Current Practice in Managing Patients on Anticoagulants and/or Antiplatelet Agents around the Time of Gastrointestinal Endoscopy

Zusammenfassung

In der Therapie kardiovaskulärer Erkrankungen sind orale Antikoagulantien (AC) und Thrombozytenfunktionshemmer (TFH) weit verbreitet. Wird bei Patienten, die solche Substanzen einnehmen, eine gastrointestinale Endoskopie erforderlich, kann zur Vermeidung von Blutungskomplikationen eine Modifizierung der Therapie notwendig sein. Demgegenüber steht das Risiko thromboembolischer Komplikationen bei Unterbrechung der Antikoagulation. Während in der chirurgischen Literatur spezifische Richtlinien für das perioperative Vorgehen vorliegen, existieren für den Umgang mit AC/TFH im Rahmen der gastrointestinalen Endoskopie nur vereinzelte Publikationen. Eine Umfrage der American Society for Gastrointestinal Endoscopy (ASGE) vor einigen Jahren zeigte große Unterschiede unter Endoskopikern im Umgang mit diesen Substanzen. Nachfolgend wurden von der ASGE sowie auch von der Deutschen Gesellschaft für Verdauungs- und Stoffwechselerkrankungen (DGVS) entsprechende Richtlinien veröffentlicht. Ziel dieser Fragebogenaktion war es, die in Deutschland derzeit praktizierten Vorgehensweisen bezüglich gastrointestinaler Endoskopie bei Patienten, die AC oder TFH einnehmen, zu ermitteln und mit den bisher publizierten Richtlinien zu vergleichen. Unsere Daten zeigen, dass das Vorgehen, insbesondere bei Patienten, die TFH einnehmen, trotz der Veröffentlichung von Richtlinien weiterhin sehr variabel ist.

Abstract

Anticoagulants and antiplatelet agents are widely used in the prophylaxis and management of thromboembolic and cardiovascular diseases. Gastrointestinal bleeding is a well-known complication of these agents. Modification of anticoagulant and antiplatelet therapy is often required in patients undergoing surgical procedures and specific recommendations for the perioperative period have been issued. Fewer data exist with regard to the use of these agents around the time of endoscopic procedures. A survey of the American Society for Gastrointestinal Endoscopy (ASGE), performed several years ago, showed a wide variation between endoscopists in the management of anticoagulants and antiplatelet agents in the periendoscopic period. Subsequently, guidelines have been proposed by the ASGE as well as the German Society for Gastroenterology (DGVS). The aim of this study was to investigate the current practices among German endoscopists regarding the use of these medications in patients undergoing endoscopic procedures and to assess their adherence to published guidelines. Our data demonstrate that, in spite of the dissemination of guidelines, there is still a wide variation in the periendoscopic management of patients who are at increased risk for bleeding due to anticoagulants, especially in patients taking antiplatelet agents.

Schlüsselwörter

Gastrointestinale Endoskopie - Antikoagulantien - Thrombozytenfunktionshemmer - Umfrage - Richtlinien - ASS - Marcumar - Warfarin

Key words

Gastrointestinal endoscopy - anticoagulation - antiplatelet therapy - questionnaire - guidelines - ASA - marcumar - warfarin

