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Anticoagulation/antiplatelet treatment in Endoscopy

  1. Low risk procedures, high or low risk conditions:
    • No need to change- ensure INR is therapeutic (<3) if on warfarin ( within 7days)
    • Clopidogrel can be continued like warfarin
  2. High risk procedures, low risk conditions:
    • Stop warfarin 5 days before the procedure (ensure INR < 1.5 on the day of the procedure)
    • Restart warfarin on the evening of the procedure with the usual daily dose
    • Stop Clopidogrel 7 days prior to the procedure.
    • Continue aspirin if already prescribed. If not on aspirin, then consider aspirin therapy while clopidogrel is discontinued.
  3. High risk procedures, high risk conditions:
    • Warfarin: stop 5 days prior to the procedure.
    • Start LMWH 2 days after stopping warfarin. Omit LMWH on the day of the procedure
    • Restart warfarin on the evening of the procedure with teh usual daily dose. Continue LMWH till the INR is therapeutic
    • Clopidogrel: Stop only if cardiologists are happy. Considerstopping clopidogrel 7 days before endoscopy if >12 months after insertion of drug eluting stent or > 1 month after insertion of bare metal stent. Aspirin can be continued. Restart clopidogrel the day after the procedure.
High risk procedure (bleeding risk 1-6%) Low risk procedures (Bleeding risk <1%)
  1. Polypectomy
  2. ERCP with sphincterotomy
  3. EMR
  4. Dilatation of strictures
  5. Therapy of varices
  6. PEG
  7. EUS with FNA
  8. Laser ablation and coagulation
  1. Diagnostic procedure+/- biopsy
  2. Biliary or pancreatic stenting
  3. Diagnostic EUS
  4. ERCP without sphincterotomy
  5. Enteroscopy
Anticoagulation has to be modified ( by modification we mean either stopped or replaced so that target INR <1.5)

NB: Aspirin can continue. Dipyridamole same as clopidogrel

Warfarin and clopidogrel can continue for diagnostic OGD and colonoscopy including biopsy- just need to measure INR within a week- and must be <3 ( ie within therapeutic range)

NB: For colonoscopy although it is low risk, most stop warfarin/clopidogrel as otherwise incidental finding of polyp would mean repeat procedure

High risk condition Low risk condition
  1. Metal valve in mitral position
  2. AF and any type of prosthetic valve
  3. AF and Mitral stenosis
  4. <3months post VTE ( DVT/PE)
  5. Thrombophilia syndromes

For clopidogrel high risk condition is coronary stent

  1. Metal valve in aortic position
  2. Tissue heart valve
  3. AF without valve disease
  4. >3 months post VTE ( DVT/PE)
For warfarin stop 5 days before

Start therapeutic LMWH 3 days before

Omit LMWH on day of procedure

Start warfarin on the evening of endoscopy at usual dose

Continue LMWH until INR therapeutic-

Stop warfarin 5 days before the procedure and ensure INR <1.5

It is worth noting that the overall risk for an embolic event in these patients is 1 to 2 per 1000 patients when anticoagulation is interrupted for four to seven days.

For clopidogrel stop and replace with aspirin 7days before only if stent>12month old (DES- drug eluting stent) or >1months old ( for BMS- bare metal stent) after discussing with cardiologist.
Before this time stopping clopidogrel is contraindicated

5. Platelet requirement and INR safe range

  1. Ascitic tap- BSG recommend platelet transfusion if <40000. No cut off INR value is quoted in guidelines. Common practice is- no supplement if INR <2 and platelet >60000 before procedure. Check local practice.
  2. Variceal banding- INR <1.5 and platelet >60000
  3. Diagnostic biopsy- Polypectomy- INR <1.5 and platelet >60000
  4. PEG/minor surgical procedure- INR <1.5 and platelet >60000
  5. Percutaneous liver biopsy- INR <1.4 and platelet >60000 and no NSAID within last 7 days- BSG however says no convincing data to support stopping of NSAID
  6. Endoscopic sphincterotomy- INR <1.5 and platelet >60000

References/Bibliography:

  1. BSG Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures 2008
  2. BSG Guidelines on the Management of Ascites in Cirrhosis 2006
  3. BSG Guidelines on the use of Liver Biopsy in Clinical Practice 2004

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