Risk Factors for Delayed Bleeding after Therapeutic Gastrointestinal Endoscopy in Patients Receiving Oral Anticoagulants: A Multicenter Retrospective Study

Kubo, Kimitoshi; Mabe, Katsuhiro; Harada, Naohiko; Iboshi, Yoichiro; Kagaya, Takashi; Ono, Masayoshi; Toyokawa, Tatsuya; Yamashita, Haruhiro; Kuwai, Toshio; Hamada, Hiroshige; Sakakibara, Yuko; Nishiyama, Hitoshi; Ara, Nobuyuki; Mori, Hideki; Matsumoto, M; Takahashi, Yasuo; Katsushima, Shinji; Watanabe, Nozomi; Ogura, Yoshito; Saito, Hiroki; Masuda, Eiji; Amano, Toraji

doi:10.1159/000502952

Cited by 21 publications

(41 citation statements)

References 33 publications

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“…These results suggest that the risk of delayed PPB is smaller in those taking DOAC than in those taking clopidogrel or warfarin. A Japanese study recently reported the delayed bleeding rate of therapeutic endoscopic procedures (including polypectomy, endoscopic mucosal resection [EMR], and endoscopic submucosal dissection [ESD]) for lesions of the esophagus (2.1%), stomach (15.4%), duodenum (0.4%), and colon (82.1%) 16 . According to their predominantly colonic procedure data, the delayed bleeding rate was not significantly different between patients taking warfarin or DOAC (13.8% vs. 9.5%, respectively), but endoscopic hemostasis was more frequently required in those taking warfarin than DOAC (12.0 vs. 6.9%, p < 0.05).…”

Section: Discussionmentioning

confidence: 99%

“…In a large population-based retrospective study regarding any kind of GI bleeding in patients taking DOACs, apixaban showed a relatively lower risk of GI bleeding than did dabigatran or rivaroxaban 20 . On the other hand, apixaban showed a higher risk of bleeding than rivaroxaban according to a Japanese multicenter retrospective study focused on GI bleeding after therapeutic endoscopy for patients taking DOACs 16 . Our data did not show any difference in delayed PPB according to the type of DOACs, which may be due to our limited number of cases.…”

Section: Discussionmentioning

confidence: 99%

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Risk of postpolypectomy bleeding in patients taking direct oral anticoagulants or clopidogrel

Kim

Lee

Choe

et al. 2021

Sci Rep

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The usage of direct oral anticoagulants (DOACs) to prevent and treat thromboembolic events is gradually increasing. We aimed to evaluate the outcomes of patients taking DOACs after polypectomy. We retrospectively reviewed 131 patients taking DOACs and 270 taking clopidogrel who underwent polypectomy between November 2010 and December 2017. The risk of delayed postpolypectomy bleeding (PPB) was evaluated and compared. A total of 989 polyps were removed (320 polyps in the DOAC and 669 polyps in the clopidogrel group). DOACs and clopidogrel were discontinued for 2.8 ± 1.7 days and 5.8 ± 2.5 days before polypectomy, respectively. DOACs and clopidogrel were restarted on 1.6 ± 2.9 days and 1.7 ± 1.1 days after polypectomy, respectively. According to per polyp analysis, delayed PPB rate was 1.6% in both groups (p = 0.924). Logistic regression analysis was performed after propensity score matching and revealed that DOACs did not increase the delayed PPB risk compared to clopidogrel (OR 0.929, 95% CI 0.436–1.975, p = 0.847). With the majority following the antithrombotic discontinuation guidelines, the incidence of delayed PPB was 3.1% in the patients taking DOACs. The delayed PPB risk was not greater in those taking DOACs than in those taking clopidogrel.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Risk of postpolypectomy bleeding in patients taking direct oral anticoagulants or clopidogrel

Kim

Lee

Choe

et al. 2021

Sci Rep

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“…After reviewing the full-text of the remaining 27 articles, a total of 19 studies were found to be ineligible for the inclusion criteria, and were excluded. Finally, eight studies 11 12 13 14 15 16 17 18 were included for the meta-analysis. Results of the study flow diagram are shown in Fig.…”

