As we look at APP's roles in gastroenterology, I think these are really important talks. So we talk about a lot of peri-procedure management, not only when we see the patients, but also kind of behind the scenes. And so the first two talks looking at sedation and analgesia and bowel prep, and then I'm going to go through management of antithrombotic agents, and we'll do a Q&A for these three talks right afterwards. I don't have any disclosures. And so what I wanted to do was to kind of take a step back and let's look at the bleeding risk for endoscopic procedures, and then talk about how are we going to work with our patients on this. And so that includes the cardio-neurovascular risk stratification, looking at the antithrombotics that patients are on, what they're taking it for and how it works, and then to discuss some of the current concepts and best practice principles that are out there right now. And so I just want to highlight there are some clinical guidelines that are available. And so this one just came out. This is the American College of Gastroenterology and the Canadian Association of Gastroenterology Clinical Practice Guideline. I will kind of refer back to this at times throughout the talk. And then ASG also has one. And so this is the way that I kind of think about it and approach it. And I think most of us do it in some kind of logical manner. The first step would be the nature of the procedure. Is this an urgent procedure or is it elective? Because that may change how we manage things. Procedure bleeding risk, is it low, moderate, or high? Cardio-neurovascular risk, the nature of the antithrombotic, and then that communication portion. And so if we start from the top, let's start with the procedure bleeding risk. And looking at the ASGE guideline, this is where this table is coming from, they did separate it from higher risk and low risk procedures. And then the table on the right is the American College of Gastroenterology's new one. And they are very similar. A couple of things to highlight on the ASGE one, Barrett's ablation was considered low risk. That's been further separated in the ECG guidelines. So radiofrequency ablation is considered high risk for bleeding. And then they had added POEM, which is a newer endoscopic treatment that's available for achalasia. And then this table looking at bleeding risk and antithrombotic agents. And so if we look at the top line, your diagnostic endoscopy and colonoscopy, and that may include a biopsy, it does not include removing of any polyps, no endoscopic mucosal resection, just plain biopsies. That's low risk to perform whether you're on warfarin, heparin, any of your antiplatelet regimens or aspirin. If you add the polypectomy portion to a colonoscopy, you are high risk for bleeding with warfarin or your antiplatelets. Still low risk on aspirin though. And actually looking at all five of these categories, it's felt the aspirin is low risk, which is why most of the time when we talk about this, the risk of stopping aspirin is much higher than the benefit because aspirin is not really inhibiting our ability to clot as much as things like your warfarin, heparin, and Plavix. And I think it's also important when we talk about risk factors for GI bleeding, not only is it the procedure, but certainly it's the patient as well. And so keeping your patient in mind, older age, cigarette smoking, sleep apnea, males, a history of CVA or DBT, prior GI bleeding, renal insufficiency. These are all risk factors for bleeding. And then your cardio neurovascular risk. And so looking at this, there are a low, moderate, and high, and really three categories. So the first is valvular disease. The second is your atrial fibrillation scores. And then third is your thrombotic risk. So somebody who's low risk would be somebody who has an aortic valve with no atrial fibrillation or other risk factors. You can compare that to somebody who's high risk, and those are your mechanical mitral valves, or if they've had a CVA or a TIA within the last three months. I'm going to the bottom, that thrombobolic risk, if it was more than 12 months ago, there's no other risk factors, they're considered low risk versus the high where it's three or less months ago, or they have a severe underlying thrombophilia. And then in the middle is the atrial fibrillation. And because I don't have a cardiology background, I wanted to just include these for reference really only. I think that a lot of the stroke risk assessment tools are really utilized by our cardiology colleagues. And so if you have somebody who's on blood thinners for anticoagulation, and you're requesting permission to hold them, then these are the scores that they're often looking at. And this is how they can help to predict what's the chance that they're going to have an adverse event if we take them off of their blood thinners temporarily. And then the nature of the antithrombotic. And so if we split our antithrombotics into your anticoagulants and your antiplatelets, and then we can take a look at them individually. So I'll start with warfarin. Warfarin inhibits vitamin K dependent clotting factors. So the factors two, seven, nine, and 10. And in general, we consider