warfarin and Colonic-Polyps

Colonoscopy frequently is performed for patients who are taking aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and other anticoagulants. These colonoscopies often involve polypectomy, which can be complicated by bleeding. The risks of precipitating thromboembolic complications if anticoagulants are stopped must be weighed against the risk of postpolypectomy bleeding if these agents are continued. This article systematically reviews the management of anticoagulation during elective and emergency colonoscopy. For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is <0.5%. Risk factors for postpolypectomy bleeding include large polyp size and anticoagulant use, especially warfarin and thienopyridines. For patients who do not stop aspirin or other nonsteroidal anti-inflammatory drugs prior to colonoscopy, the rate of postpolypectomy bleeding is not significantly different from that for patients who do not take those medications. For patients who continue thienopyridines and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4%. Even for patients who interrupt warfarin, the risk of postpolypectomy bleeding is increased. The direct oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) have a rapid onset and offset of action, and periprocedural bridging generally is not necessary. For the thienopyridines, warfarin, and the direct oral anticoagulants, the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Colonic Polyps; Colonoscopy; Gastrointestinal Hemorrhage; Humans; Platelet Aggregation Inhibitors; Pyridines; Risk Factors; Thromboembolism; Warfarin; Withholding Treatment

For patients undergoing colonoscopy with polypectomy, current guidelines recommend temporary cessation of blood-thinning medications. The data regarding periprocedural management of these medications are sparse.. To perform a systematic review and meta-analysis to determine the risk of post-polypectomy bleeding (PPB) in patients taking anti-platelet, anti-coagulant and/or thienopyridine medications.. We searched Pubmed, Scopus, Web of Science, Biosis and Proceedings First from 1970 to 2015. PPB was defined as overt haemorrhage or drop in haemoglobin of at least 2 g/dL.. Of 1490 articles identified, we included 3 papers and 1 abstract with patients on aspirin and/or NSAIDs, 1 paper on warfarin, 2 abstracts on clopidogrel, and 2 papers on clopidogrel plus aspirin and/or NSAIDs. While the rate of immediate PPB on aspirin and/or NSAIDs was not increased (OR = 1.1, 95% CI 0.7-1.9, P = 0.7), the risk of delayed PPB was increased (OR = 1.7, 95% CI 1.0-2.4, P = 0.0009, I(2)  = 60%) but rendered non-significant with elimination of a small study. There was an elevated risk of delayed PPB on clopidogrel (OR = 9.7, 95% CI 3.1-30.8, P = 0.0, I(2)  = 0). There was an increased risk of delayed PPB in patients on clopidogrel + aspirin and/or NSAIDs (OR = 3.4, 95% CI 1.3-8.8, P = 0.01, I(2)  = 0). Based on a single study on warfarin, the PPB rate was elevated. There were no data regarding PPB and usage of the newer anti-coagulant agents.. Usage of aspirin or NSAIDs does not increase risk of post-polypectomy bleeding. Clopidogrel and warfarin should be discontinued in the periprocedural period to prevent the occurrence of post-polypectomy bleeding.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Blood Coagulation Disorders; Colonic Polyps; Colonoscopy; Gastrointestinal Hemorrhage; Humans; Platelet Aggregation Inhibitors; Pyridines; Risk Factors; Warfarin

