Differences in Managing Anticoagulants and Antiplatelets for Gastrointestinal Endoscopy between East and West

Abstract

Decreasing the bleeding risk associated with gastrointestinal (GI) endoscopic procedures and minimizing the thromboembolic risk of withdrawing medications are very important for the patients taking anticoagulants and antiplatelets. Western guidelines on managing anticoagulation and antiplatelet medications in GI endoscopy suggest a polypectomy with aspirin medication or a biopsy with warfarin medication. However, Eastern endoscopists' adherence to Western guidelines may be responsible for Easteners experiencing massive bleedings. During the cessation of drugs, it should be emphasized that Asians may be predisposed to different forms of embolism more likely to be of the cerebrovascular system, whereas Westerners more likely to be of the cardiovascular variety. To better understand the differences between the East and West, differences in drug metabolism should be considered that results in greater body weight-normalized plasma unbound clearance of drug in Easterners. Taken as a whole, different managements are required for GI endoscopy in patients on anticoagulation and/or antiplatelet medications based on differences in metabolism of drugs, risk of hemorrhage, and forms of thromboembolism.

Keywords: Anticoagulation; Antiplatelet; East; Endoscopy; West.

Figure 1

Recommendations on managing anticoagulants for high-risk patients undergoing high-risk procedures. (a) Warfarin substituted with intravenous heparin infusion. Warfarin should be stopped 3-5 days before the procedure, and be substituted with unfractionized heparin during the cessation period. (b) Warfarin substituted with subcutaneous heparin injection. Subcutaneous low molecular weighted heparin (LMWH) can be used instead of unfractionized heparin. Risk of thromboembolic complications must be carefully weighed against the increased risk of bleeding by maintaining anticoagulation.

Figure 2

Recommendation on managing antiplatelets for GI endoscopy by risk stratification. For low-risk procedures, GI endoscopy could be performed without discontinuing the antiplatelets. If the patient is Easternist, taking dual therapy with anticoagulants or other antiplatelets, has a history of GI bleeding or ulcer disease, H. pylori infection, or other conditions that increase the risk of bleeding, cessation of drugs should be considered (marked as “Step up” with an arrow in the schema). For high-risk procedures with more than 1% of bleeding complication rate, cessation of antiplatelets should be considered at least 1 week before the procedure, and restarted when there is no evidence of bleeding. If the patient is Westernist, has atrial fibrillation, venous thromboembolism, valvular heart disease, mechanical valve, ischemic heart disease, coronary artery stents, past history of thromboembolism, or other conditions that increase the risk of thromboembolism, shorter cessation of antiplatelets should be considered (marked as “Step down” with an arrow in the schema). The degree of stepping up and down should be decided according to the number and severity of risk factors written above.