• ENDOSCOPIC PROCEDURES

We thank the authors for their interest in the recently published British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy (ESGE) guidelines on endoscopy in patients on antiplatelet or anticoagulant therapy.1 As stated in the summary of recommendations, these guidelines refer to the management of elective endoscopic procedures. For elective palliative colonic stenting, there is often adequate time to discontinue antithrombotic therapy, including P2Y12 antagonists. In an emergency situation, we agree with the authors that the balance of risk between haemorrhage due to stenting versus death due to colonic obstruction would favour endoscopic stenting. Importantly, stenting in this context is controversial, and ESGE guidelines recommend this only for those at high risk of postoperative mortality.2 The patient should be consented accordingly in this high-risk situation.

We are also grateful to the authors for highlighting the potential use of idarucizumab as a reversal agent for dabigatran. This was referenced in the guideline, although not by name, as were other new potential reversal agents. Since the guidelines were written, idarucizumab has been approved by the Food and Drug Administration in the USA, and by the European Commission, for management of life-threatening haemorrhage, or prior to emergency surgery, in patients on dabigatran. Further development of other antidotes for direct oral anticoagulants will improve the safety profile of these drugs in the context of therapeutic endoscopy.