Wirral University Teaching Hospital NHS Foundation Trust Oral anti-thrombotic therapy-management in patients requiring endoscopy
Management of anti-thrombotic therapy in patients requiring endoscopy This guideline suggests appropriate management of patients undergoing endoscopic procedures who are on oral anti-coagulation therapy, aspirin, nonsteroidal anti- inflammatory drugs (NSAIDS) or antiplatelets.
When preparing a patient on anti-thrombotic agents for endoscopy considerations should include 1. The risk of complications of the underlying gastrointestinal disorder related directly to anti-thrombotic therapy 2. Bleeding related to an endoscopic procedure and 3. A thromboembolic event related to interruption of anti-thrombotic therapy.
The decision to reverse anticoagulation/anti-platelets, risking thromboembolic consequences, must be weighed against the risk of continued bleeding by maintaining the anti-thrombotic state. When anticoagulation therapy is temporary, such as for DVT, elective procedures should be delayed, if possible, until anticoagulation is no longer indicated.
Patients should be advised that there is an increased risk of post procedure bleeding compared with non-anticoagulated patients.
In order to use this guideline effectively, identify the endoscopy procedural risk from the list below and then select the oral anti-thrombotic agent from the list in Appendix 1. Follow the flow chart accordingly.
Endoscopy Procedural Risks
High risk procedures Gastric and colonoscopic polypectomy Low risk procedures Dilatation of strictures Gastroscopy +/- biopsy Percutaneous endoscopic gastrostomy Flexible sigmoidoscopy +/- biopsy (PEG) Colonoscopy* +/- biopsy Therapy of varices, Argon plasma Biliary or pancreatic stenting coagulation (APC) Oesophageal stent insertion Endoscopic mucosal resection (EMR) Diagnostic EUS (endoscopic ultrasound) EUS and fine needle aspiration (FNA) ERCP +/- sphincterotomy.
*NB It is reasonable to manage elective colonoscopy as a high risk procedure as it is impossible to predict if polypectomy will be required.
Oral anti-thrombotic therapy-endoscopy V1 Author: AI Thuraisingam Approved by Medicines Clinical Guidance Team April 2014 Review date February 2017 Page 1 of 5
Wirral University Teaching Hospital NHS Foundation Trust
Additional considerations Aspirin and NSAIDs should continue for all elective low and high risk endoscopy procedures For patients on dual therapy with aspirin and dipyridamole, it is advised to omit dipyridamole 1 day prior to high risk endoscopy procedures (and restart after procedure). Advice to restart any oral anti-thrombotic agents as normal post procedure assumes there is no clinically significant risk of ongoing bleeding. Clinical judgment may override standard advice. Patients on long term LMWH prior to procedure should be discussed with the endoscopist. For dabigatran APTT may help assess anticoagulant effect. For rivaroxiban PT may help assess anticoagulant effect. Liaise with haematology as appropriate.
References
ASGE. Management of antithrombotic agents for endoscopic procedures Gastrointest Endosc 2009; 70; 6: 1060-1070
Boustiere C et al. ESGE guideline: Endoscopy and antiplatelet agents. Endoscopy 2011;43:445-458
Woodhouse C et al. The new oral anticoagulants: practical management for patients attending for endoscopic procedures. Frontline Gastroenterology 2013;4:213–218
Veitch AM et al Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008;57:1322–1329.
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Wirral University Teaching Hospital NHS Foundation Trust Appendix 1
Clopidogrel/Ticagrelor*/Prasugrel
High risk procedures Low risk procedures
Low risk conditions1 High risk conditions2 Continue as normal
Stop 7 days* before Stop 7 days* before procedure if appropriate
procedure NB- Discontinuation should only be considered
after discussion with Cardiologist. If patient on aspirin, (If bare metal stents were placed >1 month ago continue aspirin. If not then clopidogrel could be temporarily on aspirin consider discontinued. If drug eluding stents were prescribing 75mg od placed >6 months ago and the procedure is whilst antiplatelet is essential, then it may be safe to temporarily stopped discontinue clopidogrel.)
Restart the day following procedure
*Ticagrelor can be stopped 5-7 days before procedure
1Low risk condition: Ischaemic heart disease without coronary stent, cerebrovascular disease, peripheral vascular disease. 2High Risk condition: Drug eluting coronary artery stents within 12 month of placement. Bare metal coronary artery stents within 1 month of placement
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Wirral University Teaching Hospital NHS Foundation Trust
Warfarin/Acenocoumarol/Phenindione
High risk procedure Low risk procedure
1 2 Low risk conditions High risk conditions Continue
Stop 5 days before Check INR 5-7 days before Stop 5 days before endoscopy endoscopy endoscopy. If INR within therapeutic range continue 2 days after stopping commence Check INR is <1.5 prior to treatment dose LMWH** usual daily dose. If INR procedure above therapeutic range but <5 reduce daily dose until INR returns to therapeutic range Omit LMWH on day of procedure Restart day of procedure
with usual daily dose. Check INR is <1.5 on day of procedure Check INR is in range on day of procedure Restart
Ensure patient has INR warfarin/acenocoumarol/phenindione checked after 1 week on day of procedure with usual daily dose. (State instructions in Endoscopy report) Restart treatment dose LMWH the day after the procedure & continue until appropriate INR achieved.
**Arrange with DVT service (Ext 6378) on individual patient basis. Patients will need a prescription for LMWH.
1Low risk condition: Prosthetic metal heart valve in aortic position, xenograft heart valve, atrial fibrillation (AF) without valvular disease, > 3 months after venous thromboembolism. 2High Risk condition: Prosthetic metal heart valve in mitral position, prosthetic heart valve and AF, AF and mitral stenosis, < 3 months after venous thromboembolism and thrombophilia syndromes.
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Wirral University Teaching Hospital NHS Foundation Trust Dabigatran/Rivaroxaban
High risk procedure Check renal function Low risk procedure
eGFR >50ml/min stop 24-48hours pre-procedure eGFR >50ml/min stop 24hours pre-procedure
eGFR 30 -50ml/min stop 4 days pre-procedure eGFR 30-50ml/min stop 48hours pre-procedure
eGFR <30ml/min stop 5 days pre-procedure eGFR <30ml/min stop 72hours pre-procedure
Restart 48 hours post-procedure (twice daily dose of Restart 6-8hours post-procedure
dabigatran and once daily dose of rivaroxaban) (single dose of dabigatran and usual once For patients at high risk of thrombosis consider daily dose of rivarixiban) bridging with treatment dose LMWH until considered safe to restart normal anticoagulant ** Continue usual dose thereafter
**Arrange with DVT service (Ext 6378) on individual patient basis. Patients will need prescription for LMWH.
Apixaban
High risk procedure Low risk procedure
Stop >48hours before Continue usual dose thereafter Stop >24hours before
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