GI Unit Leadership: Shaping a High-Performing Endoscopy Unit (On-Demand) | February 2026-ASGE guideline

ASGE guideline_antithrombotic management

Pdf Summary

This guideline, developed by the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee, provides evidence-based recommendations for managing antithrombotic agents in patients undergoing gastrointestinal (GI) endoscopy. Antithrombotic therapies, including anticoagulants (warfarin, heparin derivatives, novel oral anticoagulants [NOACs]) and antiplatelet agents (APAs: aspirin, thienopyridines, PAR-1 inhibitors, etc.), are essential to prevent thromboembolic events in patients with conditions like atrial fibrillation, acute coronary syndrome (ACS), venous thromboembolism (VTE), and those with coronary stents.<br /><br />Endoscopic procedures vary in bleeding risk; low-risk procedures (diagnostic EGD, colonoscopy with biopsy, ERCP without sphincterotomy) generally do not require interruption of antithrombotics, whereas high-risk procedures (polypectomy, sphincterotomy, endoscopic mucosal resection, EUS-FNA) have a significant bleeding risk. The decision to continue or hold antithrombotics depends on procedural bleeding risk and patient-specific thromboembolic risk factors (e.g., CHA2DS2-VASc score for atrial fibrillation, timing of coronary stent placement).<br /><br />For anticoagulants, guidelines suggest:<br /><br />- Continuing warfarin and NOACs for low-risk procedures.<br /><br />- Discontinuing them for high-risk procedures in low thromboembolic risk patients, with drug-specific timing for cessation and reinitiation.<br /><br />- Considering bridging anticoagulation with heparin for high thromboembolic risk patients.<br /><br />For APAs:<br /><br />- Aspirin and NSAIDs may be continued safely.<br /><br />- Thienopyridines (clopidogrel, prasugrel, ticagrelor) should be discontinued 5-7 days (ticagrelor 3-5 days) prior to high-risk procedures but continued during low-risk procedures.<br /><br />- Dual antiplatelet therapy (DAPT) continuation is critical within the first 12 months post-drug-eluting stent placement to avoid stent thrombosis; elective procedures should be deferred if possible.<br /><br />In urgent cases involving GI bleeding, anticoagulants should be held; rapid warfarin reversal with 4-factor prothrombin complex concentrate and vitamin K or fresh frozen plasma is recommended. Endoscopic hemostasis should not be delayed in patients with INR ≤2.5. For severe bleeding, platelet transfusions may be necessary for APA users.<br /><br />Reinitiation of antithrombotic agents post-procedure should occur as soon as hemostasis is secured, balancing bleeding versus thrombotic risks.<br /><br />In patients with recent intracoronary stents or ACS, elective endoscopy should be deferred during the recommended antithrombotic therapy period. Urgent endoscopy, when needed for GI bleeding, carries increased risks and requires multidisciplinary management.<br /><br />Overall, treatment decisions should be individualized, factoring procedure urgency, bleeding risk, thrombotic risk, and communication among the endoscopist, cardiologist, and patient. Further studies are needed to refine management, especially regarding NOACs and newer antiplatelet agents.

Keywords

antithrombotic agents

gastrointestinal endoscopy

anticoagulants

antiplatelet agents

bleeding risk

thromboembolic risk

warfarin

novel oral anticoagulants (NOACs)

dual antiplatelet therapy (DAPT)

endoscopic hemostasis