Management of Anticoagulants and Antiplatelets for Endoscopy

Introduction to Antithrombotic Management

The European Society of Gastrointestinal Endoscopy recommends continuing all antiplatelet agents for low-risk procedures and omitting only the morning dose of direct oral anticoagulants (DOACs) on the day of the procedure 1, 3
For high-risk procedures, stop DOACs 48 hours before (72 hours for dabigatran with creatinine clearance 30-50 mL/min) and stop clopidogrel 5 days before, continuing aspirin unless the patient is at high thrombotic risk, requiring cardiology consultation 1, 2, 3

Low-risk procedures include diagnostic procedures with or without biopsies, placement of biliary or pancreatic prostheses, and enteroscopy without polypectomy 3
High-risk procedures include polypectomy, sphincterotomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD) 1, 3

For low-risk procedures, omit only the morning dose of DOACs on the day of the procedure 1, 3, 4
For high-risk procedures with normal renal function, stop DOACs at least 48 hours before the procedure (dabigatran, apixaban, rivaroxaban, edoxaban) 1, 2, 3, 4
For high-risk procedures with decreased renal function (creatinine clearance 30-50 mL/min), stop dabigatran 72 hours before the procedure and consider prolonging the interval for other DOACs 1, 2, 3, 4

Continue aspirin for all procedures, whether low or high risk, especially for secondary prevention 3, 5
For patients on aspirin for primary prevention, consider stopping it permanently in case of acute gastrointestinal bleeding 3

For low-risk procedures, continue clopidogrel (or prasugrel, ticagrelor) in monotherapy or dual antiplatelet therapy 1, 3
For high-risk procedures with low thrombotic risk, stop clopidogrel 5 days before the procedure and continue aspirin 1, 3, 5
For high-risk procedures with high thrombotic risk, continue aspirin and consult a cardiologist regarding the cessation of clopidogrel 1, 2, 3, 5

For low-risk procedures, continue warfarin and check the international normalized ratio (INR) the week before endoscopy to ensure it is within the therapeutic range 1, 3
For high-risk procedures with low thrombotic risk, stop warfarin 5 days before the procedure and do not use a heparin bridge 3
For high-risk procedures with high thrombotic risk, stop warfarin 5 days before the procedure and start a heparin bridge 2 days after stopping warfarin 2, 3

In patients with severe renal impairment, adjust the management of anticoagulants according to renal function and consider consulting a hematologist 1, 2, 3, 4
For patients with a recent coronary stent, consider them at high thrombotic risk and manage accordingly, consulting a cardiologist as needed 2, 5

Reinitiate antiplatelet agents or anticoagulants 24-72 hours after the procedure based on the perceived bleeding and thrombotic risks 3, 4
Ensure adequate hemostasis is achieved before reinitiating anticoagulation, especially after polypectomy 4

Never stop both antiplatelet agents simultaneously in patients with coronary stents due to the high risk of stent thrombosis 5
Always consider renal function when managing patients on DOACs and adjust the timing of cessation accordingly 1, 2, 3, 4
Avoid systematic bridging with heparin for all patients on warfarin; it is only necessary for those at high thrombotic risk 2, 3
Do not restart anticoagulation too early after polypectomy; wait until adequate hemostasis is confirmed 3, 4