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APAGE/APSDE publish new guidelines for management of antithrombotics in endoscopy

Roshini Claire Anthony
01 Mar 2018

New guidelines published by the Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) aim to improve care for Asian patients on antithrombotic therapy who require emergency or elective endoscopy.

According to the guidelines task force made up of gastroenterologists, endoscopists, cardiologists, neurologists, and public health specialists, management of patients on antithrombotics undergoing gastrointestinal (GI) endoscopy poses a challenge.

“It is a fine balance between the risk of thrombosis [clotting] in patients with cardiovascular risks and GI bleeding due to the procedures [especially in procedures that involve tissue cutting, or removal etc] in these patients,” said guidelines co-author Professor Lawrence Ho Khek-Yu, a senior consultant in gastroenterology and hepatology at the National University Hospital Singapore.

“These guidelines were developed to address identified insufficiencies of existing guidelines with regards to practice realities and population needs in the Asian Pacific region,” he said.

 

Recommendations for emergency endoscopy for nonvariceal upper GI bleeding

According to the task force, in cases where emergency endoscopy is not readily available, aspirin should be withheld prior to endoscopy in aspirin users who present with serious or life-threatening GI bleeding and resumed preferably within 3–5 days following endoscopic haemostasis. Emergency endoscopy should not be deferred in aspirin users as the effects of aspirin last up to 7 days following the last dose. Due to the apparent lack of benefit, platelet transfusion is not recommended for patients on antiplatelet therapy.

The task force also recommends withholding warfarin and direct oral anticoagulants (DOACs) prior to endoscopy, though DOACs should be resumed upon adequate haemostasis. For patients on warfarin, 4-factor prothrombin complex concentrate (PCC) plus low-dose vitamin K (<5 mg) is recommended for life-threatening bleeding with an international normalized ratio (INR) of >2.5. In patients with a high risk for thromboembolism, vitamin K doses exceeding 5 mg are not recommended, though warfarin should be resumed upon adequate haemostasis.

Bridging anticoagulation is not recommended in patients with low thromboembolic risk or those on DOACs but is recommended (using unfractionated heparin) in high-risk patients. Vitamin K, platelet transfusion, or desmopressin is not recommended for DOAC-related bleeding. DOACs should be withheld temporarily for non-life-threatening bleeding, while in the case of severe bleeding with haemodynamic instability, activated charcoal can be given if the last DOAC dose was within 3 hours.

For patients on proton-pump inhibitor infusion plus aspirin and clopidogrel, aspirin should be continued but not clopidogrel. For patients with coronary stents and on dual antiplatelet therapy, both antiplatelets should not be discontinued concurrently. For patients with drug-eluting coronary stents, P2Y12 receptor inhibitors should be restarted quickly following endoscopic haemostasis, preferably within 2–3 days for ticagrelor and within 5 days for clopidogrel or prasugrel.

 

Recommendations for elective endoscopy

In low-risk procedures, the task force does not recommend cessation of antiplatelets, warfarin, or DOACs. For patients on warfarin, the endoscopy should not be done if the INR is >3.5 prior to the procedure.

In high-risk procedures, aspirin should not be stopped with the exception of ultra-high-risk procedures (eg, endoscopic mucosal resection or endoscopic submucosal dissection of large polyps). P2Y12 receptor inhibitors should be stopped 5 days before the endoscopy and resumed upon adequate haemostasis; this timeframe also applies to patients on dual antiplatelet therapy with aspirin, where aspirin should be continued while P2Y12 receptor inhibitors are withheld, except for ultra-high-risk procedures where both antiplatelets may need to be withheld. The task force recommends ceasing all antithrombotics and antiplatelets (for ≤7 days) in ultra-high-risk procedures though the benefits of the procedure vs thrombotic risk should be weighed. 

The task force recommends withholding warfarin 5 days prior to endoscopy, restarting upon adequate haemostasis. For patients with low thromboembolic risk, endoscopy can proceed if the patient’s INR is <2.0. Conversely, in patients with high thromboembolic risk, bridging with heparin is recommended if the INR is <2.0 prior to endoscopy and should be continued post-procedure until INR is within therapeutic range.

DOACs should be withheld from at least 48 hours prior to endoscopy and continued upon adequate haemostasis. Bridging anticoagulation is not recommended in patients on DOACs.

 

Potential challenges

Despite the introduction of these guidelines, there are still challenges that gastroenterologists may face.

“These are guidelines that are based on expert opinion, and may not be supported by evidence in some cases. Gastroenterologists will still need to discuss with their fellow colleagues [eg, cardiologists] who are looking after their patients, as different doctors may have slightly different preferences,” said Ho.

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