Management of antiplatelet agents in patients undergoing endoscopic procedures
- Patrick S Kamath, MD
Patrick S Kamath, MD
- Professor of Medicine
- Mayo Clinic College of Medicine
Gastroenterologic procedures are commonly performed in patients taking antiplatelet agents. However, there are limited data assessing the bleeding risk of specific procedures in these settings.
This topic will review the periprocedural management of patients taking antiplatelet agents. The management of patients taking anticoagulants, as well as patients with von Willebrand's disease, hemophilia, renal failure, liver failure, and thrombocytopenia are discussed elsewhere. (See "Management of anticoagulants in patients undergoing endoscopic procedures" and "Endoscopic procedures in patients with disorders of hemostasis".)
The American Society for Gastrointestinal Endoscopy (ASGE) has issued official guidelines based upon the available evidence and consensus opinion . The recommendations in this topic review are consistent with the ASGE guidelines. This topic is also addressed in reviews and guidelines from the American College of Gastroenterology, the American College of Chest Physicians, the American College of Cardiology, and the British Society of Gastroenterology/European Society of Gastrointestinal Endoscopy, which make similar (though not identical) recommendations [2-5]. The management of newer antiplatelet agents (such as prasugrel or ticagrelor) has been the subject of review articles [6,7].
PROCEDURE-RELATED BLEEDING RISK
In general, diagnostic endoscopic procedures are at much lower risk for bleeding than are therapeutic procedures (table 1). High-risk procedures are those with a bleeding risk of greater than 1.5 percent. The procedure-related bleeding risk of various endoscopic procedures is discussed in detail elsewhere. (See "Endoscopic procedures in patients with disorders of hemostasis", section on 'Procedure-related bleeding risk'.)
RISK OF THROMBOEMBOLIC COMPLICATIONS
The probability of a thromboembolic complication following reversal or discontinuation of anticoagulation or antiplatelet agents depends upon the preexisting condition for which the medication was prescribed (table 2). This topic is discussed in detail elsewhere. (See "Perioperative management of patients receiving anticoagulants", section on 'Estimating thromboembolic risk' and "Noncardiac surgery after percutaneous coronary intervention", section on 'Complications'.)
- ASGE Standards of Practice Committee, Acosta RD, Abraham NS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016; 83:3.
- Kwok A, Faigel DO. Management of anticoagulation before and after gastrointestinal endoscopy. Am J Gastroenterol 2009; 104:3085.
- Becker RC, Scheiman J, Dauerman HL, et al. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. J Am Coll Cardiol 2009; 54:2261.
- Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S.
- Veitch AM, Vanbiervliet G, Gershlick AH, et al. 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. Gut 2016; 65:374.
- Baron TH, Kamath PS, McBane RD. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med 2013; 368:2113.
- Baron TH, Kamath PS, McBane RD. New anticoagulant and antiplatelet agents: a primer for the gastroenterologist. Clin Gastroenterol Hepatol 2014; 12:187.
- Foster CJ, Prosser DM, Agans JM, et al. Molecular identification and characterization of the platelet ADP receptor targeted by thienopyridine antithrombotic drugs. J Clin Invest 2001; 107:1591.
- Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37:383.
- Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335:909.
- Shiffman ML, Farrel MT, Yee YS. Risk of bleeding after endoscopic biopsy or polypectomy in patients taking aspirin or other NSAIDS. Gastrointest Endosc 1994; 40:458.
- Hussain N, Alsulaiman R, Burtin P, et al. The safety of endoscopic sphincterotomy in patients receiving antiplatelet agents: a case-control study. Aliment Pharmacol Ther 2007; 25:579.
- Hamada T, Yasunaga H, Nakai Y, et al. Bleeding after endoscopic sphincterotomy or papillary balloon dilation among users of antithrombotic agents. Endoscopy 2015; 47:997.
- Grossman EB, Maranino AN, Zamora DC, et al. Antiplatelet medications increase the risk of post-polypectomy bleeding. Gastrointest Endosc 2010; 71:AB138.
- Manocha D, Singh M, Mehta N, Murthy UK. Bleeding risk after invasive procedures in aspirin/NSAID users: polypectomy study in veterans. Am J Med 2012; 125:1222.
- Zuckerman MJ, Hirota WK, Adler DG, et al. ASGE guideline: the management of low-molecular-weight heparin and nonaspirin antiplatelet agents for endoscopic procedures. Gastrointest Endosc 2005; 61:189.
- Singh M, Mehta N, Murthy UK, et al. Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc 2010; 71:998.
- Feagins LA, Iqbal R, Harford WV, et al. Low rate of postpolypectomy bleeding among patients who continue thienopyridine therapy during colonoscopy. Clin Gastroenterol Hepatol 2013; 11:1325.
- Gandhi S, Narula N, Mosleh W, et al. Meta-analysis: colonoscopic post-polypectomy bleeding in patients on continued clopidogrel therapy. Aliment Pharmacol Ther 2013; 37:947.
- Boustière C, Veitch A, Vanbiervliet G, et al. Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2011; 43:445.
- Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370:1494.
- SOCIETY GUIDELINES
- PROCEDURE-RELATED BLEEDING RISK
- RISK OF THROMBOEMBOLIC COMPLICATIONS
- ELECTIVE PROCEDURES IN PATIENTS ON ANTIPLATELET AGENTS
- Aspirin and NSAIDs
- P2Y12 platelet receptor blockers
- Other agents
- URGENT PROCEDURES IN PATIENTS ON ANTIPLATELET AGENTS
- SUMMARY AND RECOMMENDATIONS