Anticoagulant and Antiplatelet Management in Endoscopy

The rapid evolution of therapeutic gastrointestinal (GI) endoscopy has revolutionized modern medicine, shifting management strategies from highly invasive open surgeries to targeted, minimally invasive endoluminal procedures. However, this shift occurs alongside a prominent global demographic challenge: an aging population with a high prevalence of chronic cardiovascular, cerebrovascular, and thromboembolic diseases. Consequently, a significant percentage of patients presenting for endoscopy are on active antithrombotic regimens, including single antiplatelet therapy, dual antiplatelet therapy (DAPT), vitamin K antagonists, or direct-acting oral anticoagulants (DOACs). Managing these medications during the periendoscopic period is a complex task. Clinicians must constantly balance two opposing risks of procedure-related hemorrhage and thromboembolic events. Achieving an optimal balance requires a strict, risk-stratified, and multidisciplinary approach that accounts for the specific bleeding risk of the procedure alongside the individual patient’s underlying thrombotic risk profile. Classification of Procedural Bleeding Risk Endoscopic interventions are broadly categorized based on the depth of tissue disruption, the vascular profile of the target organ, and the statistical likelihood of causing significant hemorrhage. According to the latest guidelines, procedures are divided into low/moderate bleeding risk procedures (≤ 2% risk) including endoscopy/colonoscopy/sigmoidoscopy, endoscopic ultrasound (EUS) (without fine-needle aspiration [FNA]), enteral stent placement, push/diagnostic balloon enteroscopy, argon plasma coagulation, small polypectomy (< 1 cm), endoscopic retrograde cholangiopancreatography (ERCP) (without sphincterotomy), and capsule endoscopy; and high bleeding risk procedures (> 2% risk) including polypectomy (≥ 1 cm), endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), EUS-FNA, cystogastrostomy, percutaneous endoscopic gastrostomy/percutaneous endoscopic jejunostomy placement, ERCP with sphincterotomy, therapeutic balloon-assisted enteroscopy, radiofrequency ablation, peroral endoscopic myotomy, variceal treatment, tumor/cyst ablation, ampullary resection, and dilation (pneumatic/bougie). Patient Thromboembolic Risk Stratification Before modifying any medication, the patient’s absolute risk of a thromboembolic event during temporary cessation must be determined. Patients with CHA 2 DS 2 -VASc score ≥ 5, stroke/transient ischemic attack (TIA)/acute coronary syndrome within the past 3 months, mitral mechanical heart valve, older generation mechanical aortic valve, coronary stenting (percutaneous coronary intervention) within the past 1 to 3 months, recent venous thromboembolism (VTE) (deep vein thrombosis or pulmonary embolism) within 3 months, and severe underlying thrombophilic states are classified to have high thrombotic risk, while patients with CHA 2 DS 2 -VASc score ≤ 4, no history of stroke or TIA, remote history of VTE > 12 months ago, and modern bileaflet mechanical aortic valve without extra risk factors are classified to have low thrombotic risk. Key Periprocedural Recommendations (a) Low bleeding risk procedures: Because the mucosal integrity is maintained, the risk of significant clinical bleeding is very low. Both aspirin monotherapy and DAPT should be continued uninterrupted. Warfarin should be continued, provided a recent laboratory evaluation confirms the international normalized ratio (INR) remains within the patient’s established therapeutic window. For DOACs, full suspension is unnecessary. The morning dose on the day of the procedure should be omitted purely to avoid peak plasma levels during the scope. (b) High bleeding risk procedures: Aspirin monotherapy for secondary prevention of cardiovascular events must always be continued through the periendoscopic window. The cardiovascular risks of stopping aspirin outweigh the endoscopic bleeding risks. If a high-risk procedure is scheduled for a patient on DAPT, it should be deferred until the mandatory high-risk cardiac period has passed (e.g., waiting until 6–12 months postdrug-eluting stent if possible). If the procedure is urgent and cannot be delayed, aspirin must be maintained while the P2Y12 inhibitor (e.g., clopidogrel, prasugrel, ticagrelor) is held for 5 to 7 days beforehand. The P2Y12 inhibitor is then safely reinitiated 1 to 2 days postprocedure, provided no signs of delayed hemorrhage are observed. DOACs (apixaban, rivaroxaban, dabigatran) should be suspended 3 days prior to the high-risk procedure. They should be held for 2 to 3 days postprocedure following complex interventions (such as EMR or ESD) to minimize the risk of delayed bleeding from the healing ulcer bed. Warfarin must be discontinued 5 days prior to the intervention targeting an INR < 1.5 on the day of the procedure. For low thrombotic risk patients, no bridging is necessary, while for high thrombotic risk patients, therapeutic bridging with low-molecular-weight heparin is required. Warfarin can typically be restarted at the patient’s maintenance dose on the evening of the procedure. Management of Acute GI Bleeding Upon the presentation of a patient with active, clinically significant GI bleeding, the primary objective shifts to promptly halt the hemorrhage while concurrently managing the patient’s overall health. All active anticoagulant medications must be discontinued immediately upon presentation. Continue aspirin, stop P2Y12 receptor antagonists. For patients on warfarin with life-threatening hemorrhage or a significantly elevated INR, rapid reversal should be achieved using four-factor prothrombin complex concentrate (4F-PCC) rather than fresh frozen plasma. Intravenous vitamin K (5–10 mg) should be coadministered to sustain the reversal effect. For patients on DOAC therapy, targeted reversal agents should be utilized if available (idarucizumab for the direct thrombin inhibitor dabigatran, or andexanet alfa for factor Xa inhibitors [apixaban, rivaroxaban]). If specific antidotes are unavailable, unactivated 4F-PCC (50 UI/kg) should be administered. Conclusion During GI endoscopy, managing antithrombotic therapy necessitates a meticulous equilibrium between procedural bleeding hazards and patient thromboembolic risks. Standardized, risk-stratified protocols facilitate clinicians in circumventing unwarranted drug interruptions during low-risk procedures while ensuring the implementation of appropriate safety measures prior to high-risk interventions. Publication History Article published online: 27 August 2026 © 2024. The Author(s). 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