Source: DGNews  |  Posted 2 years ago

OAK BROOK, Ill -- December 10, 2009 -- According to an updated guideline from
the American Society for Gastrointestinal Endoscopy (ASGE), published in the
December issue of []GIE: Gastrointestinal Endoscopy[] regarding the
management of antithrombotic agents for endoscopy, aspirin and/or nonsteroidal
antiinflammatory drugs (NSAIDs) may be continued for all elective endoscopic
procedures.

When high-risk procedures are planned, clinicians may elect to discontinue
aspirin and/or NSAIDs for 5 to 7 days before the procedure, depending on the
underlying indication for antiplatelet therapy. For patients on temporary
anticoagulation therapy, it is suggested that elective endoscopic procedures be
deferred until antithrombotic therapy is completed.

“Before performing endoscopic procedures on patients taking antithrombotic
medications, one should consider the risks of stopping these medications versus
the risk of a complication if the medications are continued. But one must also
consider the urgency of the procedure,” said Jason A. Dominitz, MD, University
of Washington School of Medicine, Seattle, Washington. “Alternative diagnostic
studies for patient evaluation, such as video capsule endoscopy or radiologic
studies, may be appropriate in some cases.”

Other key recommendations include:
· It is recommended that elective procedures be deferred in patients with a
recently placed vascular stent or acute coronary syndrome (ACS) until the
patient has received antithrombotic therapy for the minimum recommended
duration per current guidelines from relevant professional societies. Once this
minimum period has elapsed, it is suggested that clopidogrel or ticlopidine be
withheld for approximately 7 to 10 days before endoscopy and that aspirin be
continued. For those patients not taking aspirin, the addition of aspirin
during the time that clopidogrel or ticlopidine is withheld may reduce the risk
of thromboembolic events.

· When clopidogrel and ticlopidine are used for other indications, it is
suggested that these medications may be continued for low-risk procedures, but
should be discontinued for approximately 7 to 10 days before higher-risk
procedures. For those patients not taking aspirin, the addition of aspirin
during the periendoscopic period may reduce the risk of thromboembolic events.

· It is suggested to discontinue anticoagulation (ie, warfarin) in patients
with a low risk of thromboembolic events in whom it is safe to do so.

· It is suggested to continue the anticoagulation in patients at higher risk of
thromboembolic complications, switching to low molecular weight heparin (LMWH)
or unfractionated heparin (UFH) around the time of endoscopy when indicated for
known or expected therapeutic indications.

· There is insufficient evidence to recommend for or against the prophylactic
use of mechanical clips after polypectomy in patients on anticoagulation.

· There is no consensus as to the optimal timing of reinitiation of
anticoagulant therapy after endoscopic interventions, and decisions are likely
to depend on procedure-specific circumstances as well as the indications for
anticoagulation. It is suggested that the benefits of immediate anticoagulant
therapy in preventing thromboembolic events be weighed against the risk of
hemorrhage and determined in a case-by-case basis.

· In patients at high risk of thromboembolic events, it is suggested that UFH
or LMWH be restarted as soon as safely possible and that warfarin be restarted
on the day of the procedure unless there is significant concern for bleeding.
UFH may be restarted 2 to 6 hours after a therapeutic procedure. In patients
with a low risk of thromboembolic events, it is suggested that warfarin be
restarted on the evening after the endoscopy unless procedural circumstances
suggest a high risk of postprocedure bleeding. Bridging therapy in patients
with a low thromboembolic risk is not necessary.

· In pregnant patients with mechanical heart valves needing endoscopic
procedures, it is recommended that elective procedures be delayed until after
delivery whenever possible, and when delay is not possible, that bridge therapy
with LMWH or UFH be considered. Consultation with the patient’s cardiologist
and/or obstetrician should be obtained.

Recommendations for Urgent and Emergent Endoscopic Procedures
· It is suggested that patients with acute GI bleeding taking antiplatelet
agents should have these medications withheld until haemostasis is achieved.
Administration of platelets may be appropriate for patients with
life-threatening or serious bleeding. In situations of significant bleeding
occurring in patients with a recently (<1 year) placed vascular stent and/or
ACS, it is suggested that cardiology consultation be obtained before stopping
antiplatelet agents.

· It is recommended that patients with acute bleeding receiving anticoagulation
therapy have these agents withheld until haemostasis is achieved. The decision
to use fresh frozen plasma (FFP), prothrombin complex concentrate, and/or
vitamin K should be individualised. It is suggested that protamine be reserved
for patients with life-threatening bleeding on heparin because of the potential
risks of anaphylaxis and severe hypotension. In situations of significant
bleeding occurring in patients with a recently (<1 year) placed vascular stent
and/or ACS, it is recommended that consultation with the prescribing service be
obtained before stopping anticoagulants.

· It is recommended that patients with acute GI bleeding taking warfarin with a
supratherapeutic international normalised ratio (INR) undergo correction of
anticoagulation, although the target level INR required for endoscopic therapy
to be effective has not been determined.

· The absolute risk of rebleeding after endoscopic haemostasis in patients who
must resume anticoagulation is unknown, and the timing for resumption of
anticoagulation should be individualised. It is suggested that in patients with
high-risk stigmata for rebleeding intravenously administered UFH be used
initially because of its relatively short half-life.

SOURCE: American Society for Gastrointestinal Endoscopy