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

Authors: Andrew M. Veitch, Geoffroy Vanbiervliet, Anthony H. Gershlick, Christian Boustiere, Trevor P. Baglin, Lesley-Ann Smith, Franco Radaelli, Evelyn Knight, Ian M. Gralnek, Cesare Hassan, Jean-Marc Dumonceau

Summary

1 For all endoscopic procedures we recommend continuing aspirin (moderate evidence, strong recommendation), with the exception of ESD, large colonic EMR (> 2 cm), upper gastrointestinal EMR and ampullectomy. In the latter cases, aspirin discontinuation should be considered on an individual patient basis depending on the risks of thrombosis vs haemorrhage (low quality evidence, weak recommendation).

2 For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists (e. g., clopidogrel), as single or dual anti- platelet therapy (low quality evidence, strong recommendation). For low-risk endoscopic procedures we suggest that warfarin therapy should be continued (low quality evidence, weak recommendation). It should be ensured that the INR does not exceed the therapeutic range in the week prior to the procedure (low quality evidence, strong recommendation).

3 For low-risk endoscopic procedures we suggest omitting the morning dose of direct oral anticoagulant (DOACs) on the day of the procedure (very low quality evidence, weak recommendation).

4 For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists (e. g., clopidogrel) five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak re- commendation).

5 For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing warfarin 5 days before the procedure (high quality evidence, strong recommendation). Check INR prior to the procedure to ensure this value is <1.5 (low quality evidence, strong recommendation).

6 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 discontinuing P2Y12 receptor antagonists (e. g., clopidogrel) (high quality evidence, strong recommendation).

7 For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend that warfarin should be temporarily discontinued and substituted with low molecular weight heparin (low quality evidence, strong recommendation).

8 For all patients on warfarin we recommend advising that there is an increased risk of post-procedure bleeding compared to non-anticoagulated patients (low quality evidence, strong recommendation). For high-risk endoscopic procedures in patients on DOACs, we recommend that the last dose of DOACs be taken at least 48 hours before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with a CrCl (or eGFR) of 30 – 50 mL/min we recommend that the last dose be taken 72 hours prior to 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).

9 If antiplatelet or anticoagulant therapy is discontinued, then we recommend this should be resumed up to 48 hours after the procedure depending on the perceived bleeding and thrombotic risks (moderate quality evidence, strong recommendation).