Management of anticoagulants in patients undergoing endoscopic procedures

Low-risk procedures, high or low-risk conditions — No change in anticoagulation is recommended for low-risk procedures, though we suggest that elective procedures be delayed in patients taking vitamin K antagonists (eg, warfarin) if the INR or prothrombin time is in the supratherapeutic range.

High-risk procedures, low-risk conditions — In patients at low risk for thromboembolism undergoing high-risk endoscopic procedures, vitamin K antagonists (eg, warfarin) should be discontinued five days before the procedure. The INR should be confirmed to be below 1.4 before the procedure. The vitamin K antagonist can usually be reinstituted on the night of the procedure.

Patients taking an oral direct thrombin or factor Xa inhibitor (dabigatran, rivaroxaban, or apixaban) with normal renal function typically discontinue the drug one to two days prior to the procedure. These drugs have rapid onsets of action (hours) and short half-lives (9 to 17 hours) [5]. These drugs can usually be reinstituted following the procedure. (See "Management of anticoagulation before and after elective surgery", section on 'Dabigatran' and "Management of anticoagulation before and after elective surgery", section on 'Rivaroxaban and apixaban'.)

In patients in whom a sphincterotomy has been performed, the risk of bleeding persists for three to five days, and when sessile polyps are resected, the risk of bleeding may persist for more than two weeks. It is reasonable to delay attaining therapeutic levels of anticoagulation in these situations until five days or two weeks postprocedure, respectively.

High-risk procedures, high-risk conditions — For patients at high risk for thromboembolism undergoing high-risk procedures, vitamin K antagonists (eg, warfarin) should be discontinued five days before the procedure, and bridge therapy should be considered. Similarly, patients taking dabigatran should have the drug stopped one to two days prior to the procedure, assuming normal renal function. We suggest consulting the clinician prescribing the anticoagulant to discuss the options for bridge therapy. (See "Management of anticoagulation before and after elective surgery", section on 'Dabigatran'.)

Bridge therapy — Bridge therapy may be indicated in the periendoscopic period in patients on anticoagulants who are at high risk for thromboembolic complications. The American Heart Association and the American College of Cardiology recommend the following [1]:

• Atrial fibrillation – Bridge therapy is not required for a patient with isolated atrial fibrillation, but is recommended for a patient with atrial fibrillation and a mechanical valve, a history of a cerebrovascular accident or transient ischemic attack, or a history of systemic embolism.
  
  Patients with atrial fibrillation and a bileaflet aortic valve do not require bridge therapy, but should have their anticoagulant restarted within 24 hours.
• Valvular heart disease – Bridge therapy is recommended for patients with a mechanical mitral valve or a mechanical aortic valve with any of the following: atrial fibrillation, previous thromboembolic event, left ventricular dysfunction, hypercoagulable condition, mechanical tricuspid valve, or more than one mechanical valve.

SUMMARY AND RECOMMENDATIONS

• The risk of bleeding from endoscopic procedures can be classified as high or low. In general, diagnostic procedures are low-risk, whereas therapeutic procedures are high-risk (table 1). 
• The probability of a thromboembolic complication following reversal or discontinuation of anticoagulation or antiplatelet agents depends upon the preexisting condition for which the medication was prescribed (table 2). 
• For low-risk procedures, the American Society of Gastrointestinal Endoscopy (ASGE) guidelines suggest making no changes in anticoagulation (Grade 2C). We suggest that elective procedures be delayed if the INR or prothrombin time is in the supratherapeutic range (Grade 2C). (See 'Low-risk procedures, high or low-risk conditions' above.)
• In patients undergoing high-risk endoscopic procedures, we suggest discontinuing vitamin K antagonists (eg, warfarin) five days before the procedure and dabigatran, rivaroxaban, or apixaban one to two days before the procedure in patients with normal renal function (Grade 2C). (See 'High-risk procedures, low-risk conditions' above.)

• Bridge therapy is not required for patients at low-risk for thromboembolism. (See 'High-risk procedures, low-risk conditions' above.)
• For patients at high-risk for thromboembolism, we suggest bridge therapy (Grade 2C). (See 'High-risk procedures, high-risk conditions' above and 'Bridge therapy' above.)

• The management of patients taking antiplatelet agents is discussed in detail elsewhere. (See "Management of antiplatelet agents in patients undergoing endoscopic procedures".)
• Other disorders of hemostasis that may require treatment prior to gastrointestinal procedures, including von Willebrand's disease, hemophilia A and B, renal failure, liver failure, and thrombocytopenia, are discussed in detail elsewhere. (See "Endoscopic procedures in patients with disorders of hemostasis".)