stopping warfarin for four to seven days, depending on the procedure risk status. And then you should restart as soon as possible afterwards. It is recommended that we avoid vitamin K before elective procedures. The problem with vitamin K, it will help to reverse it, and it will help to reverse it fairly quickly. But then it's hard to re-anticoagulate them afterwards. And so if you give somebody vitamin K, and then you want to get them back up to a therapeutic level within the first three days, for example, it's a little bit more challenging to do that with vitamin K. And so that risk of thrombosis is higher because we reversed it in that manner. There is a 1% risk of thromboembolic events after temporary stopping your warfarin. And high risk patients should be bridged with low molecular weight heparin. So that's really those mechanical valves that we saw on the prior slide. And then this was from the ASGE guideline, just looking at who should have bridge therapy. And so again, on the bottom, you'll see those mechanical valves, or those that are really high risk should have bridge therapy. If you have the aortic valve with no other risk factors, they don't necessarily have to be bridged. And if you have atrial fibrillation with no significant risk factors, they don't generally have to be bridged as well. Your DOACs are the newer agents. Those are the ones that directly affect your factor 10A or 2A. And I think the great thing about these is that there's fast onset and fast offset. And so you can have a patient on these, you can take them off for anywhere from one to three days in general, and it'll normalize. And then when you start them back on it, usually within the next day or so, they're back up to therapeutic levels. Depending on the renal function is really how we determine these. So that's the only challenging part from behind the scenes. As with any of these, we should check with the prescriber and then have a plan for resuming them. And I think that that's one of the points that I want to emphasize is that once somebody has the procedure, we want to make sure that we do just as good of a job getting patients back on these medications than we do with them holding them in preparation for the procedure. And so just a comparison chart when we look at this. So the dotted red is your warfarin, and then the solid blue line are your DOACs. And you can see that when you start those, that percent anticoagulated within the first less than 10 hours really is nearly 100% with your DOACs. And with your warfarin, you're really kind of approaching that 70 to 80 hours before you hit that. And the same thing as you come off of it in the right side of this graph, it takes a lot longer for this warfarin to get down than it does with your DOACs. So when should we stop them? It really depends on which one. So for a pixaban, looking at creatinine clearance, it's one to three days. For your Xeralto, it takes a little bit longer for time to onset, but still short, two to four days, I'm sorry, two to four hours. And so depending on your creatinine clearance, you'll hold them from one to four days. And then for your Pradax, the same thing, it's going to take a little bit longer than your pixaban. So I think it's important to know the mechanism of action of these so that we can appropriately really request from the patient's other providers permission to hold them as long as their risk status allows us to. And if we look at our platelet aggregation, these inhibitors, so probably the ones we see the most often are the Clopidogrel and the Berlinta, but the Platix is irreversible. And so when you have that, you want it off long enough to make new platelets. And that's where that recommendation for seven to 10 days tends to come from. Berlinta is much shorter lasting and it is reversible as well. And so you only need a couple of days for that one. And just if we're going to generalize, when we say there's a low risk procedure, then we really don't need to do too much for that. But if it's a high risk procedure for bleeding, or if patient has high risk factors for bleeding, then you want to stop it for five days. Five to seven is typically what people are looking at. Somebody who's high risk though, meaning that they may have a thromboembolic event, depending on how high that procedure risk is, we'll have to make a decision. So we're really weighing those risks and benefits. And so this is really just strictly generalizing. And I think, you know, importantly, especially for any APPs that are kind of doing a pre-procedure or peri-procedure management, you want to have these discussions with the endoscopist. But for diagnostic EGDs, you really don't need to stop blood thinners unless there's some special case. If it's just an EGD, potentially with biopsies, it's okay to keep them on. For endoscopies with dilation, you really want to check with whoever's performing the procedure, because I think there's a lot of variability with this, and it depends on the type of dilation. And so if you're going with something that's, you know, a pneumatic balloon dilation, that's super high risk, you'll probably want to hold. But if you're doing something that's pretty minor, they may