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Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines
  1. Andrew M Veitch1,
  2. Geoffroy Vanbiervliet2,
  3. Anthony H Gershlick3,
  4. Christian Boustiere4,
  5. Trevor P Baglin5,
  6. Lesley-Ann Smith6,
  7. Franco Radaelli7,
  8. Evelyn Knight8,
  9. Ian M Gralnek9,10,
  10. Cesare Hassan11,
  11. Jean-Marc Dumonceau12
  1. 1Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
  2. 2Department of Gastroenterology, Hôpital Universitaire L'Archet 2, Nice Cedex 3, France
  3. 3Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
  4. 4Service Unité Endoscopie Digestive, Hopital Saint Joseph, Marseille, France
  5. 5Department of Haematology, Addenbrookes Hospital, Cambridge, UK
  6. 6Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
  7. 7Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce, Como, Italy
  8. 8AntiCoagulation Europe, Bromley, Kent, UK
  9. 9Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel
  10. 10Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Israel
  11. 11Digestive Endoscopy Unit, Catholic University, Rome, Italy
  12. 12Gedyt Endoscopy Center, Buenos Aires, Argentina
  1. Correspondence to Dr Andrew Veitch, Department of Gastroenterology, New Cross Hospital, Wolverhampton WV10 0QP, UK; andrew.veitch{at}nhs.net

Abstract

The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy.

P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor) For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation).

Warfarin The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance.

Direct Oral Anticoagulants (DOAC) For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30–50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).

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