OAK BROOK, Ill -- December 10, 2009 -- According to an updated guideline from the American Society for Gastrointestinal Endoscopy (ASGE), published in the December issue of GIE: Gastrointestinal Endoscopy regarding the management of antithrombotic agents for endoscopy, aspirin and/or nonsteroidal antiinflammatory drugs (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 5 to 7 days before the procedure, depending on the underlying indication for antiplatelet therapy. For patients on temporary anticoagulation therapy, it is suggested that elective endoscopic procedures be deferred until antithrombotic therapy is completed.
“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, University of Washington School of Medicine, Seattle, Washington. “Alternative diagnostic studies for patient evaluation, such as video capsule endoscopy or radiologic studies, may be appropriate in some cases.”
Other key recommendations include:
· 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 7 to 10 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.
· 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 7 to 10 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.
· 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) around the time of endoscopy when indicated for known or expected therapeutic indications.
· There is insufficient evidence to recommend for or against the prophylactic use of mechanical clips after polypectomy in patients on anticoagulation.
· There is no consensus as to the optimal timing of reinitiation of anticoagulant therapy after endoscopic interventions, and decisions are likely to depend on procedure-specific circumstances as well as the indications for anticoagulation. It is suggested that the benefits of immediate anticoagulant therapy in preventing thromboembolic events be weighed against the risk of hemorrhage and determined in a case-by-case basis.
· In patients at high risk of thromboembolic events, it is suggested that UFH or LMWH be restarted as soon as safely possible and that warfarin be restarted on the day of the procedure unless there is significant concern for bleeding. UFH may be restarted 2 to 6 hours after a therapeutic procedure. In patients with a low risk of thromboembolic events, it is suggested that warfarin be restarted on the evening after the endoscopy unless procedural circumstances suggest a high risk of postprocedure bleeding. Bridging therapy in patients with a low thromboembolic risk is not necessary.
· In pregnant patients with mechanical heart valves needing endoscopic procedures, it is recommended that elective procedures be delayed until after delivery whenever possible, and when delay is not possible, that bridge therapy with LMWH or UFH be considered. Consultation with the patient’s cardiologist and/or obstetrician should be obtained.
Recommendations for Urgent and Emergent Endoscopic Procedures
· It is suggested that patients with acute GI bleeding taking antiplatelet agents should have these medications withheld until haemostasis is achieved. Administration of platelets may be appropriate for patients with life-threatening or serious bleeding. In situations of significant bleeding occurring in patients with a recently (<1 year) placed vascular stent and/or ACS, it is suggested that cardiology consultation be obtained before stopping antiplatelet agents.
· It is recommended that patients with acute bleeding receiving anticoagulation therapy have these agents withheld until haemostasis is achieved. The decision to use fresh frozen plasma (FFP), prothrombin complex concentrate, and/or vitamin K should be individualised. It is suggested that protamine be reserved for patients with life-threatening bleeding on heparin because of the potential risks of anaphylaxis and severe hypotension. In situations of significant bleeding occurring in patients with a recently (<1 year) placed vascular stent and/or ACS, it is recommended that consultation with the prescribing service be obtained before stopping anticoagulants.
· It is recommended that patients with acute GI bleeding taking warfarin with a supratherapeutic international normalised ratio (INR) undergo correction of anticoagulation, although the target level INR required for endoscopic therapy to be effective has not been determined.
· The absolute risk of rebleeding after endoscopic haemostasis in patients who must resume anticoagulation is unknown, and the timing for resumption of anticoagulation should be individualised. It is suggested that in patients with high-risk stigmata for rebleeding intravenously administered UFH be used initially because of its relatively short half-life.
SOURCE: American Society for Gastrointestinal Endoscopy