be okay keeping them on. So I think it's really important that you know who's doing the procedure and have that conversation. And when you have that conversation, you want to be able to go to them and say, this is the patient, this is their history, this is their risk status. Do we want to request permission to hold, or are you comfortable keeping them on? In general, for PEG-2 placements, we will hold them. Push enteroscopy, I think same thing. It really depends on the reason that you're doing the push enteroscopy and what we think intervention-wise might be needed. And so if it's just diagnostic with biopsies, it may be okay to keep them on, but important to discuss those. ERCP, you might have seen when I had shown you the risk stratification of procedures, ERCP was on there with sphincterotomy, and so that is high risk for bleeding. ERCP with stent change is lower risk. And so again, kind of anticipating what type of interventions may be needed. And I think Erin on the side of the more aggressive intervention that might be needed is probably best practice, because we don't want to get in there and then not be able to do something because we didn't hold the blood thinners. And I think that's really where we come into the recommendations for colonoscopies. So the majority of colonoscopies are fairly low risk, but we don't know who's going to have those colon polyps. We don't have those crystal balls yet to be able to say, you'll have a polyp this time. And so without that knowledge, we want to be able to go in and remove things while we're in there, if it's safe to do so. And so I put that last caveat in there because if somebody can't come off their blood thinners for some reason, but they're overdue for colonoscopy or they're having other issues and you think a diagnostic colonoscopy is appropriate, it generally can be performed with them on blood thinners, just with the knowledge that if something is found, you may have to go back in at a later date when you are able to safely hold the blood thinners to take care of anything therapeutically. And then again, this re-initiation of anticoagulation is really dependent on what intervention was done and then the bleeding risk of that. So if no intervention's done, generally it's safe to resume the same day. If there's minimal intervention and there are low risk for bleeding, you could resume the same day or maybe the next day. Moderate risk of bleeding is one to two days and higher risk of bleeding is three days. And that's where we come in to that collaboration and that importance of that communication with our physician colleagues. And I want to emphasize that if you're holding it for more than three days post-procedure, please discuss with the prescribing team that risk and benefit analysis. So we've already had the discussion to ask if we can hold it, but now we need to have that discussion to ask if we can continue to hold it. And this is where that multidisciplinary approach comes in. And so we have gastroenterology, hematology, neurology, cardiology, vascular surgery, oncology, the GI clinic nurse. You may have even a Coumadin clinic nurse through cardiology, but at the center of all of this is the patient. And so being able to, as an APP, be a liaison and have these conversations is a really important part of what we do every day. And so the guidelines we just went through really are for our elective kind of plan procedures, but certainly somebody who comes in with GI bleeding and needs an urgent procedure might be handled a bit differently. So if somebody is on a DOAC and they have a major GI bleed, they're typically managed as an inpatient. They should have those standard resuscitation protocols, which may include blood products. It may include platelet products, IV fluids. You should hold your DOAC during a major GI bleed. And whether they need the platelet transfusion really is kind of a case by case. The newest guidelines from ACG suggest that you should not transfuse, but depending on their hemodynamic stability, they may need some platelets. So I think really looking at that, looking at the patient's status at the time. Again that multidisciplinary consultation, urgent endoscopic evaluation, and then when needed, consulting with our radiology colleagues for angiographic embolization. And so during those urgent procedures, if I try to summarize, and again, it really is just a broad summary because every case is a little bit different, but looking at Warfarin, after holding it, consider reversing it if the INR is over two and there is severe bleeding. The guidelines do not recommend FFP or the vitamin K. Vitamin K, again, because it's hard to recoagulate afterwards. But the FFP, part of the problem is the volume with that in a lot of these patients. Your PCC is probably a better option. We do have reversal agents for our DOACs. Because they're quick to come off, we don't always need them. And in fact, a lot of times we don't recommend using them unless they're needed for some special circumstance. And I think a lot of times that would be patients who also have an underlying thrombophilia in addition to being on them. And then your antiplatelet agents, consider holding, really depends