Oral Anticoagulant and Antiplatelet Drugs in Patients Attending for Elective Endoscopy - Management of

Publication: 01/10/2006  --
Last review: 28/05/2019  
Next review: 02/05/2022  
Clinical Guideline
CURRENT 
ID: 859 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Management of oral Anticoagulant and Antiplatelet drugs in patients attending for elective Endoscopy

Summary of Guideline

  • This advice relates to elective endoscopic procedures for patients on anticoagulation therapy (warfarin or the novel direct oral anti-coagulant agents: ‘DOACs’ such as dabigatran) or anti-platelet therapy (P2Y12 receptor antagonists such as clopidogrel). They reflect the 2016 BSG guidelines on this topic. More information and the rationale for the LTHT guidelines can be found in the BSG guidelines (Veitch AM, et al. Gut 2016;65:374–389; doi:10.1136/gutjnl-2015-311110). For acute gastrointestinal haemorrhage, please refer to the separate LTHT guidelines.
  • Throughout the document, any guidance regarding clopidogrel also applies to prasugrel and ticagrelor.
  • Decisions regarding the management of anticoagulation therapy prior to Endoscopy are the responsibility of the referring clinician. Thus, these guidelines are relevant to all clinicians who refer patients for elective outpatient Endoscopy. This is because the referring clinician knows most about why the patient is anticoagulated and what procedures he/she expects to be performed at the Endoscopy. Clinicians should seek advice from Cardiology or Gastroenterology consultants as necessary.
  • If the information on the request is deemed inadequate by Endoscopy staff to organise the procedure, an email will be sent to the referring consultant, and if necessary after 1 week the endoscopy referral will be returned (see Appendix 1).
  • Guidance in relation to anticoagulation and anti-platelet medication depends on the risk of haemorrhage during the procedure (high or low risk) and the risk of discontinuing medication (high and low risk). See boxes 1 - 3.
  • The endoscopist takes responsibility for the safety of the procedure and the immediate aftercare until the patient leaves the Endoscopy unit. The endoscopist may cancel the procedure if he / she is not convinced that it is safe to proceed.
  • Summaries of the guidelines are also given in the flow charts (Figures 1 and 2).

Figure 1: Management of warfarin or direct oral anticoagulents (DOACs) in patients undergoing endoscopic procedures (taken from the BSG guidelines. Please note: procedures in which large numbers of biopsies are anticipated (eg Barrett’s surveillance) are categorised as ‘high risk’ for bleeding).

Please note: procedures in which large numbers of biopsies are anticipated (eg Barrett’s surveillance) are categorized as ‘high risk’ for bleeding.

Because polypectomy is required in 20-40% of colonoscopies, colonoscopy is included as a high risk procedure.

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Treatment / Management

  • Patients on warfarin referred for low risk procedure - elective gastroscopy or flexible sigmoidoscopy
  • The referring physician should discuss the issue of anticoagulation with the patient
  • Patients referred for diagnostic procedures can usually be advised to continue on anticoagulation.  
  • It is safe to take small numbers (4-6) of biopsies at therapeutic INR levels.
  • However, patients should be told that if a lesion is found which requires sampling or removal, a second procedure may be required.
  • Patients should be told to attend anticoagulation clinic 1 week before the Endoscopy for an INR check, and to bring their anticoagulation book with them to Endoscopy.

  • If INR is in the therapeutic range continue usual dose

  • If INR is above the therapeutic range but < 5 the dose should be reduced (at the anticoagulation clinic) until the INR is in the therapeutic range.

  • If INR > 5 patient should contact department and defer appointment.

  • INR will be checked on day of procedure prior to their Endoscopy.

