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British Society of Gastroe Guidelines Endoscopy in patients on antiplatelet or Gut: first published as 10.1136/gutjnl-2015-311110 on 12 February 2016. Downloaded from anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines Andrew M Veitch,1 Geoffroy Vanbiervliet,2 Anthony H Gershlick,3 Christian Boustiere,4 Trevor P Baglin,5 Lesley-Ann Smith,6 Franco Radaelli,7 Evelyn Knight,8 Ian M Gralnek,9,10 Cesare Hassan,11 Jean-Marc Dumonceau12 For numbered affiliations see ABSTRACT guidelines on the management of acute non- end of article. The risk of endoscopy in patients on antithrombotics variceal upper gastrointestinal bleeding.1 Correspondence to depends on the risks of procedural haemorrhage versus Recommendations for the management of Dr Andrew Veitch, Department thrombosis due to discontinuation of therapy. patients on antiplatelet therapy or anticoagulants of Gastroenterology, New P2Y12 receptor antagonists (clopidogrel, undergoing elective endoscopic procedures are out- Cross Hospital, Wolverhampton prasugrel, ticagrelor) For low-risk endoscopic lined in the algorithms in figures 1 and 2. Risk WV10 0QP, UK; procedures we recommend continuing P2Y12 receptor stratification for endoscopic procedures and anti- [email protected] antagonists as single or dual antiplatelet therapy (low platelet agents (APAs) are detailed in tables 1 and This article is published quality evidence, strong recommendation); For high-risk 2. There is no high-risk category of thrombosis for simultaneously in the journal endoscopic procedures in patients at low thrombotic risk, DOACs as they are not indicated for prosthetic Endoscopy. Copyright 2016 © we recommend discontinuing P2Y12 receptor metal heart valves. Warfarin risk stratification is Georg Thieme Verlag KG antagonists five days before the procedure (moderate detailed in table 3. Our recommendations are based Received 16 November 2015 quality evidence, strong recommendation). In patients on on best estimates of risk:benefit analysis for throm- Revised 30 December 2015 dual antiplatelet therapy, we suggest continuing aspirin bosis versus haemorrhage. When discontinuing Accepted 4 January 2016 (low quality evidence, weak recommendation). For high- antithrombotic therapy, patient preference should risk endoscopic procedures in patients at high thrombotic be considered as well as clinical opinion: the risk of risk, we recommend continuing aspirin and liaising with a potentially catastrophic thrombotic event such as a cardiologist about the risk/benefit of discontinuation of a stroke may not be acceptable to a patient even if P2Y12 receptor antagonists (high quality evidence, that risk is very low. http://gut.bmj.com/ strong recommendation). For all endoscopic procedures we recommend Warfarin The advice for warfarin is fundamentally continuing aspirin (moderate evidence, strong rec- unchanged from British Society of Gastroenterology ommendation), with the exception of endoscopic (BSG) 2008 guidance. submucosal dissection (ESD), large colonic endo- Direct Oral Anticoagulants (DOAC) For low-risk scopic mucosal resection (EMR) (>2 cm), upper endoscopic procedures we suggest omitting the morning gastrointestinal EMR and ampullectomy. In the on September 26, 2021 by guest. Protected copyright. dose of DOAC on the day of the procedure (very low latter cases, aspirin discontinuation should be con- quality evidence, weak recommendation); For high-risk sidered on an individual patient basis depending endoscopic procedures, we recommend that the last on the risks of thrombosis versus haemorrhage dose of DOAC be taken ≥48 h before the procedure (low quality evidence, weak recommendation). (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30–50 mL/min we recommend that the last dose of DOAC be taken 72 h 1.1 Low-risk procedures For low-risk endoscopic procedures we recommend Open Access before the procedure (very low quality evidence, strong Scan to access more continuing P2Y12 receptor antagonists (eg, clopi- free content recommendation). In any patient with rapidly deteriorating renal function a haematologist should be dogrel), as single or dual antiplatelet therapy (low consulted (low quality evidence, strong quality evidence, strong recommendation). recommendation). For low-risk endoscopic procedures we suggest that warfarin therapy should be continued (low quality evidence, weak recommendation). It should be ensured that the International normalised ratio 1.0 SUMMARY OF RECOMMENDATIONS (INR) does not exceed the therapeutic range in the These guidelines refer to patients undergoing elect- week prior to the procedure (low quality evidence, ive endoscopic gastrointestinal procedures. strong recommendation). To