COMMENTARY

Rethinking Bleeding Risk in Polypectomy Patients on Anticoagulants or Antiplatelets

David A. Johnson, MD

Disclosures

October 03, 2019

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

When gastroenterologists perform colonoscopy and polypectomy, we're always very concerned about the immediate and postoperative bleeding risk. The patient population on anticoagulation and antiplatelet therapy certainly is not decreasing in my practice, as I'm sure is the same for you. But there's growing evidence that we can be a lot more supportive of continuing these therapies, perhaps even through the procedure, rather than interrupting them.

The Risks of Interrupting Therapy

Because of our fears regarding bleeding, we typically recommend patients stop their anticoagulation and antiplatelet therapy. There are clearly risks related to that, and we need to be very sanguine about which patients we are telling to stop these therapies. Recommendations have changed a bit in light of growing evidence that we can continue anticoagulation therapy, and perhaps even antiplatelet therapy, and safely perform colonoscopy with polypectomy.

Stopping these agents for concern about bleeding results in an embolic event in approximately 1% of patients,[1] which is a sequelae we may not see as gastroenterologists. In 2017, we looked at a database of approximately 500,000 colonoscopies to capture the cardiopulmonary and neurovascular complications 30 days after colonoscopy.[2] Patients who were on anticoagulants and antiplatelets had a nearly 11.5 times greater incidence of those complications, which we don't typically think about as gastroenterologists.

The Latest Data

We have strong data that my good friend and colleague, Dr Doug Rex, has referred to as "the cold snare revolution," which I've discussed recently on Medscape, meaning that we're able to successfully perform polypectomy in smaller polyps, typically < 10 mm, in a very proactive way without cautery.

We avoid cautery because it results in a deeper coagulative effect that potentially can result in a deeper coagulative injury. The principal problem with cautery is the delayed hemorrhage risk. As the eschar sloughs off, you have an arterial in the submucosa that may be subject to a more significant bleed. This is opposed to the superficial bleed we may see with the mucosal vascularity, particularly in the vascular pattern of serrated lesions and superficial polyps where there's very minimal vascularity, which we can intervene in once it is identified.

We have data on warfarin continuation and cold snare that look good.[3] They show that cold snare can be performed with small polyps, < 10 mm.

We have recent data for the same effect as it relates to continuation with clopidogrel. In a brilliant double-blinded study by Dr Francis Chan and colleagues, published this past spring,[4] the investigators looked at polypectomy in patients continuing clopidogrel versus placebo. They found that there was no significant difference in bleeding between these groups.

A recent multicenter study[5] from a group in Japan looked at continuation and interruption of anticoagulants in patients undergoing cold or hot snare polypectomy. Anticoagulation took the form of warfarin for roughly a third of patients, whereas the rest received direct oral anticoagulants, which have become increasingly popular for, among other reasons, not requiring INR monitoring. The direct oral anticoagulants used in the study were dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), or edoxaban (Savaysa). Patients were randomized to either continuous anticoagulants and cold snare polypectomy; or to stop treatment, receive a periprocedural heparin bridge, undergo hot snare polypectomy, and then restart anticoagulants post-procedure.

Investigators reported that the patients who continued oral anticoagulation had a comparative 7.3% reduction in the risk for subsequent bleeding problems post-polypectomy. This is a fairly striking incidence rate, in a favorable way, and supports continuing the anticoagulation rather than using a heparin bridge, which we've done for a lot of higher-risk patients with the hot snare–type technique. This again suggests that cold snare is the way that we should approach these patients if we're going to continue them on anticoagulation.

Gaining a Better Perspective on Continuing Therapy

When I think of this issue, I always harken back to the great parable by John Godfrey Saxe from the 1800s, which told the story of blind men touching different parts of an elephant and each getting a different perspective on what they were feeling. I think we've done the same thing as gastroenterologists when it comes to our perspective of bleeding risk in these patients. We want no bleeding, but a thromboembolic event like a stroke may be more catastrophic. We need a better perspective on this if we are going to do better as gastroenterologists.

In my own practice, I'm starting to be a lot more fluid when it comes to the patients whom I believe to have a very low likelihood of having an advanced large polyp. These therapies can be continued in selected patients. We have to recognize that 90% of the polyps that we identify and take out are < 10 mm.[6] Explain to patients upfront that we think it may be safer [to continue their antiplatelets and anticoagulants]; but if we see a large polyp, we may have to bring them back, and we'd stop the antiplatelets and anticoagulants at that time.

It is reassuring that the direct oral anticoagulants like warfarin and the antiplatelet therapy clopidogrel have been well studied in this setting and appear to show no increased bleeding risk if continued in appropriate patients. I also think we would do better if we employ this cold snare technique.

I'm Dr David Johnson. I hope this helps, and I look forward to chatting again with you soon.

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