1. The management of anti-thrombotics in patients undergoing GI endoscopy
Dr Osman Mapkar
Gastroenterolgy Unit
Jahra Hospital

4. Antithrombotic therapy
Indications AF
ACS
DVT
Hypercoagulable states
Endoprostheses

5. Antithrombotic agents
Anticoagulants
VKAs
Heparin derivatives eg UFH, LMWH, fondaparinux
Direct factor Xa inhibitors eg Rivaroxaban, apixaban
Direct thrombin inhibitors eg dabigatran, hirudins, argatraban
Antiplatelet agents (APAs)
Aspirin
Thienopyridines eg clopidogrel, prasugrel, ticagrelor
Protease-activated receptor-1 inhibitor eg Vorapaxar
GP IIb/IIIa receptor inhibitors eg abciximab, eptifibatide, tirofiban

6. Endoscopy considerations
The urgency of the procedure
The bleeding risk of the procedure
The effect of the antithrombotic drugs on the bleeding risk
The risk of a thromboembolic event related to interruption of these agents

9. High thrombosis risk scenarios for patients on APA therapy
DES in coronaries ≤ 3 months
BMS ≤ 4-6 Weeks
PTCA with balloon dilatation 2-4 Weeks
Pts with prior history of stent occlusion

10. Antiplatelet agents Aspirin Thienopyridine agents
Cyclo-oxygenase inhibitor
MI, stroke
7-9 days
Thienopyridine agents
P2Y12 component of ADP receptors
Ticlopidine
Clopidogrel: sec prevent of MI/ stroke/ PVD. 5-7 days
Prasugrel: incrsd risk of bleeding. 5-7 days
Ticagrelor: reversible P2Y12 inh. Quickly absorbed, metab active & rapid anti platelet effect. 3-5 days

11. Antiplatelet agents Protease-activated receptor1 (PAR-1) inhibitor
Vorapaxar: 2014 Jan. Increased risk of bleeding
Decreases risk of MI, stroke, CV death and need for revascularization in pts with previous MI or PVD with DAPT.
CI (Black box warning): h/o stroke, TIA or ICH
4 weeks

12. Anticoagulant Agents

15. Reinitiation of Antithrombotic agents after elective endoscopy
Consensus that therapy should be resumed upon completion of the procedure
AHA/ACC 2014 guideline recommends that warfarin be restarted within 24 hours of the procedure in patients with valvular heart disease and low risk for thromboembolism
In high risk for thromboembolism, UFH or LMWH should be restarted as soon as “bleeding stability allows” and continued until the INR reaches appropriate therapeutic level.
UFH restarted 2 to 6 hours after a therapeutic procedure

16. LMWH- optimal time not been determined
LMWH- optimal time not been determined ACCP recommend delaying reinitiation upto 48 to 72 hours in high risk for bleeding patients
NOACs- optimal timing- no data yet. Because they have short onset of action, if a NOAC cannot be restarted within 24 hours after a high risk procedure because of concern regarding adequate hemostasis then bridge therapy should be considered for patients at high risk for thromboembolism
Cardiac ASA should not be stopped in most cases
Other APAs should be resumed once hemostasis has been achieved

17. Endoscopic procedures in acutely bleeding patient on antithrombotics
Endoscopic hemostatic therapy is very effective in patients with moderately elevated INR, normalizing the INR does not reduce rebleeding but does delay time to endoscopy, and INR at the time of endoscopy may not be predictive of rebleeding…. Reasonable to perform endoscopic therapy in bleeding patients with INRs < 2.5
Decision to stop, reduce, and/or reverse antithrombotic therapy must be weighed against the risk of continued bleeding.
ACCP recommends that warfarin be held and rapid reversal of anticoagulation in patients having major bleeding with PCC and additional use of vit K.

18. AHA/ACC 2014 guideline on management of valvular heart disease recommends that FFP or PCC is reasonable in patients with uncontrollable bleeding… high dose vit K should not be given routinely.
In massive haemorrhage, hemodialysis can be used in patients receiving dabigatran .

