DOACs Versus Warfarin: Is One Safer During Endoscopy?

DOACs Versus Warfarin: Is One Safer During Endoscopy?

Vanessa M. Shami, MD, FASGE, reviewing Tien A, et al. Gastrointest Endosc 2020 Feb 29.

Gastroenterologists are seeing an increasing number of patients taking direct-acting oral anticoagulants (DOACs), including dabigatran, rivaroxaban, and apixaban. While there are guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) on periendoscopic anticoagulation management, there are limited data on postendoscopic GI bleeding (GIB) and thromboembolic events (myocardial infarction, stroke, or venous embolism) within 30 days of endoscopy in patients on newer anticoagulants. 

This retrospective study assessed these primary endpoints in patients who had active prescriptions for DOACs (n=1587) or warfarin (n=5178) and underwent both diagnostic and therapeutic endoscopic evaluations between January 2013 and October 2019. Patients were instructed to hold their anticoagulation, per ASGE recommendations, prior to endoscopy.

When capturing all endoscopic procedures, there was no statistical difference in postprocedure GIB between the DOAC (4.3%; 68/1587 patients) versus warfarin (3.8%; 198 of 5178 patients) (P=.41) populations. On subgroup analysis, there were no differences in GIB between the DOAC and warfarin patients (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.67-1.56; P=.92) after colonoscopies, but esophagogastroduodenoscopies (EGDs) did demonstrate an increased risk for the DOAC population (OR, 1.80; 95% CI, 1.15-2.83; P=.011). Postprocedure thromboembolic events were similar between patients on DOACs (2.3%; 36 of 1587 patients) and warfarin (2.6%; 134 of 5178 patients). 

This study demonstrates that the risk of GI bleeding and thromboembolic events for patients undergoing endoscopy on DOACs is similar to patients on warfarin, with a slightly increased risk of GI bleeding after EGDs for patients on DOACs. Studies like this allow gastroenterologists to better inform these patients of the risks of endoscopy.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Vanessa M. Shami, MD, FASGE


Tien A, Kwok K, Dong E, et al. Impact of direct-acting oral anticoagulants and warfarin on postendoscopic GI bleeding and thromboembolic events in patients undergoing elective endoscopy. Gastrointest Endosc 2020 Feb 29. (Epub ahead of print) (

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