GI endoscopy in patients on direct oral anticoagulants is risky : BMJ

Elective gastrointestinal (GI) endoscopy in patients on direct oral anticoagulants (DOACs) is associated with a substantial bleeding risk which is further increased by heparin bridging. Adoption of the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines seems to be beneficial in the periendoscopic management of DOACs.

These are the results of a new study published in the BMJ Journal Gut.

Franco Radaelli, Gastroenterology Unit, Valduce Hospital, Como, Italy, and colleagues conducted the study to assess the frequency of adverse events associated with periendoscopic management of DOACs in patients undergoing elective GI endoscopy and to determine the efficacy and safety of the BSG/ESGE guidelines for this scenario.

For the study, the researchers prospectively included consecutive patients on DOACs scheduled for elective GI endoscopy. DOAC interruption and resumption timings were recorded before and after the procedures, along with the procedural and clinical data. Procedures were stratified into low-risk and high-risk for GI-related bleeding, and patients into low-risk and high-risk for thromboembolic events. Patients were followed-up for 30 days for major and clinically relevant non-major bleeding events (CRNMB), arterial and venous thromboembolism and death.

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Key Results:

• Of 529 patients, 38% and 62% underwent high-risk and low-risk procedures, respectively.


• There were 45 (8.5%; 95% CI 6.3% to 11.2%) major or CRNMB events and 2 (0.4%; 95% CI 0% to 1.4%) thromboembolic events (transient ischaemic attacks).


• Overall, the incidence of bleeding events was 1.8% (95% CI 0.7% to 4%) and 19.3% (95% CI 14.1% to 25.4%) in low-risk and high-risk procedures, respectively.


• For high-risk procedures, the incidence of intraprocedural bleeding was similar in patients who interrupted anticoagulation according to BSG/ESGE guidelines or earlier (10.3%vs10.8%), with a trend for a lower risk as compared with those who stopped anticoagulation later (10.3%vs25%).


• The incidence of delayed bleeding appeared similar in patients who resumed anticoagulation according to BSG/ESGE guidelines or later (6.6%vs7.7%, p=0.76), but it tended to increase when DOAC was resumed earlier (14.4%vs6.6%).


• The risk of delayed major bleeding was significantly higher in patients receiving heparin bridging than in non-bridged ones (26.6%vs5.9%).

"High-risk procedures in patients on DOACs are associated with a substantial risk of bleeding, further increased by heparin bridging. Adoption of the BSG/ESGE guidelines in the periendoscopic management of DOACs seems to result in a favorable benefit/risk ratio," concluded the authors.

For further reference log on to http://dx.doi.org/10.1136/gutjnl-2018-316385