ACCP/AHA PERIOPERATIVE RECOMMENDATIONS ASGE 2016 RECOMMENDATIONS FOR PATIENTS UNDERGOING ELECTIVE GI ENDOSCOPY
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ASGE 2016 ANTITHROMBOTIC RECOMMENDATIONS FOR ELECTIVE GI ENDOSCOPY
Cardiovascular risk Procedure bleeding risk Antithrombotic therapy Recommendation
Low Low Anticoagulation
  1. Continue anticoagulation
Low Low Antiplatelet
  1. Continue ASA/NSAIDs
  2. Continue P2Y12 inhibitor
Low High Anticoagulation
  1. Discontinue anticoagulation
  2. Restart warfarin on same day as procedure
  3. Restart Factor Xa inhibitors and direct thrombin inhibitors once adequate hemostasis is achieved
Low High Antiplatelet
  1. Continue ASA/NSAIDs
  2. Discontinue P2Y12 inhibitors at least 5 days before endoscopy or switch to ASA✝
  3. For patients taking dual antiplatelet therapy, hold P2Y12 inhibitors for at least 5 days and continue ASA✝
High Low Anticoagulation
  1. Continue anticoagulation
High Low Antiplatelet
  1. Continue ASA/NSAIDs
  2. Continue P2Y12 inhibitors
High High Anticoagulation
  1. Discontinue anticoagulation
  2. Bridging therapy
  3. Restart warfarin on same day as procedure
  4. Restart Factor Xa inhibitors and direct thrombin inhibitors once adequate hemostasis is achieved
High High Antiplatelet
  1. Continue ASA/NSAIDs
  2. Discontinue P2Y12 inhibitors at least 5 days before endoscopy or switch to ASA✝
  3. For patients taking dual antiplatelet therapy, hold P2Y12 inhibitors for at least 5 days and continue ASA✝




ASGE PROCEDURE BLEEDING RISK CATEGORIES
High bleeding risk Low bleeding risk
  • Polypectomy
  • Biliary or pancreatic sphincterotomy
  • Treatment of varices
  • PEG placement (PEG on aspirin or clopidogrel
    is low risk. DAPT is high risk)
  • Therapeutic balloon-assisted enteroscopy
  • Endoscopic ultrasound (EUS) with FNA
    (EUS-FNA of solid masses on ASA/NSAIDs is low risk)
  • Endoscopic hemostasis
  • Tumor ablation
  • Cystogastrostomy
  • Ampullary resection
  • Endoscopic mucosal resection (EMR)
  • Endoscopic submucosal dissection
  • Pneumatic or bougie dilation
  • Percutaneous endoscopic jejunostomy
  • Diagnostic (EGD, colonoscopy, flexible sigmoidoscopy)
    including mucosal biopsy
  • ERCP with stent (biliary or pancreatic) placement or
    papillary balloon dilation without sphincterotomy
  • Push enteroscopy and diagnostic balloon-assisted enteroscopy
  • Capsule endoscopy
  • Enteral stent deployment (Controversial)
  • Endoscopic ultrasound (EUS) without FNA
  • Argon plasma coagulation
  • Barrett’s ablation




ASGE CARDIOVASCULAR RISK CATEGORIES
Risk factor High cardiovascular risk Medium cardiovascular risk Low cardiovascular risk
Nonvalvular
atrial fibrillation
Mechanical
heart valve
  • Any mitral valve prosthesis
  • Any caged-ball or tilting disc aortic valve prosthesis
  • Recent (within 6 months) CVA or TIA
  • Bileaflet aortic valve prosthesis and one or more of the following risk factors: A fib, prior CVA or TIA, hypertension, diabetes, congestive heart failure, age ≥ 75 years
  • Bileaflet aortic valve prosthesis without A fib and no other risk factors for CVA
Venous
thromboembolism (VTE)
  • Recent (within 3 months) VTE
  • Severe thrombophilia (deficiency of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities)
  • VTE within the past 3 - 12 months
  • Nonsevere thrombophilia (heterozygous factor V Leiden or prothrombin gene mutation)
  • Recurrent VTE
  • Active cancer (treated within 6 months or palliative)
  • VTE > 12 months previous and no other risk factors
Recent cardiac
stent
(antiplatelet therapy)
  • Placement of drug-eluting stent ≤ 12 months
  • Placement of bare metal stent ≤ 1 month
  • Placement of bare metal stent after acute coronary syndrome ≤ 12 months
Other conditions that can raise cardiovascular risk include:
  • Prior history of stent occlusion
  • History of acute coronary syndrome or ST-elevation MI
  • Multivessel PCI
  • Diabetes
  • Kidney failure




