Endoscopy 2016; 48(04): 385-402
DOI: 10.1055/s-0042-102652
Guideline
© Georg Thieme Verlag KG Stuttgart · New York

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

Andrew M. Veitch
1   Consultant Gastroenterologist, Clinical Director of Endoscopy and Bowel Cancer Screening, New Cross Hospital, Wolverhampton
,
Geoffroy Vanbiervliet
2   Pôle digestif, Hôpital Universitaire L’Archet 2
,
Anthony H. Gershlick
3   Honorary Professor of Interventional Cardiology, Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital
,
Christian Boustiere
4   Secrétaire Général de la FMCHGE, Chef de Service Unité Endoscopie Digestive, Hopital Saint Joseph, Marseille, France
,
Trevor P. Baglin
5   Consultant Haematologist, Department of Haematology, Addenbrookes Hospital, Cambridge
,
Lesley-Ann Smith
6   Consultant Gastroenterologist, Level 6, Support Building, Auckland City Hospital
,
Franco Radaelli
7   Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce
,
Evelyn Knight
8   AntiCoagulation Europe
,
Ian M. Gralnek
9   Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center Afula, Israel
,
Cesare Hassan
10   Digestive Endoscopy Unit, Catholic University, Rome, Italy
,
Jean-Marc Dumonceau
11   Gedyt Endoscopy Center, Buenos Aires, Argentina
› Author Affiliations
Further Information

Publication History

Publication Date:
18 February 2016 (online)

The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage vs. 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 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 hours 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 hours 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).