cite: Veitch AM, Management of antiplatelet therapy and direct oral For low-risk endoscopic procedures we suggest Vanbiervliet G, Gershlick AH, anticoagulants (DOACs) in acute gastrointestinal omitting the morning dose of DOACs on the day et al. Gut 2016;65: haemorrhage is discussed in detail in European of the procedure (very low quality evidence, weak – 374 389. Society of Gastrointestinal Endoscopy (ESGE) recommendation) 374 Veitch AM, et al. Gut 2016;65:374–389. doi:10.1136/gutjnl-2015-311110 Guidelines High Risk Procedure Gut: first published as 10.1136/gutjnl-2015-311110 on 12 February 2016. Downloaded from Polypectomy Low Risk Procedure ERCP with sphincterotomy Diagnostic procedures +/- Ampullectomy biopsy EMR/ESD Biliary or pancreatic stenting Dilation of strictures Diagnostic EUS Therapy of varices Device-assisted enteroscopy PEG without polypectomy EUS with FNA Oesophageal, enteral or colonic stenting clopidogrel clopidogrel prasugrel prasugrel ticagrelor ticagrelor Continue therapy Low Risk Condition High Risk Condition Ischaemic heart disease Coronary artery stents without coronary stent Cerbrovascular disease Peripheral vascular disease Liaise with cardiologist Consider stopping clopidogrel, Stop clopidogrel, prasugrel or ticagrelor 5 days prasugrel or ticagrelor before endoscopy if: 5 days before endoscopy >12 months after insertion of Continue aspirin if already drug-eluting coronary stent prescribed >1 month after insertion of bare metal coronary stent Continue aspirin Figure 1 Guidelines for the management of patients on P2Y12 receptor antagonist antiplatelet agents undergoing endoscopic procedures. 1.2 High-risk procedures patients on dual antiplatelet therapy, we suggest continuing For high-risk endoscopic procedures in patients at low throm- aspirin (low quality evidence, weak recommendation). botic risk, we recommend discontinuing P2Y12 receptor For high-risk endoscopic procedures in patients at low throm- antagonists (eg, clopidogrel) five days before the procedure botic risk, we recommend discontinuing warfarin 5 days before (moderate quality evidence, strong recommendation). In the procedure (high quality evidence, strong recommendation). http://gut.bmj.com/ High Risk Procedure Polypectomy ERCP with sphincterotomy Ampullectomy Low Risk Procedure EMR/ESD Diagnostic procedures +/- Dilation of strictures biopsy Therapy of varices Biliary or pancreatic stenting PEG Device-assisted enteroscopy EUS with FNA on September 26, 2021 by guest. Protected copyright. without polypectomy Oesophageal, enteral or colonic stenting DOAC Warfarin Dabigatran Warfarin DOAC Rivaroxaban Dabigatran Apixaban Rivaroxaban Edoxaban Apixaban Edoxaban Continue Warfarin Low Risk Condition High Risk Condition Check INR during the week Prosthetic metal heart valve in Prosthetic metal heart valve in before endoscopy Omit DOAC on aortic position mitral position If INR within therapeutic range morning of Xenograft heart valve Prosthetic heart valve and AF continue usual daily dose procedure AF without valvular disease AF and mitral stenosis Take last dose of drug If INR above therapeutic range >3months after VTE <3months after VTE > 48 hours before but <5 reduce daily dose until Thrombophilia syndromes (liaise – INR returns to therapeutic with haematologist) procedure range For dabigatran with CrCl (eGFR) 30-50ml/min take last dose of drug 72 hours before procedure Stop warfarin 5 days In any patient with rapidly before endoscopy deteriorating renal function a Stop warfarin 5 days Start LMWH 2 days after stopping haematologist should be consulted before endoscopy warfarin Check INR prior to procedure to Give last dose of LMWH >– 24 ensure INR<1.5 hours before procedure Restart warfarin evening of Restart warfarin evening of procedure with usual daily dose procedure with usual daily dose Check INR 1 week later to Continue LMWH until INR ensure adequate anticoagulation adequate Figure 2 Guidelines for the management of patients on warfarin or direct oral anticoagulants (DOAC) undergoing endoscopic procedures. Veitch AM, et al. Gut 2016;65:374–389. doi:10.1136/gutjnl-2015-311110 375 Guidelines Table 1 Risk stratification of endoscopic procedures based on the Table 3 Risk stratification for discontinuation of warfarin therapy Gut: first published as 10.1136/gutjnl-2015-311110 on 12 February 2016. Downloaded from risk of haemorrhage with respect to the requirement for heparin bridging High risk Low risk High risk Low risk Endoscopic polypectomy Diagnostic procedures±biopsy Prosthetic metal heart valve in Prosthetic metal heart valve in aortic ERCP with sphincterotomy Biliary or pancreatic stenting mitral position position Sphincterotomy+large balloon
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