Anticoagulants and antiplatelet (guidance for referring doctors)

Instructions concerning taking anticoagulants and antiplatelet medicaments

In major cases, it is no need for discontinuation of anticoagulants before routine endoscopy (diagnostic examination). If endoscopic procedure shall be performed (i.e. polypectomy), it is recommended to modify the anticoagulation under supervision and in agreement with a physician who ordered such treatment (i.e. GP, surgeon, internist, cardiologist, neurologist). Principles of conduct with patients treated for antiplatelet and anticoagulation with planned endoscope procedure within GOPP, are regulated by instructions of the Working Group of the Polish Association of Gastroenterology and National Consultant in the field of Gastroenterology published in 2013 as well as recommendations of ESGE, 2011. Even in the situation of double antiplatelet therapy, there is no need to discontinue antiplatelet treatment (aspirin, thenopyridines) at patients with diagnostic gastroscopy with the biopsy without electro-coagulation.

In case of a planned treatment of removing polyps >1cm at patients taking double antiplatelet therapy, it is recommended to consider to postpone the surgery or discontinue (after the consultancy with a cardiologist) of thenopyridines 7 days before the planned treatment; it is no need, however, to discontinue aspirin preparations. 

It is furthermore recommended to discontinue antiplatelet medicaments in case of planned endoscopic treatment of mucosectomy (EMR) and submucosal dissection (ESD). It shall be stressed that “the bridge” application of low molecular weight heparin at patients being subject of antiplatelet treatment is ineffective, which results from separate mechanisms of activity of these medicaments. In case of patients taking long-term oral anticoagulants (coumarin derivative) prepared for planned endoscopic treatment within GOPP, the “bridge” therapy with low molecular weight heparin shall be taken into account (it is not necessary in case of diagnostic gastroscopy with the biopsy).

  In addition, at patients with antiplatelet or anticoagulant treatment and symptoms of gastrointestinal bleeding, the discussed medicaments shall be discontinued until endoscopic haemostatis. Intervention endoscopy, however, performed in  order to stop bleeding, may and shall be performed at patients being subject of antiplatelet and anticoagulation treatment.

Recommendations concerning principles of conduct in cases of patients treated with so called antiplatelet and anticoagulation medicaments have been published by ASGE in 2014. According to quoted recommendations, inhibitors of the Xa factor (rivaroxaban and apixaban) shall be discontinued 24 hours before diagnostic EGD and before procedures with law bleeding risk and 48 hours before procedures with high risk of bleeding. The period before endoscope procedure in which direct thrombin shall be discontinued (dabigatran) depends upon renal function of the patient and amounts from 24 to 120 hours in case of procedures with low bleeding risk and from 2 to > 5 days in case of procedures with a high bleeding risk.

Therapy with tieropiridne derivate of new generation (prasugrel, ticagrelor) shall be discontinued for 5-10 days before planned endoscope treatment within GOPP. There are instructions concerning discontinuation of tieropiridine derivates before diagnostic EGD. In case of therapy with inhibitors of glycoprotein receptor IIb/IIIb, abciximab shall be discontinued 12-24 hours before each diagnostic and therapeutic procedure within GOPP, and treatment with eptifibatide shall be discontinued 2-4 hours before planned treatment within GOPP.

Study: based upon instructions of the Working Group of the Polish Association of Gastroenterology of 2013, and instructions  ASGE of 2014.