Anticoagulation/antiplatelet treatment in Endoscopy
- 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
- 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.
- 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%) | |
|---|---|---|
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| 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 |
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| High risk condition | Low risk condition | |
For clopidogrel high risk condition is coronary stent |
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| 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. |
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| 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 |
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5. Platelet requirement and INR safe range
- 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.
- Variceal banding- INR <1.5 and platelet >60000
- Diagnostic biopsy- Polypectomy- INR <1.5 and platelet >60000
- PEG/minor surgical procedure- INR <1.5 and platelet >60000
- 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
- Endoscopic sphincterotomy- INR <1.5 and platelet >60000
References/Bibliography:
