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Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures
  1. A M Veitch1,
  2. T P Baglin2,
  3. A H Gershlick3,
  4. S M Harnden1,
  5. R Tighe4,
  6. S Cairns5
  1. 1
    Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
  2. 2
    Department of Haematology, Addenbrooke’s Hospital, Cambridge, UK
  3. 3
    Department of Cardiology, University Hospitals of Leicester, Leicester, UK
  4. 4
    Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
  5. 5
    Department of Gastroenterology, Royal Sussex County Hospital, Brighton, UK
  1. Dr A M Veitch, New Cross Hospital, Wolverhampton, WV10 0QP, UK; andrew.veitch{at}rwh-tr.nhs.uk

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1.0 SUMMARY OF RECOMMENDATIONS

Please refer to fig 1 for an algorithmic representation of the recommendations, and tables 1–3 for a risk stratification of endoscopic procedures and medical conditions requiring anticoagulant or antiplatelet therapy. Aspirin therapy can be continued for all endoscopic procedures.

Figure 1 Guidelines for the management of patients on warfarin or clopidogrel undergoing endoscopic procedures. AF, atrial fibrillation; EMR, endoscopic mucosal resection; ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; FNA, fine needle aspiration; INR, international normalised ratio; LMWH, low molecular weight heparin; PEG, percutaneous endoscopic gastroenterostomy; VTE, venous thromboembolism.
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Table 1 Risk stratification of endoscopic procedures based on risk of haemorrhage
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Table 2 Risk stratification for discontinuation of anticoagulant therapy
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Table 3 Risk stratification for discontinuation of clopidogrel

1.1 Acute gastro-intestinal haemorrhage

Acute gastro-intestinal haemorrhage in patients on anticoagulant or antiplatelet agents is a high-risk situation. The immediate risk to the patient from haemorrhage may outweigh the risk of thrombosis as a result of stopping anticoagulant or antiplatelet therapy. Patients need to be assessed on an individual basis, and it is not possible to give unequivocal guidance to cover all situations. For patients with high-risk conditions on warfarin, then this can be discontinued with or without substitution of heparin depending on the severity of haemorrhage and risk of discontinuing anticoagulant therapy. There is a high risk of acute myocardial infarction or death if clopidogrel is discontinued in patients with coronary stents, particularly early after implantation, but extending up to 1 year after this. Endoscopy should be attempted as soon as safely possible after urgent liaison between the patient’s cardiologist and the consultant specialist undertaking endoscopy. Clopidogrel should not be discontinued without discussion with a cardiologist. If clopidogrel therapy needs to be discontinued in this context, then this should be limited to a maximum of 5 days as the risk of stent thrombosis increases after this interval. (Evidence grade III. Recommendation grade B.) Early therapeutic endoscopic intervention may achieve haemostasis with minimal or no cessation of anticoagulant or antiplatelet therapy, and should be the first aim. (Evidence grade IV. Recommendation grade C.)

1.2 Low-risk endoscopic procedures

Anticoagulation or antiplatelet therapy should be continued. (Evidence grade IV. Recommendation grade C.) If warfarin is continued then it should be ensured that the international normalised ratio (INR) does not exceed the therapeutic range: (Evidence grade IV. Recommendation grade C.)

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    BMJ Publishing Group Ltd and British Society of Gastroenterology