1. How Do You Manage Anticoagulants and Antiplatlet Agents? Steve Schrock, MD, FAAFP November 5, 2015

2. Objectives Review Classes of Medications which increase Bleeding Risk Identify Procedures as Low or High Risk for Bleeding Identify Diseases States with Significant Risk for Thromboembolic Events Review Data on Individual Medications and Endoscopy Discuss an Endoscopy Strategy

3. Antiplatlets and Anticoagulants Aspirin – Irreversible inhibition of COX-1 and COX-2 – 1 week Thienopyridines – Irreversible inhibition of P2Y12 receptor – 5-9 days – Effient, Ticlid, Plavix Coumadin – Inhibition of Vitamin K dependent synthesis of clotting factors

4. Some of the Latest Agents Effient - Thienopyridine Brilinta – Cyclo-pentyltriazolo-pyrimidine Pradaxa-Direct Thrombin Inhibitor – Praxbind (Idarcizumab) Xarelto-Direct Factor Xa Inhibitor

5. Procedure Risk of Bleeding Low-risk procedures Diagnostic upper endoscopy, flexible sigmoidoscopy, and colonoscopy (including biopsies) Push enteroscopy and diagnostic balloon assisted enteroscopy Enteral stent deployment without dilation Anderson MA, Ben-Menachem T, Gan SI, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70:1060.

6. Procedure Risk of Bleeding High-risk procedures Polypectomy or endoscopic resection – The size of the polyp influences the risk of bleeding, and it may be more appropriate to categorize polyps less than 1 cm in size as low-risk for bleeding. Argon plasma coagulation and thermal ablative therapy Endoscopic sphincterotomy Pneumatic or bougie dilation of benign or malignant strictures Percutaneous endoscopic gastrostomy tube placement Endoscopic ultrasound (EUS)-guided fine-needle aspiration Endoscopic hemostasis Therapeutic balloon assisted enteroscopy Treatment of varices Anderson MA, Ben-Menachem T, Gan SI, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70:1060.

7. Risk of Thromboembolic Event Dependent upon Condition RiskMechanical Heart Valve Atrial FibrillationVTE Very High Thrombotic Risk Any mitral valve Some aortic valves CVA or TIA w/in 6 months CHADSVASC >6 CHADS 5-6 CVA or TIA w/in 3 months Rheumatic Valvular Heart Disease VTE within 3 months Severe Thrombophilia High Thrombotic Risk Bi-leaflet aortic valve with at least one risk factor CHADSVASC 4-5 CHADS 3-4 VTE 3-12 months Non-Severe Thrombophilia Recurrent VTE Active Cancer Moderate Thrombotic Risk Bi-leaflet aortic valve with no A Fib or risk factors CHADSVASC 2-3 CHADS 0-2 VTE>12 months and no other risk factors Douketis JD, et al. Perioperative Management of Thombotic Therapy,Chest 2012; 14(Supplement 2)e3265.

8. Stents Bare metal stent – Highest risk of thrombosis within first 6 weeks Drug-eluting stent – Highest risk of thrombosis within 3-6 months Baron TH, et al. N Engl J Med. 2013 May 30;368(22):2113-24

9. Aspirin And Endoscopy Aspirin - continued for all endoscopic procedures Gastrointest Endosc Vol 70, No. 6: 2009

10. Thienopyridines and Endoscopy Multiple observational studies Meta analysis No significant increase in immediate post polypectomy bleeding Meta analysis Delayed PPB 2.65%; similar to population based PPB not on anti-platelets Two observational studies Delayed PPB <2.65% Gandhi S et al. Aliment Pharmacol Ther. 2013 May;37(10):947-52 Singh M et al. Gastrointest Endosc. 2010 May;71(6):998-1005 Feagins LA et al. Dig Dis Sci. 2011 Sep;56(9):2631-8.

11. Coumadin and Endoscopy 7 major studies in patients on anticoagulants undergoing colonoscopy and polypectomy 6 studies retrospective 1 prospective randomized controlled study Retrospective study with significant limitations Increased risk of immediate bleeding – successfully detected Increased risk of delayed bleeding with and without interruption of Coumadin

12. Coumadin and Endoscopy Prospective randomized controlled study Polyps up to 10mm Cold snare vs ERBE No difference in immediate bleeding Significant difference in delayed bleeding Cold snare 0% (0/35) ERBE 14% (5/35) > P= 0.027 Horiuchi A, et al. Gastrointest Endosc. 2015 Mar;79(3):417-23

13. One Practical Approach? Studies-approach Safe to perform polypectomy (<10mm) PPB not usually life threatening; no fatalities in studies Can you stop the bleeding? – Clips! Fatality for stent thrombosis is high You can’t reverse death Risk of bleeding vs re-infarction, neurological event, thrombosis or death

14. What do You Do? Colonoscopy on therapy Communication – Patient and Cardiologist/Neurologist? Inform and educate patient Polyps <10mm; INR therapeutic range Explain risks of bleeding, risks of adverse events and need for repeat colonoscopy