According to a new guideline from the American Society for Gastrointestinal Endoscopy (ASGE) regarding the management of antithrombotic agents for endoscopy, aspirin and/or NSAIDs may be continued for all elective endoscopic procedures. When high-risk procedures are planned, clinicians may elect to discontinue aspirin and/or NSAIDs for five to seven days before the procedure, depending on the underlying indication for antiplatelet therapy. For patients on temporary anticoagulation therapy (e.g., warfarin for deep venous thrombosis), it is suggested that elective endoscopic procedures be deferred until antithrombotic therapy is completed. The guideline, "Management of antithrombotic agents for endoscopic procedures," was developed by ASGE's Standards of Practice Committee and appears in the December issue of GIE: Gastrointestinal Endoscopy, the monthly peer-reviewed scientific journal of the ASGE.
Antithrombotic agents include anticoagulants (e.g., warfarin, heparin, and low molecular weight heparin) and antiplatelet agents (e.g., aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), thienopyridines (e.g., clopidrogrel and ticlopidine), and glycoprotein IIb/IIIa receptor inhibitors. Antithrombotic therapy is used to reduce the risk of thromboembolic events (blocking of a blood vessel by a blood clot dislodged from its site of origin) in patients with certain cardiovascular conditions (e.g., atrial fibrillation and acute coronary syndrome), deep venous thrombosis (DVT), hypercoagulable states, and endoprostheses. The most common site of significant bleeding in patients receiving oral anticoagulation therapy is the gastrointestinal (GI) tract.
"Before performing endoscopic procedures on patients taking antithrombotic medications, one should consider the risks of stopping these medications versus the risk of a complication if the medications are continued. But one must also consider the urgency of the procedure," said Jason A. Dominitz, MD, MHS, FASGE, chair of ASGE's Standards of Practice Committee. "Alternative diagnostic studies for patient evaluation, such as video capsule endoscopy or radiologic studies, may be appropriate in some cases."
Potential thromboembolic events that may occur with the withdrawal of medication can be devastating, whereas bleeding after high-risk procedures, although increased in frequency, is often not associated with any significant morbidity or mortality. Discussion with the patient and his or her prescribing physician before the procedure is invaluable to help determine whether antithrombotic agents should be stopped or adjusted in any particular patient. This guideline is an update of two previous ASGE guidelines and addresses the management of patients undergoing endoscopic procedures who are receiving antithrombotic therapy, providing recommendations and management algorithms.
RECOMMENDATIONS FROM THE ASGE STANDARDS OF PRACTICE COMMITTEE:
Elective Endoscopic Procedures
1. For patients on temporary anticoagulation therapy (e.g., warfarin for DVT), it is suggested that elective endoscopic procedures be deferred until antithrombotic therapy is completed.
2. It is recommended that aspirin and/or NSAIDs may be continued for all endoscopic procedures. When high-risk procedures are planned, clinicians may elect to discontinue aspirin and/or NSAIDs for five to seven days before the procedure, depending on the underlying indication for antiplatelet therapy.
3. It is recommended that elective procedures be deferred in patients with a recently placed vascular stent or acute coronary syndrome (ACS) until the patient has received antithrombotic therapy for the minimum recommended duration per current guidelines from relevant professional societies. Once this minimum period has elapsed, it is suggested that clopidogrel or ticlopidine be withheld for approximately seven to ten days before endoscopy and that aspirin be continued. For those patients not taking aspirin, the addition of aspirin during the time that clopidogrel or ticlopidine is withheld may reduce the risk of thromboembolic events. Clopidogrel or ticlopidine may be reinitiated as soon as deemed safe with consideration of the patient's condition and any therapy performed at the time of endoscopy. Consultation with the patient's cardiologist or other relevant provider may help determine the optimal management of these patients.
4. When clopidogrel and ticlopidine are used for other indications, it is suggested that these medications may be continued for low-risk procedures, but should be discontinued for approximately seven to ten days before higher-risk procedures. For those patients not taking aspirin, the addition of aspirin during the periendoscopic period may reduce the risk of thromboembolic events. Clopidogrel or ticlopidine may be reinitiated as soon as deemed safe with consideration of the patient's condition and any therapy performed at the time of endoscopy.
5. It is suggested to discontinue anticoagulation (ie, warfarin) in patients with a low risk of thromboembolic events in whom it is safe to do so. It is suggested to continue the anticoagulation in patients at higher risk of thromboembolic complications, switching to low molecular weight heparin (LMWH) or unfractionated heparin (UFH) (ie, bridging therapy) around the time of endoscopy when indicated for known or expected therapeutic indications.
6. There is insufficient evidence to recommend for or against the prophylactic use of mechanical clips after polypectomy in patients on anticoagulation.