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Anticoagulant policy: Endoscopy Unit 2009
RLUH Endoscopy Unit: guidance for patients on anticoagulants or anti-platelet agents who require an Endoscopic procedure.
This guidance and process is based on guidelines published in 2008 by the British Society of Gastroenterology [http://www.bsg.org.uk/clinicalguidelines/endoscopy/anticoagulant-antiplatelet-therapy.html] and further information is available from the American Society of Gastroenterology
[http://www.asge.org/WorkArea/showcontent.aspx?id=3014]. The guidance was agreed within the Division of Medicine in association with the Anticoagulant
Nurse Practitioners.
There are two essential components to this guidance:
1. Consider the risk of the procedure in causing haemorrhage for patients on anticoagulation.
2. Consider the risk to the patient of not having anti-coagulation in order for the procedure to take place.
The following is a summary of the guidance:
1. Aspirin: omit on morning of procedure only, otherwise continue as normal
2. Non-steroidal anti-inflammatory drugs (eg brufen, narpoxed etc): omit on morning of procedure only, otherwise continue as normal
3. Pentoxyfilene: omit on morning of procedure only, otherwise continue as normal
4. Clopidogrel: see specific advice
5. Warfarin: see specific advice
6 Heparin: omit on morning of procedure only, otherwise continue as normal
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Anticoagulant policy: Endoscopy Unit 2009
Clopidogrel:
Continue if the patient is having any of the following:
Diagnostic Gastroscopy
Gastroscopy for assessment or treatment of varices
Diagnostic Enteroscopy
Diagnostic Colonoscopy (ie surveillance or for colitis: not if known polyp or EMR),
Diagnostic EUS (unless staging oesophageal tumour),
ERCP with stent insertion or stent change only
Stop for 7 days if patient is having any of the following:
PEG or PEJ
ERCP planned with sphincterotomy
EUS-FNA
Gastroscopy or Colonoscopy with planned EMR
Planned dilatation of strictures
DO NOT STOP if patient has had a coronary artery stent within the last 12 months – call a cardiologist!.
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Anticoagulant policy: Endoscopy Unit 2009
Warfarin:
Continue if the patient is having any of the following:
Diagnostic Gastroscopy
Gastroscopy for assessment or treatment of varices
Diagnostic Enteroscopy
Diagnostic Colonoscopy (ie surveillance or for colitis: not if known polyp or EMR),
Diagnostic EUS (unless staging oesophageal tumour),
ERCP with stent insertion or stent change only
INR to be checked within the 7 days before the test (patients usually arrange this themselves with anticoagulation monitoring service): level should be <2.5
and patient can continue taking their regular dose. They will have a ‘Coag-u-Check’ in the endoscopy unit on the day of the procedure.
Change process if patient is having any of the following:
PEG or PEJ
ERCP planned with sphincterotomy
EUS-FNA
Gastroscopy or Colonsocopy with planned EMR
Planned dilatation of strictures
Convert to Heparin in these circumstances. Book the procedure as normal but inform the Anticoagulant nurse practitioner (Ext 4347 or Bleep 4929
or via ICE) that patient needs a low target INR. The anticoagulant Nurse Practitioner will arrange to see the patient and stop the warfarin 5 days
prior to planned procedure and start on LMWHeparin 2 days later – this should be omitted on the morning of the planned procedure. Warfarin can
be restarted on the evening of the procedure or on the following morning unless bleeding continues after the procedure. NB: take extra care if
patients also require antibiotics as this can cause warfarin displacement and increase the INR.
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Anticoagulant policy: Endoscopy Unit 2009
Figure 1: Guidelines for the management of patients on warfarin or clopidogrel undergoing endoscopic procedures
High Risk Procedure
Low Risk Procedure
Polypectomy
ERCP with sphincterotomy
EMR
Dilation of strictures
Therapy of varices
PEG
EUS with FNA or Cyst puncture
Diagnostic procedures +/biopsy
Biliary or pancreatic stenting
Diagnostic EUS
Warfarin
Continue Warfarin
Check INR 1 week before
endoscopy
If INR within therapeutic range
continue usual daily dose
If INR above therapeutic range
but <5 reduce daily dose until
INR returns to therapeutic
range
Clopidogrel
Continue clopidogrel
Clopidogrel
Warfarin
Low Risk Condition
High Risk Condition
Prosthetic metal heart valve in
aortic position
Xenograft heart valve
AF without valvular disease
>3months after VTE
Prosthetic metal heart valve in
mitral position
Prosthetic heart valve and AF
AF and mitral stenosis
<3months after VTE
Thrombophilia syndromes
Low Risk Condition
Ischaemic heart disease
without coronary stent
Cerbrovascular disease
Peripheral vascular disease
Stop warfarin 5 days
before endoscopy
Stop warfarin 5 days
before endoscopy
Stop clopidogrel 7 days
before endoscopy
Check INR prior to procedure to
ensure INR<1.5
Restart warfarin evening of
procedure with usual daily dose
Check INR 1 week later to
ensure adequate anticoagulation
Start LMWH 2 days after stopping
warfarin
Omit LMWH on day of procedure
Restart warfarin evening of
procedure with usual daily dose
Continue LMWH until INR
adequate
Continue aspirin if already
prescribed
If not on aspirin, then consider
aspirin therapy while clopidogrel
discontinued
High Risk Condition
Coronary artery stents
Liaise with cardiologist
Consider stopping clopidogrel 7
days before endoscopy if:
>12 months after insertion of
drug-eluting coronary stent
>1 month after insertion of bare
metal coronary stent
R
(EUS: endoscopic ultrasound, ERCP: endoscopic retrograde cholangiopancreatography, EMR: endoscopic mucosal resection, PEG:
percutaneous endoscopic gastroenterostomy, FNA: fine needle aspiration, INR: international normalised ratio, AF: atrial fibrillation,
VTE: venous thromboembolism, LMWH: low molecular weight heparin)
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