Management of Direct Oral Anticoagulants Before Digestive Endoscopy

Stratification According to Procedure Risk

For low-risk endoscopic procedures, such as diagnostic endoscopy with biopsies, it is sufficient to omit the morning dose of Xarelto, Pradaxa, or Eliquis on the day of the procedure, without any other interruption necessary, as recommended by the European Society of Gastrointestinal Endoscopy 1, 2, 3
Diagnostic procedures with or without biopsies are considered low-risk, according to the European Society of Gastrointestinal Endoscopy 1, 2
The recommendation is to omit only the morning dose on the day of the procedure for all direct oral anticoagulants (Xarelto/rivaroxaban, Pradaxa/dabigatran, Eliquis/apixaban), as stated by the European Society of Gastrointestinal Endoscopy 1, 2, 3

The following procedures are classified as high-risk: polypectomy 2, endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy 2, endoscopic mucosal resection (EMR/ESD) 3, dilation of stenoses 3, treatment of varices 3, percutaneous endoscopic gastrostomy (PEG) 2, and echoendoscopy with fine-needle aspiration 3

For Xarelto (rivaroxaban) and Eliquis (apixaban), the recommended stop is ≥48 hours before the procedure, as suggested by the European Society of Gastrointestinal Endoscopy 1, 3, 4
For patients with normal renal function, the last dose should be taken at least 48 hours before the intervention, according to the European Society of Gastrointestinal Endoscopy 1, 3, 4

For patients at low thrombotic risk, no heparin bridging is necessary, and simple cessation of direct oral anticoagulants according to the protocol above is sufficient, as recommended by the European Society of Gastrointestinal Endoscopy 6
For patients at high thrombotic risk, conditions such as mechanical heart valve in mitral position, mechanical heart valve in aortic position, and atrial fibrillation with mitral stenosis are considered high-risk, according to the European Society of Gastrointestinal Endoscopy 1, 3, 4

Direct oral anticoagulants should be resumed as soon as adequate hemostasis is achieved, as recommended by the European Society of Gastrointestinal Endoscopy 6
For low-risk procedures, resumption is possible on the same day, according to the European Society of Gastrointestinal Endoscopy 5
For high-risk procedures, resumption is generally 24-72 hours after the procedure, as suggested by the European Society of Gastrointestinal Endoscopy 5