How to Manage Anticoagulants and Antiplatelets During Endoscopic Procedures

Vanessa M. Shami, MD, FASGE, reviewing Abraham NS, et al. Am J Gastroenterol 2022 Mar 17.

The increasing use of anticoagulant and antiplatelet agents has made the management of these medications during and around the time of endoscopy for GI bleeding vexing. The American College of Gastroenterology and the Canadian Association of Gastroenterology utilized the Grading of Recommendations Assessment, Development and Evaluation methodology to develop a joint guideline for the management of periendoscopic antithrombotic therapy.   

The following statements from the guideline are conditional recommendations with very low certainty of evidence and apply to patients who are hospitalized or under observation with acute GI bleeding:

  • Fresh frozen plasma (FFP) should not be administered to patients receiving warfarin. 
  • Prothrombin complex concentration (PCC) rather than FFP should be administered to patients receiving warfarin.
  • Vitamin K use should be avoided in patients receiving warfarin.
  • Idarucizumab should not be given to patients receiving dabigatran.
  • Andexanet alfa should not be administered to patients receiving rivaroxaban or apixaban.
  • PCC administration is not recommended for patients receiving direct oral anticoagulants (DOACs).
  • Antiplatelet transfusions are not recommended for patients receiving antiplatelet agents.

The following statements are conditional recommendations with very low certainty of evidence and apply to patients with GI bleeding who are receiving cardiac aspirin (ASA) for secondary cardiovascular prevention:

  • Do not hold the ASA, but for patients whose ASA is interrupted, the ASA should be resumed on the day hemostasis is confirmed by endoscopy.

The following statements are conditional recommendations with very low certainty of evidence and apply to patients undergoing elective or planned endoscopic GI procedures:

  • For patients receiving warfarin, treatment should continue rather than temporarily interrupting it (1-7 days).
  • Bridging anticoagulation is not recommended for patients whose warfarin is held in the periprocedural period.
  • For patients receiving DOACs, DOACs should be temporarily interrupted.
  • For patients receiving dual antiplatelet therapy for secondary cardiovascular prevention, temporary interruption of the P2Y12 inhibitor while continuing ASA is suggested.
  • For patients receiving ASA (81-325 mg/d) alone for secondary cardiovascular prevention, interruption of ASA is not recommended.

Refer to the guideline for additional statements with insufficient data for the authors to make firm recommendations.

Vanessa M. Shami, MD, FASGE

COMMENT

These guideline statements provide recommendations on managing antithrombic agents during the periendoscopic period. Based on the conditional recommendation and very low certainty of evidence of these statements, there is a need for large, randomized, controlled trials on this topic.

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.

CITATION(S)

Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology clinical practice guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol 2022 Mar 17. (Epub ahead of print) (https://doi.org/10.14309/ajg.0000000000001627)

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