Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines

Abstract

The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy.P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor)For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation).WarfarinThe advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance.Direct Oral Anticoagulants (DOAC)For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30–50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).

Gastrointestinal Bleeding With the Use of New Oral Anticoagulants: Epidemiology, Risk Factors, Treatment, and Prevention

“…2). После пла-нового вмешательства вернуться к приему НОАК возмож-но через 12-24 ч в обычных случаях и через 48 ч в группах высокого риска, если манипуляция прошла без осложне-ний [56].…”

Procedimientos endoscópicos y terapias antitrombóticas, una visión actual

“…A continuación, se presenta un resumen de las principales recomendaciones registradas en las guías de la ESGE 2016 (26).…”

Management of anticoagulant and antiplatelet therapy in patients undergoing interventional pulmonary procedures

“…Current guidelines on the use of antiplatelet and anticoagulant agents for patients undergoing endoscopic ultrasound (EUS) [7] recommend no interruption in therapy for patients on clopidogrel, prasugrel or ticagrelor who are undergoing diagnostic EUS. For patients undergoing high-risk procedures, including EUS with fine needle aspiration (FNA) it is recommended to discontinue therapy 5 days prior to the procedure for patients without coronary stents.…”

“…Surprisingly, statements on interventional pulmonology from the American College of Chest Physicians [4] and the European Respiratory Society/ American Thoracic Society [5] do not discuss the management of these medications in the peri-procedural setting. There are some guidelines on management of antithrombotic and antiplatelet agents in patients undergoing endoscopic procedures [6,7] as well as those undergoing diagnostic flexible bronchoscopy [8], but there are no specific guidelines to date regarding the management of antithrombotic agents in patients undergoing interventional pulmonary procedures.…”