Direct-acting oral anticoagulant use before and after endoscopic procedures

The direct-acting oral anticoagulants (DOACs) include factor Xa inhibitors (eg apixaban, rivaroxaban) and direct thrombin inhibitors (eg dabigatran).

Note: The timing of the last preprocedural dose of a DOAC depends on the elimination half-life of the drug used, which varies with renal function.

It is recommended that DOACs should be stopped before endoscopic procedures. The timing of the last preprocedural dose depends on the elimination half-life of the drug used, which varies with renal function; see Timing of preprocedural interruption of direct-acting oral anticoagulant (DOAC) therapy ASGE Standards of Practice Committee, 2016.

Crossover therapy with a parenteral anticoagulant is rarely used for the interruption of DOAC therapy; this should be discussed with the patient’s cardiologist or vascular physician.

When to restart DOAC therapy postprocedurally should be decided in consultation with the proceduralist. Following a procedure with a low postprocedural bleeding risk, patients can usually restart DOAC therapy the day after the procedure (assuming haemostasis is achieved). If the procedure has a moderate to high postprocedural bleeding risk (eg removal of a large polyp), consider delaying restarting DOAC therapy until day 2 or 3 postprocedure. DOACs achieve maximum anticoagulant effect within hours of the first dose; prophylactic anticoagulant drug therapy to prevent venous thromboembolism may be appropriate in the interim if delaying restarting DOAC therapy after the procedure (see Venous thromboembolism (VTE) prophylaxis).

For management of bleeding or overanticoagulation with DOACs, seek expert advice from a haematologist (see also Overview of oral anticoagulants).