COMMENTARY

Antithrombotic Agents and Endoscopic Procedures

David A. Johnson, MD

Disclosures

January 05, 2010

Management of Antithrombotic Agents for Endoscopic Procedures

ASGE Standards of Practice Committee, Anderson MA, Ben-Menachem T, et al.
Gastrointest Endosc. 2009;70:1060-1070

The risk of developing a gastrointestinal (GI) hemorrhage during or following a GI endoscopic procedure is rare albeit well recognized. Clearly some procedures have a higher risk potential for bleeding, for example, polypectomy or sphincterotomy. Given the risk potentials, it has been fairly standard practice to withhold antiplatelet agents for a time before the endoscopy and to continue holding these for a defined period following a therapeutic endoscopy.

The use of antiplatelet agents, however, has clear benefit in patients with cardiovascular or neurovascular disease. Withholding these agents for even a short time may have considerable risks -- in particular, for coronary stent thrombosis, myocardial infarct, stroke, and death. Cardiology guidelines recommend dual antiplatelet therapy (aspirin + clopidogrel) for a minimum of 1 month following a bare metal stent and ideally continuing for 12 months. For patients who have a drug-eluting stent, a minimum of 6 months of dual therapy is recommended with extended benefit of continued use for up to 3 years.

Accordingly, in these patients, the risk for a thrombotic event during interruption of therapy must be carefully balanced against the potential risk for GI bleeding. Two recent publications address this balance and make new recommendations for the management of these antithrombotic agents for patients undergoing elective endoscopy. The first article is a guideline from the American Society of Gastrointestinal Endoscopy.[1] The second article is a consensus "white paper" by a writing group appointed from the American College of Cardiology and the American College of Gastroenterology.[2] Although physicians who deal with these patients should carefully review both of these documents, I have highlighted some of the important changes for clinical practice:

  1. Diagnostic endoscopy: No clinical trials have demonstrated an increased bleeding incidence for patients taking aspirin or clopidogrel who undergo diagnostic GI endoscopy of any type when no biopsy is performed.

  2. In assessing the risk for temporary discontinuation of antiplatelet therapies, it is important to assess the inherent risk of bleeding related to the procedures. High-risk procedures associated with increased bleeding risk include endoscopic polypectomy or mucosal resection, therapeutic enteroscopy, and laser ablation. Furthermore, some procedures are associated with bleeding that may be inaccessible or uncontrollable by endoscopic means. This includes dilation of strictures, percutaneous gastrostomy, fine needle aspirations, or Tru-Cut biopsy.

  3. Aspirin should not be stopped at any point if the patient is high risk and aspirin is clearly needed for cardiovascular or neurovascular indications. For high risk procedures, clinicians may elect to stop aspirin or nonsteroidal anti-inflammatory drugs for 5-7 days depending on the underlying indication for the antiplatelet therapy.

  4. Clopidogrel can be stopped for a short duration (typically 7-10 days prior to the procedure) if 1 month has elapsed since a bare metal stent procedure. For drug-eluting stents, short-term discontinuance of clopidogrel within 3 months should be avoided, and, ideally, clopidogrel should not be interrupted for the first 6 months. Abrupt cardiac stent thrombosis (which can occur when clopidogrel is withheld or discontinued) is associated with a myocardial infarct rate of 50% and related death rate of approximately 20%. Aspirin should be continued when clopidogrel is held.

  5. In patients whose antiplatelet therapy is temporarily interrupted, treatment should be resumed as soon as possible following elective GI endoscopy. Whether a loading dose (600 mg) of clopidogrel is used for the initial dose or the patient is started on a maintenance dose (300 mg) should be gauged by the individual patient level of risk (stent type, time from stenting).

Viewpoint

Clearly the routine discontinuance of antiplatelet therapy in all patients undergoing elective endoscopy should be avoided. These 2 recent articles highlight the more appropriate balanced risk perspectives -- emphasizing a cognizance of both the GI and cardiovascular aspects of relative risks. Gastroenterologists should look closely at their patient pre-endoscopy instructions to ensure that these new changes are incorporated.

Furthermore, it has become our practice to never stop antiplatelet therapy for any patient unless the prescribing physician (typically the cardiologist if coronary stents have been placed) says it is allowable for the time outlined. We ask the patient to have that physician recommend the short-term interruption of clopidogrel, if appropriate. Remember that aspirin is continued in these patients! It is with this type of dialogue with the cardiologists that we can stop treating our patients from a single organ perspective of relative risks (cardiology vs GI) but with more global balanced risk assessment to optimize patient outcomes!

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