The bleeding risk after cold snare polypectomy in anticoagulated patients is not known.. To compare the bleeding risk after cold snare polypectomy or conventional polypectomy for small colorectal polyps in anticoagulated patients.. Prospective randomized controlled study.. Municipal hospital in Japan.. Anticoagulated patients with colorectal polyps up to 10 mm in diameter were enrolled. Patients were randomized to polypectomy with either cold snare technique (Cold group) or conventional polypectomy (Conventional group) without discontinuation of warfarin. The primary outcome measure was delayed bleeding (ie, requiring endoscopic intervention within 2 weeks after polypectomy). Secondary outcome measures were immediate bleeding and retrieval rate of colorectal polyps.. Seventy patients were randomized (159 polyps): Cold group (n = 35, 78 polyps) and Conventional group (n = 35; 81 polyps). The patients' demographic characteristics including international normalized ratio and the number, size, and shape of polyps removed were similar between the 2 techniques. Immediate bleeding during the procedure was more common with conventional polypectomy (23% [8/35]) compared with cold polypectomy (5.7% [2/35]) (P = .042). No delayed bleeding occurred in the Cold group, whereas 5 patients (14%) required endoscopic hemostasis in the Conventional group (P = .027). Complete polyp retrieval rates were identical (94% [73/78] vs 93% [75/81]). The presence of histologically demonstrated injured arteries in the submucosal layer with cold snare was significantly less than with conventional snare (22% vs 39%, P = .023).. Small sample size, single-center study.. Delayed bleeding requiring hemostasis occurred significantly less commonly after cold snare polypectomy than conventional polypectomy despite continuation of anticoagulants. Cold snare polypectomy is preferred for removal of small colorectal polyps in anticoagulated patients. (. NCT 01553565.).

Topics: Adenoma; Aged; Aged, 80 and over; Anticoagulants; Arteries; Blood Loss, Surgical; Colon; Colonic Polyps; Colonoscopy; Colorectal Neoplasms; Female; Hemostasis, Endoscopic; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Hemorrhage; Rectum; Vascular System Injuries; Warfarin

Topics: Anticoagulants; Colonic Polyps; Colonoscopy; Humans; Warfarin

There were limited data on the risk of post-polypectomy bleeding (PPB) in patients on direct oral anticoagulants (DOAC). We aimed to evaluate the PPB and thromboembolic risks among DOAC and warfarin users in a population-based cohort.. We performed a territory-wide retrospective cohort study involving patients in Hong Kong from 2012 to 2020. Patients who received an oral anticoagulant and had undergone colonoscopy with polypectomy were identified. Propensity-score models with inverse probability of treatment weighting were developed for the warfarin-DOAC and between-DOAC comparisons. The primary outcome was clinically significant delayed PPB, defined as repeat colonoscopy requiring haemostasis within 30 days. The secondary outcomes were 30-day blood transfusion requirement and new thromboembolic event.. Apixaban was associated with lower PPB risk than warfarin (adjusted HR (aHR) 0.39, 95% CI 0.24 to 0.63, p<0.001). Dabigatran (aHR 2.23, 95% CI 1.04 to 4.77, adjusted p (ap)=0.035) and rivaroxaban (aHR 2.72, 95% CI 1.35 to 5.48, ap=0.002) were associated with higher PPB risk than apixaban. In subgroup analysis, apixaban was associated with lower PPB risk in patients aged ≥70 years and patients with right-sided colonic polyps.For thromboembolic events, apixaban was associated with lower risk than warfarin (aHR 0.22, 95% CI 0.11 to 0.45, p<0.001). Dabigatran (aHR 2.60, 95% CI 1.06 to 6.41, ap=0.033) and rivaroxaban (aHR 2.96, 95% CI 1.19 to 7.37, ap =0.013) were associated with higher thromboembolic risk than apixaban.. Apixaban was associated with a significantly lower risk of PPB and thromboembolism than warfarin, dabigatran and rivaroxaban, particularly in older patients with right-sided polyps.

