ASGE Advanced Endoscopic Lesion Resection Course | November 2022-14 Sinha

14 Sinha_Management of Anti-Thrombotic Therapy

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This document is a summary of a presentation on managing anti-thrombotic therapy, specifically focusing on antiplatelet therapy, anticoagulant therapy, and DOAC periprocedural strategy. <br /><br />The presentation emphasizes the risk of post-polypectomy bleeding (PPB) associated with antiplatelet therapy, particularly aspirin and clopidogrel. It is noted that there is a modest increase in PPB with aspirin use, but the American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) recommend not holding aspirin for elective procedures or acute gastrointestinal bleeding due to increased risk of cardiovascular events. Clopidogrel, on the other hand, has a modest increase in early PPB and a significant increase in delayed PPB. The ACG and CAG recommend holding P2Y12 inhibitors for patients undergoing elective procedures on dual antiplatelet therapy (DAPT), but there is no consensus for those on monotherapy.<br /><br />Regarding anticoagulant therapy, studies show that the rate of PPB is higher in patients on anticoagulation compared to controls, but there is no difference between warfarin and Direct Oral Anticoagulants (DOACs) in terms of PPB rate. The ACG and CAG recommend continuing warfarin without interruption for elective endoscopy, unless undergoing advanced procedures. The use of heparin bridge therapy is associated with a higher risk of PPB and is not recommended for elective endoscopy.<br /><br />When it comes to DOAC therapy, it is recommended to hold DOAC therapy for elective endoscopy. The PAUSE study supports this recommendation. For reversal therapy, platelet transfusion is not recommended for reversal of antiplatelet therapy. For warfarin, fresh frozen plasma (FFP) and vitamin K are not recommended, and there is no consensus on the use of prothrombin complex concentrate (PCC). For DOACs, reversal agents are not recommended due to their short half-life.<br /><br />In conclusion, this presentation provides guidance on managing anti-thrombotic therapy in the context of endoscopic procedures, highlighting the risks associated with different medications and strategies for peri-procedural management.

Keywords

anti-thrombotic therapy

antiplatelet therapy

anticoagulant therapy

DOAC periprocedural strategy

post-polypectomy bleeding

aspirin

clopidogrel

P2Y12 inhibitors

warfarin

Direct Oral Anticoagulants