ACG-CAG provided suggestions for periendoscopic management of anticoagulants and antiplatelets
The recommendations from the American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG), particularly those for withholding antithrombotics before planned endoscopic procedures, require individualized decision making with multidisciplinary input, an ACP Journal Club commentary said.
The American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) recently published a new guideline on managing anticoagulants and antiplatelets during GI bleeding and before endoscopy. The guideline addressed clinical questions that arise in common emergent and elective settings and covered management of patients on warfarin, direct oral anticoagulants (DOACs), and antiplatelet agents, among other topics.
The guideline was published online March 17 by the American Journal of Gastroenterology and was summarized in the March ACP Gastroenterology Monthly. The following commentary by David R. Lichtenstein, MD, and Neil Dharmadhikari, MD, was published in the ACP Journal Club section of the July Annals of Internal Medicine.
The new guideline jointly developed by the ACG and CAG updates suggestions for managing antithrombotic agents (anticoagulants and antiplatelets) in the common clinical settings of acute GI bleeding and elective periendoscopic care. Most of the recommendations are conditional and based on a very low certainty of evidence.
Withholding antithrombotic agents to reduce GI bleeding is weighed against the increased risk for thromboembolic events. The guideline often favors cardiovascular protection over bleeding risk with continuation of antithrombotics in both acute GI bleeding and elective endoscopy. The guideline suggests against reversal of antiplatelet agents, vitamin K antagonists (VKAs), and direct oral anticoagulants (DOACs) in patients with acute GI bleeding. No recommendation could be made for prothrombin complex concentrate (PCC) administration in patients receiving VKAs, but PCC reversal of VKAs and DOAC-specific reversal agents could be considered for life-threatening GI bleeding.
For elective endoscopies, periprocedural continuation of most antithrombotic agents (warfarin and aspirin) is suggested, but DOACs should be temporarily interrupted; for the highest-risk procedures, warfarin can be held. If a VKA is held, the guideline suggests against bridging anticoagulation unless the risk for thromboembolic events is very high (e.g., patients with mechanical heart valve). P2Y12 receptor inhibitors should be interrupted while continuing aspirin in patients receiving dual antiplatelet therapy. The guidelines could not inform for or against temporary interruption of monotherapy with a P2Y12 receptor inhibitor and timing of resumption of VKAs, DOACs, and P2Y12 receptor inhibitors after the procedure (same day vs. 1 to 7 d).
The recommendations, particularly withholding antithrombotics before planned endoscopic procedures, require individualized decision making with multidisciplinary input from the appropriate physicians. Guideline updates informed by higher-quality evidence are anticipated.