References

• 1 Kearon O, Hirsh J. Management of anticoagulation before and after elective surgery.  N Engl J. 1997;  336 1506-1511
• 2 Kakkar V, Cohen A, Edmonson R. et al . Low molecular weight versus standard heparin for prevention of venous thromboembolism after major abdominal surgery.  Lancet. 1993;  341 259-265
• 3 Madura J, Rookstool M, Wease G. The Management of patients on chronic coumadin therapy undergoing subsequent surgical procedures.  Am Surgeon. 1994;  60 542-546
• 4 Wagner T. ASS und das operative Risiko.  Internist. 1998;  39 220
• 5 Standards o f Practice Committee. Complications of upper GI endoscopy.  Gastrointest Endosc. 2002;  55 784-788
• 6 Hart R, Classen M. Complications of diagnostic gastrointestinal endoscopy.  Endoscopy. 1990;  22 229-233
• 7 Silvis S E, Nebel O, Rogers G. et al . Endoscopic complications.  JAMA. 1976;  235 928-930
• 8 Miller G. Complications of endoscopy of the upper gastrointestinal tract.  Leber Magen Darm. 1987;  17 299-304
• 9 Sander R, Posl H, Weber W. et al . Endoscopic polypectomy in the colon, a calculated risk.  Leber Magen Darm. 1979;  9 122-127
• 10 Jentschura D, Raute M, Winter J. et al . Complications in endoscopy of the lower gastrointestinal tract. Therapy and prognosis.  Surg Endosc. 1994;  8 672-676
• 11 Freeman M, Nelson D, Sherman S. et al . Complications of endoscopic biliary sphincterotomy.  N Engl J Med. 1996;  335 909-918
• 12 Boujaoude J, Pelletier G, Fritsch J. et al . Management of clinically relevant bleeding following endoscopic sphincterotomy.  Endoscopy. 1994;  26 217-221
• 13 Hui A, Wong R, Ching J. et al . Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases.  Gastrointest Endosc. 2004;  59 44-48
• 14 American Society for Gastrointestinal Endoscopy . Guidelines on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.  Gastrointest Endosc. 2002;  55 775-779
• 15 Kadakia S C, Angueira C E, Ward J A. et al . Gastrointestinal endoscopy in patients taking antiplatelet agents and anticoagulants: survey of ASGE members.  Gastrointest Endosc. 1996;  44 309
• 16 Gerson L B, Gage B F, Owens D K. et al . Effect and outcomes of the ASGE guidelines on the periendoscopic management of patients who take anticoagulants.  Am J Gastroenterol. 2000;  95 1717-1724
• 17 Schepke M, Unkrig C, Sauerbruch T. Endoskopie bei Patienten mit Blutungsrisiko.  Z Gastroenterol. 1997;  35 147-153
• 18 Oren A, Breumelhof R, Timmer R. et al . Abnormal clotting parameters before therapeutic ERCP: do they predict major bleeding?.  Eur J Gastroenterol Hepatol. 1999;  11 1093-1097
• 19 Hill J, Maxwell A, Tweedle D. et al . Do measured parameters of blood clotting help predict hemorrhage after endoscopic sphincterotomy?.  Gut. 1990;  31 A608
• 20 Shiffman M L, Farrel M T, Yee Y S. Risk of bleeding after endoscopic biopsy or polypectomy in patients taking aspirin or other NSAIDs.  Gastrointest Endosc. 1994;  40 458-462
• 21 Cotton P B, Lehman G, Vennes J. et al . Endoscopic sphincterotomy complications and their management: An attempt at consensus.  Gastrointest Endosc. 1991;  37 383-393

Appendix

The questionnaire contained 17 questions:

1 General data regarding the responding endoscopist:

information is provided regarding (1) the type of practice setting (solo, group, hospital with number of beds < 400, 400 to 1000, > 1000 respectively); (2) the number of years in practice; (3) the percentage of worktime spent on gastrointestinal endoscopy; (4) number of endoscopic procedures performed per year.

2 Antiplatelet agents: ASA, NSAIDs, clopidogrel:

This section contained the following questions regarding the management of patients in the periendoscopic period who take antiplatelet agents for different reasons: (1) if it is of relevance for the planning of diagnostic or therapeutic endoscopy, if the patient is taking any kind of antiplatelet agent; (2) if the patient is routinely asked if he/she is taking antiplatelet agents; (3) how often various antiplatelet agents (ASA, NSAIDs, clopidogrel) are stopped before endoscopic procedures [esophagogastroduodenoscopy (EGD), colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP)] (4) if antiplatelet agents are stopped before specific endoscopic interventions (cold biopsy, polypectomy, ligation therapy of esophageal varices, sphincerotomy, enteral or biliary dilatation, mucosal resection, endoscopic ultrasound); (5) how many days prior to endoscopy these agents are stopped; (6) if specific endoscopic interventions (cold biopsy, polypectomy, ligation therapy of esophageal varices, sphincterotomy, dilatation, mucosal resection) are performed in patients who are still on antiplatelet agents; (7) at what time after diagnostic or therapeutic endoscopy the antiplatelet agent is restarted.

3 Anticoagulants: coumarin, heparin

This section contained the following questions regarding the management of patients in the periendoscopic period who take anticoagulant agents for different reasons: (1) if anticoagulants are stopped prior to endoscopy in patients who are anticoagulated for different reasons (prosthetic heart valve, atrial fibrillation, pulmonary embolism, deep vein thrombosis, left ventricular dysfunction with mural thrombus); (2) how many days anticoagulants are stopped prior to endoscopy; (3) if and in which patients a heparin window is used when anticoagulants are paused and (4) which dose (low dose vs. therapeutic dose) and (5) kind of heparin (low molecular heparin vs. conventional heparin) is preferred; (6) if various laboratory parameters (PT, PTT, RBC) are routinely checked.