Management of antithrombotic drugs in association with endoscopic procedures

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Abstract

The use of antithrombotic drugs (anticoagulants and antiplatelets) has increased significantly with our understanding of cardiovascular risk. Encountering patients on these therapies who require an endoscopic procedure is therefore increasingly common. At decision making the endoscopist must rely on other specialists (basically cardiologists and hematologists) as risk not only lies among increased bleeding odds but also in the possibility of thrombosis following dose discontinuation or change. Understanding the pharmacology, indications, and risks of endoscopic procedures is therefore essential if sound decisions are to be made. The efforts of four scientific societies have been brought together to provide clinical answers on the use of antiplatelets and anticoagulants, as well as action algorithms and a practical protocol proposal for endoscopy units.

Translated abstract

Los fármacos antitrombóticos (anticoagulantes y antiagregantes) han experimentado un importante incremento de su uso derivado de los conocimientos sobre el riesgo cardiovascular. Por ello, es cada vez más frecuente encontrarnos con pacientes con estos tratamientos a los que hay que realizar procedimientos endoscópicos. En el acto de la toma de decisiones el endoscopista debe apoyarse en otros especialistas (básicamente cardiólogos y hematólogos) pues el riesgo no sólo se encuentra en las posibilidades aumentadas de sangrado, sino también en la posibilidad de trombosis ante la suspensión o variación de las dosis de dichos fármacos. Por ello es esencial conocer su farmacología, sus indicaciones y el riesgo de los procedimientos endoscópicos para poder tomar decisiones correctas. Se han aunado los esfuerzos de cuatro sociedades científicas para aportar respuestas clínicas con respecto al uso de antiagregantes y anticoagulantes, elaborando algoritmos de actuación, así como una propuesta práctica de un protocolo para las unidades de endoscopia.

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Most cited references 89

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Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.

A Sieg, U Hachmoeller-Eisenbach, T Eisenbach (2001)

Although most diagnostic GI endoscopic procedures in Germany are performed on an outpatient basis, there is no large-scale prospective evaluation of complication rates. Ninety-four gastroenterologists and internists from all regions of Germany recorded the number of EGD, colonoscopies, and polypectomies performed over a period of 1 year. All serious complications occurring in relation to the procedure, including the use of medication, were recorded in a structured protocol. A total of 110,469 EGDs, 82,416 colonoscopies, and 14,249 polypectomies were evaluated. The "reach-the-cecum-rate" was 97% (median). The overall complication rates for EGD, colonoscopy, and polypectomy were low compared with published data (0.009%, 0.02%, and 0.36%, respectively). The perforation rates were 0.0009%, 0.005%, and 0.06%, respectively, the rates of significant hemorrhage 0.002%, 0.001%, and 0.26%, respectively, and the mortality rates 0.0009%, 0.001%, and 0.007%, respectively. The rates of cardiorespiratory complications associated with EGD and colonoscopy were 0.005% and 0.01%, respectively. The overall complication rate for all procedures (diagnostic and therapeutic) was lower for gastroenterologists (1 per 5155 procedures) than internists (1 per 1539 procedures). Most of the adverse events associated with diagnostic endoscopy were attributable to use of medication. The severity score ranged from 2 to 5 for most of the adverse events occurring as a result of diagnostic procedures and 2 to 50 for polypectomy. The severity sum score per 10,000 procedures was 26 for EGD, 67 for colonoscopy, and 1185 for polypectomy. Outpatient endoscopy performed in practice settings by German gastroenterologists and internists is safe. The low complication rates may partly be explained by the high degree of experience resulting from the larger numbers of procedures performed relative to the numbers performed by gastroenterologists in hospitals and in other countries.

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Antithrombotic drugs are risk factors for delayed postoperative bleeding after endoscopic submucosal dissection for gastric neoplasms.

S Yahara, Satoshi Morita, Ryonho Koh … (2013)

The discontinuation of antithrombotic drugs is recommended during endoscopic submucosal dissection (ESD) for gastric neoplasms; however, controversy remains as to whether antithrombotic drugs are risk factors for postoperative bleeding. To determine the risk factors for post-ESD bleeding. Single-institution, retrospective review. University hospital. From June 2000 to December 2010, we treated 1192 gastric neoplasms in 1032 consecutive patients. The ESD procedures were performed by using the standard techniques. Antithrombotic drug therapy was principally interrupted preoperatively and was restarted when hemostasis was confirmed by second-look endoscopy. Risk factors for postoperative bleeding after ESD (early, delayed, and overall [combined] occurrence of bleeding during the first 5 postoperative days or thereafter) were analyzed by using logistic regression analysis. Among 1166 ESD-induced ulcer lesions, overall postoperative bleeding was evident in 62 lesions (5.3%); early and delayed bleeding occurred in 30 and 32 lesions (2.6% and 2.7%), respectively. Based on a multivariate analysis, a specimen size of >40 mm was the sole independent risk factor for overall bleeding. Moreover, oral antithrombotic drug therapy was selected as independent risk factor for delayed but not early bleeding, according to the multivariate analysis. The delayed bleeding rate in patients who had a specimen size of >40 mm and who used antithrombotic drugs was 11.6%. Retrospective design and single-site data collection. Interruption of antithrombotic drug therapy may be adequate for preventing early post-ESD bleeding; however, reinitiating antithrombotic drug therapy is a significant independent risk factor for delayed post-ESD bleeding. Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.

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Author and article information

Contributors

Fernando Alberca-de-las-Parras: Role: ND

Francisco Marín: Role: ND

Vanessa Roldán-Schilling: Role: ND

Fernando Carballo-Álvarez: Role: ND

Journal

Journal ID (publisher-id): diges

Title: Revista Española de Enfermedades Digestivas

Abbreviated Title: Rev. esp. enferm. dig.

Publisher: Sociedad Española de Patología Digestiva (Madrid, Madrid, Spain )

ISSN (Print): 1130-0108

Publication date (Print and electronic): May 2015

Volume: 107

Issue: 5

Pages: 289-306

Affiliations

[03] Murcia orgnameInstituto Murciano de Investigación Biosanitaria (IMIB) Spain

[01] orgnameHospital Clínico Universitario Virgen de la Arrixaca orgdiv1Unit of Digestive Diseases

[02] orgnameHospital Clínico Universitario Virgen de la Arrixaca orgdiv1Department of Cardiology

[04] Murcia orgname. Hospital Universitario Morales Meseguer orgdiv1Department of Hematology and Oncology Spain

Article

Publisher ID: S1130-01082015000500007

SO-VID: d1fac27f-2441-4664-b1aa-4ec964728dab

License:

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 International License.

History

Date received : 25 January 2015

Date accepted : 16 February 2015

Page count

Figures: 0, Tables: 0, Equations: 0, References: 59, Pages: 18

Product

SciELO Spain

Keywords: Fármacos antitrombóticos,Antiagregantes,Anticoagulantes,Procedimientos endoscópicos,Antithrombotic drugs,Antiplatelets,Anticoagulants,Endoscopic procedures

Data availability:

Keywords: Fármacos antitrombóticos, Antiagregantes, Anticoagulantes, Procedimientos endoscópicos, Antithrombotic drugs, Antiplatelets, Anticoagulants, Endoscopic procedures

Management of antithrombotic drugs in association with endoscopic procedures Translated title: Manejo de los fármacos antitrombóticos asociados a los procedimientos endoscópicos

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