ASGE Endoscopy Course at ACG: Everyday Endoscopy: Expertise Meets Evidence | October 2024-14_Barkun

14_Barkun - antithrombotic management

Pdf Summary

The document outlines best practices for managing antithrombotic therapy in the context of endoscopic procedures, offering guidelines for gastroenterologists. It highlights the complexity of balancing the risks of bleeding and thromboembolic events when patients on antithrombotic therapy undergo elective or emergency endoscopic procedures.<br /><br />Key points include:<br /><br />1. **Antithrombotic Management Overview**: The document stresses that while gastroenterologists do not need to be experts in antithrombotic management, they should understand the general principles to ensure appropriate peri-procedural care.<br /><br />2. **Elective Endoscopic Procedures**: <br />   - For patients on anticoagulants (e.g., warfarin, DOACs), bridging is generally not recommended. Warfarin should be stopped five days before, and DOACs 1-2 days before the procedure.<br />   - Antiplatelet therapy (ASA, P2Y12 inhibitors) management varies, with emphasis on continuing ASA unless the procedure risk is high. P2Y12 inhibitors (like clopidogrel) might need temporary interruption.<br />   - Procedures should be deferred for high-risk thrombosis patients unless necessary.<br /><br />3. **Emergency Management in GI Bleeding**:<br />   - Life-threatening bleeds on anticoagulants may necessitate prothrombin complex concentrates (PCC) or DOAC-specific reversal agents.<br />   - Non-life-threatening bleeds often do not require reversal agents.<br />   - For bleeding and antiplatelets, platelet transfusions are generally not recommended unless severe thrombocytopenia is present.<br /><br />4. **Resumption of Therapy**:<br />   - Anticoagulation should resume within a few days once bleeding is controlled, with a preference for earlier resumption of warfarin compared to DOACs.<br />   - Aspirin should be continued or carefully resumed after bleeding resolution.<br /><br />5. **Secondary Prophylaxis**: Use of proton pump inhibitors (PPIs) is encouraged in patients with past ulcer bleeding who need to continue antithrombotic therapy.<br /><br />The document emphasizes the need for tailoring management strategies to individual patient risk profiles and procedural risk, ensuring safer outcomes for patients undergoing endoscopic procedures while on antithrombotics.

Keywords

antithrombotic therapy

endoscopic procedures

gastroenterologists

bleeding risk

thromboembolic events

anticoagulants

antiplatelet therapy

emergency management

therapy resumption

proton pump inhibitors