Overview of the use of antithrombotic therapy before and after endoscopic procedures in adults

ASGE Standards of Practice Committee, 2016

Antithrombotic therapy includes anticoagulant drugs (eg warfarin, apixaban, rivaroxaban, dabigatran) and antiplatelet drugs (eg aspirin, clopidogrel, prasugrel, ticagrelor). Patients taking antithrombotic therapy who need gastrointestinal endoscopy should be managed in conjunction with the specialist who prescribed the therapy and the endoscopist.

Note: The use of antithrombotic therapy before and after endoscopic procedures should be managed in conjunction with the specialist who prescribed the antithrombotic therapy and the endoscopist.

The periprocedural management of antithrombotic therapy depends on both the procedural and patient bleeding risk and the patient’s risk for a thromboembolic event. Summary of the use of antithrombotic therapy before endoscopic procedures provides information on the use of antithrombotic therapy before endoscopic procedures. The potential harm of continuing a drug that may increase the chance of bleeding from an intervention (eg polypectomy, sphincterotomy) should be balanced against the chance that stopping the drug could cause a fatal or incapacitating thromboembolic event. Stopping antithrombotic therapy may have greater potential harm than continuing it.

The procedural bleeding risk can be obtained from the endoscopist or, if available, a local hospital protocol. If these are unavailable, information on the procedural bleeding risk can be found in the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Whether to continue antithrombotic drugs in patients undergoing high-risk procedures depends on their underlying risk factors and the drug(s) in use.

Note: The need to stop antithrombotic therapy before an endoscopic procedure should be assessed on an individual basis; it depends on the procedural bleeding risk and the patient’s risk for a thromboembolic event.

If antithrombotic therapy has been prescribed for a specific period (eg dual antiplatelet therapy following an acute coronary syndrome or implantation of a drug-eluting stent) and cannot be stopped, it may be appropriate to delay a nonurgent colonoscopy.

If a colonoscopy is required and the antithrombotic therapy cannot be stopped, a diagnostic colonoscopy may be performed on the understanding that polyps will not be removed on that occasion because of the potential risk of postpolypectomy bleeding. If polyps are found, a subsequent colonoscopy is required to remove the polyps. The patient should be informed of this as part of the consent process.

For the risk of a thromboembolic event associated with cardiovascular conditions (for which antithrombotic therapy is prescribed), see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE. For patients with high-risk conditions receiving short-term antithrombotic therapy (eg following insertion of a drug-eluting stent), consider deferring elective procedures until therapy is completed.

Table 1. Summary of the use of antithrombotic therapy before endoscopic proceduresASGE Standards of Practice Committee, 2016
warfarin direct-acting oral anticoagulants (eg apixaban, rivaroxaban, dabigatran) clopidogrel, prasugrel and ticagrelor aspirin
Warfarin
Procedure with a low risk of bleeding [NB1]		Procedure with a high risk of bleeding [NB1]
low risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	high risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	low risk of a thromboembolic event] (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	high risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)
continue [NB2]	continue [NB2]	check INR 5 to 7 days before the procedure consider stopping 3 to 5 days before the procedure, depending on INR	seek expert advice bridging therapy may be required
Direct-acting oral anticoagulants (eg apixaban, rivaroxaban, dabigatran)
Procedure with a low risk of bleeding [NB1]		Procedure with a high risk of bleeding [NB1]
low risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	high risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	low risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	high risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)
stop 1 to 2 days before the procedureDouketis, 2019 Douketis, 2022, depending on renal function (see Timing of preprocedural interruption of direct-acting oral anticoagulant (DOAC) therapy)	stop 1 to 3 days before the procedure, depending on renal function (see Timing of preprocedural interruption of direct-acting oral anticoagulant (DOAC) therapy)	stop 2 to 4 days before the procedure, depending on renal function (see Timing of preprocedural interruption of direct-acting oral anticoagulant (DOAC) therapy)	stop 2 to 4 days before the procedure, depending on renal function (see Timing of preprocedural interruption of direct-acting oral anticoagulant (DOAC) therapy)
Clopidogrel, prasugrel and ticagrelor
Procedure with a low risk of bleeding [NB1]		Procedure with a high risk of bleeding [NB1]
low risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	high risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	low risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	high risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)
continue	continue	stop clopidogrel and ticagrelor 5 days before the procedure, and prasugrel 7 days before the procedure [NB3] if the patient is taking single antiplatelet therapy, substitution with aspirin may be required—seek expert advice if the patient is taking dual antiplatelet therapy, continue aspirin	defer procedure if possible seek expert advice consider stopping clopidogrel and ticagrelor 5 days before the procedure, and prasugrel 7 days before the procedure [NB3]
Aspirin
Procedure with a low risk of bleeding [NB1]		Procedure with a high risk of bleeding [NB1]
low risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	high risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	low risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)	high risk of a thromboembolic event (see Suggested risk stratification for a periprocedural thromboembolic event in a patient with a mechanical heart valve, atrial fibrillation or history of VTE)
continue	continue	continue	continue
Note: INR = international normalised ratio NB1: The risk of bleeding can be obtained from the endoscopist or, if available, a local hospital protocol. If these are unavailable, information on the risk of bleeding can be found in the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. NB2: Check INR 5 to 7 days before endoscopy. If the INR is above the therapeutic range consult the specialist who prescribed the warfarin and the endoscopist performing the procedure. NB3: If antiplatelet therapy has been prescribed for a specific period (eg dual antiplatelet therapy for 12 months following an acute coronary syndrome or implantation of a drug-eluting stent), delay elective procedures until after this period whenever possible.