Section: Resultsmentioning

confidence: 99%

“…All articles demonstrated the outcome, and five of these 11 12 13 14 15 reported no thrombotic events. Therefore, the meta-analysis was conducted using three studies 16 17 18 with a total of 1,085 patients (601 patients with warfarin and 484 patients with DOACs). No significant difference was found between the warfarin and DOACs groups (OR = 2.0, 95 % CI [0.32–12.39]), and there was no heterogeneity (I² = 0, P = 0.879) ( Fig.…”

Section: Resultsmentioning

confidence: 99%

Management of anticoagulants in delayed bleeding after endoscopic resection: A systematic review and meta-analysis

Zhao

Huang

et al. 2021

Endosc Int Open

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Background and study aims Delayed bleeding and thrombotic events are uncontrolled adverse events that are hard to balance in patients receiving anticoagulants after endoscopic resection. The present study aims to assess the clinical effect of warfarin, when compared to direct oral anticoagulants (DOACs), in terms of delayed bleeding and thrombotic events. Methods A comprehensive electronic literature search was conducted for eligible literature. Pairwise meta-analyses were performed on outcomes of delayed bleeding and thrombotic events. Two networks within the Bayesian framework were established based on the management of anticoagulants and type of DOAC. Results Eight cohort studies with 2,046 patients were eligible for inclusion, including 1,176 patients treated with warfarin and 870 with DOACs. There was no significant difference between warfarin and DOACs, in terms of delayed bleeding (OR = 1.29, 95 % CI [0.99–1.69]) and thromboembolism (OR = 2.0, 95 % CI [0.32–12.39]). In the network meta-analyses for delayed bleeding, the rank probabilities revealed that the safest management was discontinuous warfarin without heparin bridge therapy (HBT). Rank probabilities for the types of DOACs demonstrated that the safest drug was dabigatran. Conclusions There was no significant difference in delayed bleeding and thromboembolism between warfarin and DOACs in patients receiving endoscopic treatment. In terms of delayed bleeding, discontinuous warfarin without HBT was suggested as the best management, and dabigatran was recommended as the best type of DOAC.

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“…Peri-endoscopic management with HBT is now becoming a controversial management decision with regards to its efficacy and safety. Numerous studies highlighted in this review have demonstrated that the use of HBT is associated with a two- to three-fold increased risk of PPB[ 7 , 41 , 142 ], while being non-superior in thromboembolic event prevention, compared to warfarin cessation without HBT[ 1 , 107 , 143 , 144 ]. This heightened risk of PPB associated with HBT has been shown in a range of endoscopic procedures, including EMR, ESD, polypectomy, EUS ± FNA and ERCP with sphincterotomy.…”

Section: Discussionmentioning

confidence: 99%

Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence

Chan

Philpott

Lim

et al. 2020

WJGE

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The role of endoscopic procedures, in both diagnostic and therapeutic purposes is continually expanding and evolving rapidly. In this context, endoscopists will encounter patients prescribed on anticoagulant and antiplatelet medications frequently. This poses an increased risk of intraprocedural and delayed gastrointestinal bleeding. Thus, there is now greater importance on optimal pre, peri and post-operative management of anticoagulant and/or antiplatelet therapy to minimise the risk of post-procedural bleeding, without increasing the risk of a thromboembolic event as a consequence of therapy interruption. Currently, there are position statements and guidelines from the major gastroenterology societies. These are available to assist endoscopists with an evidenced-based systematic approach to anticoagulant and/or antiplatelet management in endoscopic procedures, to ensure optimal patient safety. However, since the publication of these guidelines, there is emerging evidence not previously considered in the recommendations that may warrant changes to our current clinical practices. Most notably and divergent from current position statements, is a growing concern regarding the use of heparin bridging therapy during warfarin cessation and its associated risk of increased bleeding, suggestive that this practice should be avoided. In addition, there is emerging evidence that anticoagulant and/or antiplatelet therapy may be safe to be continued in cold snare polypectomy for small polyps (< 10 mm).

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Risk Factors for Delayed Bleeding after Therapeutic Gastrointestinal Endoscopy in Patients Receiving Oral Anticoagulants: A Multicenter Retrospective Study

Cited by 21 publications

References 33 publications

Risk of postpolypectomy bleeding in patients taking direct oral anticoagulants or clopidogrel

Risk of postpolypectomy bleeding in patients taking direct oral anticoagulants or clopidogrel

Management of anticoagulants in delayed bleeding after endoscopic resection: A systematic review and meta-analysis

Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence

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