  • Patients on warfarin for ‘low risk conditions’ referred for ‘high risk procedure’- see Box 1 - elective colonoscopy, ERCP, or for Endoscopy with intended therapy or multiple biopsies (eg Barrett's surveillance)
  • The referring physician should discuss the issue of anticoagulation with the patient 
  • Patients who are anticoagulated with warfarin for ‘low risk indications’ (see Box 1) are generally advised to stop anticoagulation 5 days before the examination.
  • If the patient is an in-patient please review the VTE risk assessment and prescribe LMWH (if required) once INR is < 2.
  • If the risk of stopping anticoagulation is uncertain, advice may be sought from the team which commenced the anticoagulation therapy.
  • INR should be checked to be < 1.5 before the procedure; for outpatients this will be done in Endoscopy prior to the procedure.
  • The endoscopist recommends when warfarin should be restarted - usually restart the night of the procedure at the usual daily dose.
  • Patient to attend anticoagulation clinic 1 week after procedure.

NB. Because polypectomy is required in 20-40% of colonoscopies, colonoscopy is included as a high risk procedure. However diagnostic colonoscopy can be performed as a low risk procedure as in (1), so long as the patient is informed of the possible need to repeat the procedure if polyps are found..

 Box 1: Low risk indications for anticoagulation

  • DVT more than 3 months ago
  • PE more than 3 months ago
  • Chronic or paroxysmal AF without valvular heart disease.
  • Bioprosthetic heart valves
  • Mechanical valves in aortic position

 

 Box 2: High risk Endoscopic Procedures

  • Colonoscopy and polypectomy
  • ERCP and sphincterotomy
  • Endoscopic mucosal resection
  • Endoscopic dilatation or stent insertion
  • PEG insertion
  • Variceal therapy
  • EUS and FNA or biopsy
  • Procedures requiring large numbers of biopsies eg Barrett’s surveillance
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  • Patients on warfarin for ‘high risk conditions’ (Box 3) referred for ‘high risk procedure’ (Box 2)- elective colonoscopy, ERCP, or for Endoscopy with intended therapy or multiple biopsies (eg Barrett's surveillance)
  • The referring physician discusses the issue of anticoagulation with the patient
  • Anticoagulation with warfarin is discontinued 5 days before the elective procedure.
  • 2 days after stopping warfarin (3 days before the procedure) Heparin (generally low molecular weight heparin (LMWH: tinzaparin) at therapeutic dose) is started and continued following the endoscopy until oral anticoagulation is at the appropriate therapeutic level.
  • LMWH can be prescribed in hospital (if patients live in Leeds they are generally sent to the anticoagulant clinic at SJUH to organise bridging). If patients live outside Leeds, bridging is organised via the GP surgery.  
  • LMWH should be prescribed in the mornings and omitted on day of procedure
  • INR should be checked before the procedure to be < 1.5.
  • The endoscopist should recommend when anticoagulation is to be restarted.

NB. Because polypectomy is required in 20-40% of colonoscopies, colonoscopy is included as a high risk procedure. However diagnostic colonoscopy can be performed as a low risk procedure., with the patient on warfarin, so long as the patient is informed of the possible need to repeat the procedure if polyps are found.

 Box 3: High risk indications for anticoagulation

  • Thrombo-embolic event less than 3 months ago
  • Thrombophilia syndromes
  • AF and mitral stenosis
  • AF and prosthetic heart valve
  • Prosthetic mechanical heart valve in the mitral position
  • Older type mechanical heart valve (caged-ball type) in aortic position 

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DIRECT ORAL ANTICOAGULENTS (DOACs) AND ELECTIVE PROCEDURES

  • For low-risk endoscopic procedures the morning dose of DOAC should be omitted on the day of the procedure. This applies to both once daily and twice daily DOAC regimes.
  • For high-risk endoscopic procedures the last dose of DOAC should be taken at least 48 hours before the procedure.  Because polypectomy is required in 20-40% of colonoscopies, colonoscopy is included as a high risk procedure. Therefore the referring clinician should discuss stopping the DOAC for 48 hours prior to the procedure so that any identified polyps can be removed at the same sitting.
  • For high-risk endoscopic procedures, in patients on dabigatran with eGFR of 30–50 mL/min the last dose should be taken 72 h prior to the procedure.
  •  In any patient with rapidly deteriorating renal function a haematologist should be consulted.
  • DOACs  will usually be restarted the day after a low risk procedure, but may be delayed until 48 hours or more post-procedure after high risk procedures, bearing in mind their rapid onset of action (unlike warfarin).

