The management of antithrombotic agents for patients undergoing GI endoscopy

Acosta, Ruben D.; Abraham, Neena S.; Chandrasekhara, Vinay; Chathadi, Krishnavel V.; Early, Dayna S.; Eloubeidi, Mohamad A.; Evans, John A.; Faulx, Ashley L.; Fisher, Deborah A.; Fonkalsrud, Lisa; Hwang, Joo Ha; Khashab, Mouen A.; Lightdale, Jenifer R.; Muthusamy, V. Raman; Pasha, Shabana F.; Saltzman, John R.; Shaukat, Aasma; Shergill, Amandeep K.; Wang, Amy; Cash, Brooks D.; DeWitt, John M.

doi:10.1016/j.gie.2015.09.035

“…Thus, the BSG/ESGE suggestion to omit the morning dose of DOACs on the day of the procedure so that biopsies can be sampled at a trough level (ie, 12 or 24 hours after the last drug intake) appears reasonable. We believe that a 5.2% risk of clinically relevant intraprocedural bleeding after biopsies in patients who did not omit the morning dose, balanced with the negligible risk of thromboembolic events for this very short period of drug interruption, deserves a critical reassessment of American Society for Gastrointestinal Endoscopy10 and the joint Asian Pacific Association of Gastroenterology and Asian Pacific Society for Digestive Endoscopy guidelines,11 which recommend to continue anticoagulation in case of low-risk procedures. Again, as clinically relevant intraprocedural bleeding occurred in about 3% of the procedures after biopsy mapping (ie, biopsies in multiple sites), greater awareness should be reserved to these patients, and a possible reassessment of the guidelines for this subgroup of patients may be considered.…”

Section: Discussionmentioning

confidence: 98%

Periendoscopic management of direct oral anticoagulants: a prospective cohort study

Radaelli

¹

,

Fuccio

²

,

Paggi

³

et al. 2018

Gut

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Objective To assess the frequency of adverse events associated with periendoscopic management of direct oral anticoagulants (DOACs) in patients undergoing elective GI endoscopy and the efficacy and safety of the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) recommendations (NCT 02734316). Design Consecutive patients on DOACs scheduled for elective GI endoscopy were prospectively included. The timing of DOAC interruption and resumption before and after the procedures were recorded, along with clinical and procedural data. Procedures were stratified into low-risk and high-risk for GI-related bleeding, and patients into low-risk and high-risk for thromboembolic events. Patients were followed-up for 30 days for major and clinically relevant non-major bleeding events (CRNMB), arterial and venous thromboembolism and death. Results Of 529 patients, 38% and 62% underwent high-risk and low-risk procedures, respectively. There were 45 (8.5%; 95% CI 6.3% to 11.2%) major or CRNMB events and 2 (0.4%; 95% CI 0% to 1.4%) thromboembolic events (transient ischaemic attacks). Overall, the incidence of bleeding events was 1.8% (95% CI 0.7% to 4%) and 19.3% (95% CI 14.1% to 25.4%) in low-risk and high-risk procedures, respectively. For high-risk procedures, the incidence of intraprocedural bleeding was similar in patients who interrupted anticoagulation according to BSG/ESGE guidelines or earlier (10.3%vs10.8%, p=0.99), with a trend for a lower risk as compared with those who stopped anticoagulation later (10.3%vs25%, p=0.07). The incidence of delayed bleeding appeared similar in patients who resumed anticoagulation according to BSG/ESGE guidelines or later (6.6%vs7.7%, p=0.76), but it tended to increase when DOAC was resumed earlier (14.4%vs6.6%, p=0.27). The risk of delayed major bleeding was significantly higher in patients receiving heparin bridging than in non-bridged ones (26.6%vs5.9%, p=0.017). Conclusion High-risk procedures in patients on DOACs are associated with a substantial risk of bleeding, further increased by heparin bridging. Adoption of the BSG/ESGE guidelines in periendoscopic management of DOACs seems to result in a favourable benefit/risk ratio. Trial registration number NCT 02734316; Pre-results.