PERIPROCEDURAL RECOMMENDATIONS FOR FACTOR Xa INHIBITORS AND DIRECT THROMBIN INHIBITORS
Drug Recommendations
Dabigatran
(Pradaxa®)
Manufacturer
  • CrCl ≥ 50 ml/min - discontinue 1 - 2 days before invasive or surgical procedures
  • CrCl < 50 ml/min - discontinue 3 - 5 days before invasive or surgical procedures
  • Consider longer times for patients undergoing major surgery, spinal puncture, or placement of a spinal or epidural catheter or port, in whom complete hemostasis may be required
Other
  • A normal aPTT indicates the absence of a dabigatran effect
  • An aPTT > 2 X ULN drawn at trough dosing time indicates excessive bleeding risk [8,9]

  • Reference [8]
Recommended last intake before surgery based on CrCl and surgery bleeding risk
CrCl Low risk High risk
≥ 80 ml/min ≥ 24 h ≥ 48 h
50 - 80 ml/min ≥ 36 h ≥ 72 h
30 - 50 ml/min ≥ 48 h ≥ 96 h
Apixaban
(Eliquis®)
Manufacturer
  • Procedure with moderate or high risk of bleeding - discontinue at least 48 hours prior to surgery
  • Procedure with low risk of bleeding - discontinue at least 24 hours prior to surgery
  • Restart apixaban as soon as adequate hemostasis is achieved
Other

  • Reference [8]
Recommended last intake before surgery based on CrCl and surgery bleeding risk
CrCl Low risk High risk
≥ 80 ml/min ≥ 24 h ≥ 48 h
50 - 80 ml/min ≥ 24 h ≥ 48 h
30 - 50 ml/min ≥ 24 h ≥ 48 h
15 - 30 ml/min ≥ 36 h ≥ 48 h
Edoxaban
(Savaysa®)
Manufacturer
  • Discontinue edoxaban at least 24 hours before invasive or surgical procedures
  • Restart as soon as adequate hemostasis has been established noting that the time to onset of pharmacodynamic effect is 1 - 2 hours
Rivaroxaban
(Xarelto®)
Manufacturer
  • Discontinue rivaroxaban at least 24 hours before invasive or surgical procedures
  • Restart as soon as adequate hemostasis has been established noting that the time to therapeutic effect is short
Other

  • Reference [8]
Recommended last intake before surgery based on CrCl and surgery bleeding risk
CrCl Low risk High risk
≥ 80 ml/min ≥ 24 h ≥ 48 h
50 - 80 ml/min ≥ 24 h ≥ 48 h
30 - 50 ml/min ≥ 24 h ≥ 48 h
15 - 30 ml/min ≥ 36 h ≥ 48 h




BRIDGING THERAPY RECOMMENDATIONS
Pre-operative
  • Stop warfarin 5 days prior to scheduled surgery
  • When INR becomes subtherapeutic, start a bridging regimen

Bridging regimens
  • Enoxaparin (Lovenox®) 1 mg/kg twice a day OR 1.5 mg/kg once daily
  • Dalteparin (Fragmin®) 100 IU/kg twice a day OR 200 IU/kg once daily
  • IV unfractionated heparin to maintain aPTT 1.5 - 2 X the control aPTT
  • NOTE: When patient has a mechanical heart valve, twice daily LMWH regimens are recommended

Before procedure
  • LMWH
    • Twice daily regimen - withhold the last LMWH dose before surgery
    • Once daily regimens - give half the total daily dose the morning of the day before surgery
  • Unfractionated heparin (UFH)
    • Stop UFH 4 - 6 hours before surgery

Post-operative
  • Restart warfarin 12 - 24 hours after surgery and when adequate hemostasis is achieved
  • In patients who underwent surgery that has a high bleeding risk, resume LMWH or UFH (without bolus dose) 48 - 72 hours after surgery
  • In patients who underwent surgery that has a moderate or low bleeding risk, resume LMWH or UFH (without bolus dose) 24 hours after surgery
  • Continue bridging therapy until INR is therapeutic