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ANTIPLATELET THERAPY AND ELECTIVE PROCEDURES



 

Figure 2:  Management of anti-platelet agents in patients undergoing endoscopic procedures

  • Antiplatelet therapy with aspirin and/or dipyridamole are safe to continue. However, to avoid any confusion, if patients are on aspirin plus dipyridamole, dipyridamole is generally stopped for 5 days before a therapeutic procedure, as per guidelines for other dual anti-platelet therapy.
  1. Patient on clopidogrel (with or without aspirin), low risk procedure - elective gastroscopy and flexible sigmoidoscopy
    • The referring physician discusses the issue of continuing antiplatelet therapy with the patient.
    • Patients are usually advised to continue taking the antiplatelet agents.
    • Patients should be told that if a lesion is found which requires multiple biopsies or removal, a second procedure would probably be required.

  2. Patient on clopidogrel, high risk procedure (elective colonoscopy, ERCP and therapeutic endoscopic) procedures
    • Clopidogrel should usually be discontinued before therapeutic endoscopy unless patient has a high risk condition. In general, because polypectomy is required in 20-40% of colonoscopies, colonoscopy is considered as a high risk procedure. Procedures in which large numbers of biopsies are anticipated (eg Barrett’s surveillance) are also categorized as ‘high risk’.
    • The referring physician discusses the issue of anti-platelet therapy with the patient and if necessary the cardiologist.
    • The patient should be advised to stop clopidogrel 5 days before the endoscopy.
    • Aspirin should be continued, or can be used to replace the clopidogrel if patient not already on it.
    • Clopidogrel should not be discontinued:
    • < 12 months after insertion of a drug-eluting coronary stent
    • <1 month after insertion of bare metal coronary stent
    • Clopidogrel should be restarted at the endoscopist’s discretion, usually the day after the procedure.

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Appendix 1 - Pathway for Endoscopy pre-assessment nurses on receipt of Endoscopy request:

  • Check on request for patients taking:
  • Anticoagulation with Warfarin / NOAC
  • Clopidogrel
  • If either is positive, check whether the instructions to stop these drugs are clear on the request.
  • If the instructions are unclear or you are unsure, the referring consultant is emailed for further advice. If after 7 days they have not replied, a copy of the endoscopy request with a copy of the email is sent to the referring consultant, explaining why the procedure has not yet been booked.
  • For patients who require heparin (as stated on request or following additional information from the referring doctor):
    1. Set date for procedure . If patients live in Leeds they can be referred to the anticoagulation clinic. For patients out of the Leeds area, phone/fax the GP surgery to inform them of this date and the tinzaparin instructions.
    2. Ring the patient to pre-assess them. Advise patient to stop warfarin 5 days before procedure.
    3. Check the results server to ensure that a) platelet count is normal and b) check recent creatinine level.
    4. Send the patient the appointment letter and instructions to the GP on prescribing LMWH (see appendix 2) plus the LMWH timeline letter (see appendix 3). Inform the patient to take both of these to the GP who will then prescribe LMWH.
  • INR levels will be checked in the Endoscopy department prior to the procedure to ensure they do not exceed the therapeutic range.
  • For patients who are to stop warfarin but not to have heparin, advise patient to stop warfarin 5 days before procedure. INR levels will be checked in the Endoscopy department prior to the procedure.

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Appendix 2: Letter to the GP regarding stopping warfarin and bridging with LMWH

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Appendix 3: Advice for patients who are replacing warfarin with 175 units tinzaparin per KG body weight prior to endoscopic procedures

Provenance

Record: 859
Objective:
Clinical condition:

Patients referred for Gastrointestinal endoscopy

Target patient group: Adult Patients attending for Endoscopy who take oral anticoagulants or anti-platelet therapy
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Not supplied

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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