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“…Risk factors for PPB include larger polyp size, right colon, pedunculated type and anticoagulants[6-9], although these are still controversial. Major guidelines recommend cessation of anticoagulants before polypectomy and heparin bridge therapy for high thrombotic risk cases[10-12]. Nevertheless, a study demonstrated that the incidence of PPB was higher in patients taking anticoagulants, even if they were interrupted[13].…”

Section: Introductionmentioning

confidence: 99%

Heparin bridge therapy and post-polypectomy bleeding

Kubo

¹

,

Yamashita

²

,

Onodera

³

et al. 2016

WJG

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AIMTo identify risk factors for post-polypectomy bleeding (PPB), focusing on antithrombotic agents.METHODSThis was a case-control study based on medical records at a single center. PPB was defined as bleeding that occurred 6 h to 10 d after colonoscopic polypectomy and required endoscopic hemostasis. As risk factors for PPB, patient-related factors including anticoagulants, antiplatelets and heparin bridge therapy as well as polyp- and procedure-related factors were evaluated. All colonoscopic hot polypectomies, endoscopic mucosal resections and endoscopic submucosal dissections performed between January 2011 and December 2014 were reviewed.RESULTSPPB occurred in 29 (3.7%) of 788 polypectomies performed during the study period. Antiplatelet or anticoagulant agents were prescribed for 210 (26.6%) patients and were ceased before polypectomy except for aspirin and cilostazol in 19 cases. Bridging therapy using intravenous unfractionated heparin was adopted for 73 patients. The univariate analysis revealed that anticoagulants, heparin bridge, and anticoagulants plus heparin bridge were significantly associated with PPB (P < 0.0001) whereas antiplatelets and antiplatelets plus heparin were not. None of the other factors including age, gender, location, size, shape, number of resected polyps, prophylactic clipping and resection method were correlated with PPB. The multivariate analysis demonstrated that anticoagulants and anticoagulants plus heparin bridge therapy were significant risk factors for PPB (P < 0.0001). Of the 29 PPB cases, 4 required transfusions and none required surgery. A thromboembolic event occurred in a patient who took anticoagulant.CONCLUSIONPatients taking anticoagulants have an increased risk of PPB, even if the anticoagulants are interrupted before polypectomy. Heparin-bridge therapy might be responsible for the increased PPB in patients taking anticoagulants.

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“…The recent guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) in 2016[21] and the Japan Gastroenterological Endoscopy Society in 2014[22] recommend the continuous use of aspirin during endoscopic procedures in high thrombosis-risk patients, even if the procedures carry a high risk of bleeding. For gastric ESD, a multivariate analysis[23-25] found that the continuous use of aspirin did not increase delayed bleeding, supporting the application of this treatment; however, the delayed bleeding rate was slightly increased (3.6%-21.1%)[23-26].…”

Section: Effect Of Antiplatelet Agents On Gastric Esdmentioning

confidence: 99%

“…A delayed bleeding rate as high as 35.5%[25] was reported when ESD was performed with continuous aspirin and cessation of thienopyridines following the guidelines[21,22,29]. Moreover, patients receiving DAPT for ESD face thrombotic risk from the cessation of thienopyridines, and this thrombotic risk can be increased if delayed bleeding occurs[11,14].…”

Section: Effect Of Antiplatelet Agents On Gastric Esdmentioning

confidence: 99%

Clinical problems with antithrombotic therapy for endoscopic submucosal dissection for gastric neoplasms

Yoshio

¹

,

Nishida

²

,

Hayashi

³

et al. 2016

WJGE

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Endoscopic submucosal dissection (ESD) is minimally invasive and thus has become a widely accepted treatment for gastric neoplasms, particularly for patients with comorbidities. Antithrombotic agents are used to prevent thrombotic events in patients with comorbidities such as cardio-cerebrovascular diseases and atrial fibrillation. With appropriate cessation, antithrombotic therapy does not increase delayed bleeding in low thrombosis-risk patients. However, high thrombosis-risk patients are often treated with combination therapy with antithrombotic agents and occasionally require the continuation of antithrombotic agents or heparin bridge therapy (HBT) in the perioperative period. Dual antiplatelet therapy (DAPT), a representative combination therapy, is frequently used after placement of drug-eluting stents and has a high risk of delayed bleeding. In patients receiving DAPT, gastric ESD may be postponed until DAPT is no longer required. HBT is often required for patients treated with anticoagulants and has an extremely high bleeding risk. The continuous use of warfarin or direct oral anticoagulants may be possible alternatives. Here, we show that some antithrombotic therapies in high thrombosis-risk patients increase delayed bleeding after gastric ESD, whereas most antithrombotic therapies do not. The management of high thrombosis-risk patients is crucial for improved outcomes.

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The management of antithrombotic agents for patients undergoing GI endoscopy

Cited by 538 publications

References 107 publications

Periendoscopic management of direct oral anticoagulants: a prospective cohort study

Periendoscopic management of direct oral anticoagulants: a prospective cohort study

Heparin bridge therapy and post-polypectomy bleeding

Clinical problems with antithrombotic therapy for endoscopic submucosal dissection for gastric neoplasms

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