Recent clinical management of antithrombotic agents for gastrointestinal endoscopy after revision of guidelines in Japan

Abstract

In 2012, the Japan Gastroenterological Endoscopy Society (JGES) revised guidelines for the management of gastrointestinal endoscopy for patients using antithrombotic agents. The conventional guidelines emphasized reducing the bleeding risk that accompanies gastrointestinal endoscopy, but the present guidelines prioritize reduction of thromboembolism risk during discontinuation of antithrombotic agents, which is consistent with Western guidelines. When the advantages outweigh the disadvantages, the guidelines permit endoscopic biopsy and high‐bleeding‐risk procedures without discontinuation of selected antithrombotic agents. These guidelines created a paradigm shift that has slowly, but surely, changed clinical daily practice in Japan. As a result, endoscopic biopsy without discontinuation of antithrombotic agents has been widely accepted, although solid evidence for its support is still lacking. Additionally, feasibility of high‐bleeding‐risk procedures without discontinuation of selected antithrombotic agents is also controversial because evidence newly acquired after publication of the present guidelines is low in evidence level. Consequently, clinical studies with a high evidence level, including randomized controlled studies, are mandatory to establish reliable upcoming guidelines. At the same time, under the present guidelines, the accomplishment of such studies in Japan is expected.

Current Status in the Treatment of Acute Cholecystitis Patients Receiving Antithrombotic Therapy: Is Endoscopic Drainage Feasible?- A Systematic Review

“…Guidelines from the Japan Gastroenterological Endoscopy Society 74 stipulate that low-bleeding-risk procedures can be performed without discontinuation of all types of antithrom- botic agents, although procedures with a high bleeding risk should be carried out with discontinuation of antithrombotic agents. The guidelines also recommend substituting heparin bridging for warfarin or DOACs for these procedures, although the efficacy of bridging therapy is controversial, as Ono et al reported that heparin bridging therapy increased the bleeding rates to approximately 20%.…”

“…The guidelines also recommend substituting heparin bridging for warfarin or DOACs for these procedures, although the efficacy of bridging therapy is controversial, as Ono et al reported that heparin bridging therapy increased the bleeding rates to approximately 20%. 74 Further accumulation of evidence concerning the management of NOACs is required. 74 EST and EUS-GBD are also classified as high-bleedingrisk procedures, 74 and are allowed without discontinuation of aspirin monotherapy only in patients with a high risk of thromboembolism.…”

Manajemen Terapi Antitrombotik pada Prosedur Endoskopi

“…Pasien yang memerlukan terapi dual antiplatelet sebaiknya tetap melanjutkan penggunaan aspirin, dan keputusan untuk menghentikan thienopyridine sebaiknya dikonsultasikan dengan ahli kardiologi. 3,5,12 Berdasarkan pedoman Japan Gastroenterogical Endoscopy Society, pada pasien yang mendapatkan novel oral anticoagulant, pemberian dapat dilanjutkan atau dikurangi dosisnya pada pagi hari jika akan dilakukan prosedur dengan risiko perdarahan yang rendah. Sedangkan, pada prosedur dengan risiko perdarahan yang tinggi, pemberian dapat ditunda 24-48 jam sebelum tindakan, tergantung dengan jenis agen yang dipakai.…”

“…Apabila terdapat kelainan eliminasi obat, maka penghentian pemberian dapat dilakukan lebih lama. 7,12…”

Endoscopists should keep up with the current trends of antithrombotic therapy in other fields

“…Thus, accumulation of evidence to validate the recommendations in the guidelines became easier than before. Nowadays, the acceptance of biopsy and high‐bleeding‐risk procedures without cessation of any antithrombotics and aspirin are growing, respectively …”