Blood thinners and gastrointestinal endoscopy

Table 1 Summary of recommendations for elective endoscopic procedure

	Low-risk conditions	High-risk conditions
Low-risk procedures	Continue APA, warfarin and NOAC	Continue APA, warfarin and NOAC
	Keep INR in therapeutic range in case of warfarin	Keep INR in therapeutic range in case of warfarin
High-risk procedures	Hold thienopyridines for 5 to 7 d before the procedure. Resume theonopyridine once hemostasis is obtained In case of dual APA, hold thienopyridines for 5 to 7 d before the procedure but continue aspirin Hold warfarin 5 d before the procedure. Resume warfarin on the same day as the procedure Hold NOAC: Rivaroxaban 2 to 4 d, apixaban 2 to 4 d, edoxaban 1 d and dabigatran 2 to 6 d before the procedure depending on creatinine clearance. Resume NOAC when adequate hemostasis is obtained	Hold thienopyridines for 5 to 7 d before the procedure after discussion with the cardiologist. Resume theonopyridine once hemostasis is obtained In case of dual APA, hold thienopyridines for 5 to 7 d before the procedure but continue aspirin Delay endoscopic procedure if coronary artery stenting done and thienopyridines cannot be discontinued If the patient is on warfarin, bridge therapy with LMWH

APA: Antiplatelet agents; NOAC: Novel oral anticoagulants; LMWH: Low molecular weight heparins; INR: International normalized ratio.

Table 2 Summary of recommendations for emergency endoscopic procedures

	Anticoagulant	APA
Active GI bleed	Hold the anticoagulant	Do not stop thienopyridines without discussion with the
	If on warfarin, give FFP, 4-factor PCC or IV Vitamin K to improve INR	cardiologist in high risk situations like within 3 mo of ACS,
	Avoid vitamin K in case of mechanical heart valve	within 1 mo of placing a bare metal coronary stent and within
	Hemodialysis in case of Dabigatran	12 mo of placing a drug eluting coronary stent
	Endoscopic therapy when INR is less than 2.5

APA: Antiplatelet agents; PCC: Prothrombin complex; ACS: Acute coronary syndrome; GI: Gastrointestinal; FFP: Fresh frozen plasma; INR: International normalized ratio; IV: Intravenous injection.