Management of anticoagulation for patients scheduled for elective endoscopic procedures

LMW: low molecular weight; DOAC: direct oral anticoagulant; INR: international normalized ratio; ERCP: endoscopic retrograde cholangiopancreatography.
* Consult the clinician who is managing the patient's long-term anticoagulation prior to any interruption in therapy. Examples of conditions that confer a low or moderate thrombotic risk include atrial fibrillation with CHA2DS2-VASc score ≤3 or venous thromboembolism greater than 12 months previously. Examples of conditions that confer a high thrombotic risk include atrial fibrillation with CHA2DS2-VASc score ≥4 or venous thromboembolism within the past 12 months. Refer to UpToDate topics for discussion on estimating thrombotic risk.
¶ Examples of low risk procedures include upper gastrointestinal endoscopy or colonoscopy, including mucosal biopsy. Examples of high risk procedures include colonoscopy with polypectomy of large polyp (≥1cm) or ERCP with sphincterotomy. An example of a procedure with uncertain risk is a screening colonoscopy.
Δ For patients on warfarin, confirm that INR is ≤2.5 prior to procedure.
◊ If a lesion is found that requires a high risk intervention, the procedure is repeated while following periprocedure management for high risk patients undergoing a high risk procedure.
§ The day of the procedure is regarded as day 0. The day of the last dose is determined by counting each hold day while starting with the procedure day (day 0). For example, warfarin is held for 5 days prior to the procedure. If the procedure is on a Monday, the last dose of warfarin will be taken on day –5 (ie, the Wednesday before the procedure).
¥ For patients with renal impairment, a longer discontinuation period may be required. Please refer to UpToDate content on dosing for patients with renal impairment.
‡ Some patients at high risk for thromboembolism require bridging anticoagulation. Refer to other UpToDate topics for details on when bridging therapy is warranted and how it is given before the procedure and resumed after the procedure.
† The decision to restart anticoagulation is contingent upon achieving hemostasis as determined by the endoscopist. For patients who undergo ERCP with sphincterotomy, a longer delay is needed prior to resuming anticoagulation because of the increased risk of bleeding.