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'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- 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.
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- 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.
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- 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.
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- 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