on their risk status, and consider platelet transfusion if there's severe bleeding. And I would just add, you know, if there's hemodynamic instability, you want to make sure that you're able to resuscitate these patients appropriately. And so I think this is a really important one for us to stop and think about also. You know, what do we do if their risk is too high to stop their antithrombotic treatment? And it's probably not going to change soon. And that may be something on the outpatient setting or the inpatient setting. And an example on the outpatient setting is somebody who has a history of a complex adenoma or a history of colon cancer. And they are two years overdue for colonoscopy, but they're on blood thinners, and they won't be able to stop it for at least the next six months. So the first question is, what's the indication for the procedure? And the second, what harm comes if you don't do the procedure or if you delay the procedure? Can you safely wait six months till they can come off? Or should you consider doing at least a diagnostic now while they're on it? Third is the risk of endoscopic intervention, predictably catastrophic and inevitable. Fourth, what are the risks and benefits? That shared decision-making, super important to be able to have the conversations with the patient. And again, it should be done in a multidisciplinary setting. If you do proceed with the procedure, you want to make sure that there's appropriate backup and support. And so if you have a hospital endoscopy center, these should be performed there. Ideally, with surgical backup, you know, your interventional radiology colleagues, having people in-house, these are not things you want to do at five o'clock on a Friday. These patients may need to be admitted for 23-hour observation post-procedure just to watch for that immediate post-procedure bleeding. That communication to other providers to say, this is what we did. They're still on blood thinners. They have to go back on blood thinners early. They're at high risk for bleeding. And then close outpatient follow-up as well. And if you look at it with just a visual graphic, I like visuals. When you say, what risk are we willing to take? And so we can have recurrent bleeding or continued bleeding if we keep somebody on the blood thinners. But if we stop them, then we are risking stent thrombosis, CVA, DVT, PEs. And the thing that Dr. Call has always taught me is you can almost always stop GI bleeding, but we can't always reverse CVAs or stent thrombosis. And so to summarize, the first thing when we talk about antithrombotics is what's the risk stratification? The risk of bleeding versus the risk of clotting. And what's the procedure bleeding risk? And then coordinating that with your other providers. And just trying to summarize, if you're a low bleeding risk but high thromboembolic risk, consider continuing. High bleeding risk, low thromboembolic, you want to hold. High bleeding risk, high thromboembolic, consider bridging. But all of this should be done with coordination with their other providers. Aspirin should be continued. Very few, if any, circumstances where it's beneficial to stop that. Restarting your medications as soon as possible post-procedure, usually same day or within three days. If you're going to hold it longer than that, make sure you have that discussion with the prescribing provider so that you're repeating that risk stratification. And then finally, that patient-centered, multidisciplinary approach is best. So I have two questions for you guys. The first one, all of the following should be considered when stratifying risk of interrupting antithrombotic agents prior to an endoscopic procedure except nature of procedure, gender, cardiovascular risk, procedure risk, and nature of antithrombotic. Absolutely. So patient gender is the right answer. And I put this in there on purpose just to make sure that we're all awake and paying attention. It's a little tricky because I did say that men are at higher risk of bleeding. But when we're looking at our total risk stratification, although they may be a little bit more likely to bleed, that is not the significant thing that we're going to make our decision based on. Just one of those things you want to keep in the back of your mind. And then the second polling question, the risk of bleeding is highest during which of the following endoscopic procedures? Diagnostic EGD, flexible sigmoidoscopy with APC, colonoscopy with polypectomy, EUS with no FNA, and ERCP with stent exchange, no sphincterotomy. Which one has the highest risk of bleeding? Yep, so colonoscopy with polypectomy is the highest risk. APC is considered low risk. EUS, if you're not performing any FNA, I would kind of equate it to a diagnostic endoscopy. If you're just taking a look, you're not taking any samples of anything, then that is fairly low risk. And ERCP, if you're doing a sphincterotomy, is very high risk. But if you're just changing a stent with no other intervention, that is considered low risk as well. Good job, everyone. Thank you.

advanced practice providers

gastroenterology

peri-procedure management

antithrombotic agents

bleeding risk

multidisciplinary collaboration