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- therapy, , 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 , 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 APTT may help assess effect. For rivaroxiban PT may help assess anticoagulant effect. Liaise with haematology as appropriate.

References

ASGE. Management of 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 : 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.

Oral anti-thrombotic therapy-endoscopy V1 Author: AI Thuraisingam Approved by Medicines Clinical Guidance Team April 2014 Review date February 2017 Page 2 of 5

Wirral University Teaching Hospital NHS Foundation Trust Appendix 1

Clopidogrel/*/

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 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

Oral anti-thrombotic therapy-endoscopy V1 Author: AI Thuraisingam Approved by Medicines Clinical Guidance Team April 2014 Review date February 2017 Page 3 of 5

Wirral University Teaching Hospital NHS Foundation Trust

Warfarin/Acenocoumarol/

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 /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.

Oral anti-thrombotic therapy-endoscopy V1 Author: AI Thuraisingam Approved by Medicines Clinical Guidance Team April 2014 Review date February 2017 Page 4 of 5

Wirral University Teaching Hospital NHS Foundation Trust Dabigatran/

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

Oral anti-thrombotic therapy-endoscopy V1 Author: AI Thuraisingam Approved by Medicines Clinical Guidance Team April 2014 Review date February 2017 Page 5 of 5