective low and high risk endoscopy s For patients on dual therapy with aspirin and dipyridamole, it is advised to omit dipyridamole 1 day prior to high risk endoscopy s (and restart after ). Advice to restart any oral anti-thrombotic agents as normal post assumes there is no clinically significant risk of ongoing bleeding. Clinical judgment may override standard advice. Patients on long term LMWH prior to should be discussed with the endoscopist. For dabigatran APTT may help assess anticoagulant effect. For rivaroxiban PT may help assess anticoagulant effect. Liaise with haematology as appropriate. References ASGE. Management of antithrombotic agents for endoscopic s Gastrointest Endosc 2009; 70; 6: 1060-1070 Boustiere C et al. ESGE guideline: Endoscopy and antiplatelet agents. Endoscopy 2011;43:445-458 Woodhouse C et al. The new oral anticoagulants: practical management for patients attending for endoscopic s. Frontline Gastroenterology 2013;4:213 218 Veitch AM et al Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic s. Gut 2008;57:1322 1329. Page 2 of 5
Appendix 1 Clopidogrel/Ticagrelor*/Prasugrel High risk s Low risk s Low risk conditions 1 High risk conditions 2 Continue as normal Stop 7 days* before If patient on aspirin, continue aspirin. If not on aspirin consider prescribing 75mg od whilst antiplatelet is stopped Stop 7 days* before if appropriate NB- Discontinuation should only be considered after discussion with Cardiologist. (If bare metal stents were placed >1 month ago then clopidogrel could be temporarily discontinued. If drug eluding stents were placed >6 months ago and the is essential, then it may be safe to temporarily discontinue clopidogrel.) Restart the day following *Ticagrelor can be stopped 5-7 days before 1 Low risk condition: Ischaemic heart disease without coronary stent, cerebrovascular disease, peripheral vascular disease. 2 High Risk condition: Drug eluting coronary artery stents within 12 month of placement. Bare metal coronary artery stents within 1 month of placement Page 3 of 5
Warfarin/Acenocoumarol/Phenindione High risk Low risk Low risk conditions 1 High risk conditions 2 Continue Stop 5 days before endoscopy Check INR is <1.5 prior to Restart day of with usual daily dose. Ensure patient has INR checked after 1 week (State instructions in Endoscopy report) Stop 5 days before endoscopy 2 days after stopping commence treatment dose LMWH** Omit LMWH on day of Check INR is <1.5 on day of Restart warfarin/acenocoumarol/phenindione on day of with usual daily dose. Restart treatment dose LMWH the day after the & continue until appropriate INR achieved. Check INR 5-7 days before endoscopy. If INR within therapeutic range continue usual daily dose. If INR above therapeutic range but <5 reduce daily dose until INR returns to therapeutic range Check INR is in range on day of **Arrange with DVT service (Ext 6378) on individual patient basis. Patients will need a prescription for LMWH. 1 Low risk condition: Prosthetic metal heart valve in aortic position, xenograft heart valve, atrial fibrillation (AF) without valvular disease, > 3 months after venous thromboembolism. 2 High Risk condition: Prosthetic metal heart valve in mitral position, prosthetic heart valve and AF, AF and mitral stenosis, < 3 months after venous thromboembolism and thrombophilia syndromes. Page 4 of 5
Dabigatran/Rivaroxaban Wirral University Teaching Hospital High risk Check renal function Low risk egfr >50ml/min stop 24-48hours pre- egfr 30-50ml/min stop 4 days pre- egfr <30ml/min stop 5 days pre- egfr >50ml/min stop 24hours pre- egfr 30-50ml/min stop 48hours pre- egfr <30ml/min stop 72hours pre- Restart 48 hours post- (twice daily dose of dabigatran and once daily dose of rivaroxaban) For patients at high risk of thrombosis consider bridging with treatment dose LMWH until considered safe to restart normal anticoagulant ** Restart 6-8hours post- (single dose of dabigatran and usual once daily dose of rivarixiban) Continue usual dose thereafter **Arrange with DVT service (Ext 6378) on individual patient basis. Patients will need prescription for LMWH. Apixaban High risk Low risk Stop >48hours before Continue usual dose thereafter Stop >24hours before Page 5 of 5