19. Endoscopic procedures in acutely bleeding patient on antiplatelets
For patients on APAs with life-threatening or serious bleeding, options include stopping these agents and/or administration of platelets.
Resume therapy after endoscopic control of GI bleeding.
Limited data to guide the timing of reinitiation of therapy; current consensus statements recommend reinitiation of therapy as soon hemostasis is achieved
For ASA-related peptic ulcer bleeding, resumption of ASA with concurrent PPI is superior to Clopidogrel

20. Endoscopy in pts with intracoronary stents or ACS taking antithrombotics
Elective endoscopy
Use of DAPT confers 3-fold increase in risk of UGI bleeding
All elective high-risk endoscopic procedures on DAPT should be delayed until the pt has received the minimum length of therapy as recommended by ACC/ACG guidelines.
Once this period has elapsed endoscopic procedures to be done after discussion of risks and benefits with patient and cardiologists.

21. Urgent endoscopy in pt with ACS or recently placed stent
1-3% pts with ACS present with or develop GI bleeding during their index hospitalisation with 4-7 fold increased risk of mortality.
1 retrospective study with 200 pts underwent endoscopy within 30 days. Serious adverse events occurred in 2 patients (1%)
Pts may develop ACS after GI bleed, and these patients are likely to benefit from endoscopic evaluation.
The benefit of endoscopy in the setting of ACS is supported by a decision analysis that showed upper endoscopy before PCI to be beneficial in pts who presented with overt GI bleeding in the setting of ACS, reducing overall deaths form 600 to 97 per pts.
Endoscopy was not found to be beneficial in pts who present with occult GI bleeding and ACS.

22. Recommendations (Summarized)
Elective Endoscopic procedures – Pts on anticoagulant therapy
Elective endoscopic procedures be deferred until short-term anticoagulation therapy (eg warfarin for VTE) is completed
Hold anticoagulation for appropriate drug-specific interval in the periendoscopic period if high-risk procedure are planned in pt at low risk for thromboembolism
Continue Warf/NOAC in pts undergoing low-risk procedures
Bridge therapy for pts undergoing high-risk procedures who are at high risk for thromboembolism
Warfarin be restarted on the same day as procedure in all patients who do not have ongoing bleeding
Reinitiation of NOACs after high risk procedures delayed until adequate hemostasis. If NOACs cannot be restarted within hrs bridge therapy to be considered

23. Elective Endoscopic procedures – Pts receiving APA therapy
Continue Low doses of ASA and NSAIDs may be continued safely in periendoscopic period
Thienopyridines be continued for all low-risk procedures
Discontinuation of thienopyridines at least 5 to 7 days before high-risk procedure or switching to ASA monotherapy and continuing until the thienopyridine can be safely resumed
Elective procedures be deferred in pts with recently placed coronary stents and/or ACS until the patient has received antithrombotic for the minimum duration
Thienopyridines be held for at least 5 to 7 days (ticagrelor 3-5 days) before high- risk endoscopic procedures and that ASA be continued for pts requiring dual APA

24. Urgent & emergent endoscopic procedures- Pts on anti-coag therapy
Pts with Ac GI bleeding on anticoag therapy have anticoag agents held to facilitate achievement of hemostasis.
Use either (1) 4-factor PCC and vit K or (2) FFP can be given for life-threatening GI bleeding in pts on warfarin.
Endoscopic therapy not to be delayed in patients with serious GI bleeding and INR <2.5
Pts who require anticoag receive UFH because of its relatively short half-life after successful endoscopic hemostasis for high-risk stigmata.

25. Urgent & emergent endoscopic procedures- Pts on APA therapy
Consult with the prescribing specialist before stopping APAs in situations of significant GI bleeding in pts (1) with recently (<1 month) placed drug eluting stents (2) within 30 days after insertion of a bare metal stent or (3) within 90 days of ACS. The risk of an adverse cardiac event assoc with cessation of the APA therapy likely exceeds the benefit of decreasing postendoscopic bleeding.
Pts on APAs with life-threatening or serious GI bleeding should have these agents held after discussion with their cardiologist

26. Thank You