Topics: Aged; Anticoagulants; Blood Transfusion; Cohort Studies; Colonic Polyps; Colonoscopy; Dabigatran; Factor Xa Inhibitors; Gastrointestinal Hemorrhage; Hong Kong; Humans; Male; Postoperative Complications; Pyrazoles; Pyridones; Retrospective Studies; Risk Assessment; Rivaroxaban; Thromboembolism; Warfarin

Although there are international guidelines on the management of antithrombotic therapy in patients undergoing colonoscopic polypectomy, whether clinicians and patients follow these recommendations are largely unknown. We aimed to evaluate clinician adherence and patient compliance to periendoscopic management of antithrombotic therapy and their impact on clinical outcomes.. Consecutive patients on antithrombotic therapy scheduled for elective colonoscopy in a tertiary referral center were recruited prospectively. Demographic data, indications and periprocedural management of antithrombotic drugs, colonoscopy findings, postpolypectomy bleeding, and serious cardiovascular events were collected systematically. We used Joint Asian Pacific Association of Gastroenterology-Asian Pacific Society for Digestive Endoscopy Practice Guidelines 2018 and assumed clinicians should hold antithrombotics for polypectomy in all colonoscopy patients. Patient compliance was assessed by checking whether discontinuation and resumption of antithrombotic drugs were in accordance with clinician advice.. Between December 2017 and October 2019, there were 602 patients recruited who were on antithrombotic drugs undergoing colonoscopy with polypectomy. A total of 98.4%, 41.2%, and 40.0% of clinicians adhered to the guidelines for aspirin alone, clopidogrel alone, and dual-antiplatelet therapy, respectively. Adherence rates were 8.5% for warfarin and 5.2% for direct oral anticoagulants. Compliance to instructions for aspirin alone, clopidogrel alone, dual-antiplatelet therapy, warfarin, and direct oral anticoagulants were achieved in 74.8%, 41.2%, 0%, 36.2%, and 17.5% of patients, respectively. Clinician nonadherence to guidelines was a risk factor for delayed postpolypectomy bleeding (adjusted hazard ratio, 3.54; 95% CI, 1.46-8.58; P = .005), and serious cardiovascular events (hazard ratio, 15.63; 95% CI, 1.83-133.80; P = .012).. Physician adherence to the guideline and patient compliance, with the exception of aspirin, were poor and contributed to adverse clinical outcomes. ClinicalTrials.gov number: NCT03363061.

Topics: Anticoagulants; Colonic Polyps; Colonoscopy; Humans; Patient Compliance; Physicians; Platelet Aggregation Inhibitors; Warfarin

Postpolypectomy bleeding (PPB) is the most common adverse event after colorectal polypectomy. Use of anticoagulants is an important risk factor for PPB. This study aimed to evaluate PPB in patients receiving treatment with warfarin and direct oral anticoagulants (DOACs).. Between August 2017 and July 2019, 5449 patients with 12,601 polyps who underwent endoscopic snare resection of colorectal polyps were enrolled. Endoscopic snare resection was performed in patients receiving continuous warfarin (C-warfarin) and in patients who experienced 1 day cessation of (O-) of DOACs in accordance with the Japanese Gastroenterological Endoscopy Society guidelines.. The PPB rate in the group receiving anticoagulants was statistically higher than that in the group without anticoagulants (8.5% [33/387] vs 1.2% [63/5,062], respectively; P < .001). By multivariate logistic regression analysis, male gender (odds ratio [OR], 2.17; P = .007), warfarin (OR, 4.64; P < .001), DOACs (OR, 6.59; P < .001), and multipolyp removal (OR, 1.77; P = .007) were significant risk factors for PPB. PPB was observed in 9 and 21 patients in the C-warfarin and O-DOACs groups, respectively: C-warfarin (8.0% [9/113]), O-dabigatran (6.1% [2/33]), O-rivaroxaban (14.8% [9/61]), O-apixaban (9.8% [9/92]), and O-edoxaban (1.8% [1/56]). The PPB rate with the O-edoxaban group was significantly lower than that with the O-rivaroxaban group (P < .05).. Use of anticoagulant therapy was an independent risk factor for PPB. The rates of PPB in patients receiving C-warfarin and O-DOACs were also higher than those in patients not receiving anticoagulants. Edoxaban may be safe through short-term withdrawal in patients undergoing endoscopic snare resection of colorectal polyps.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Colonic Polyps; Dabigatran; Hemorrhage; Humans; Male; Pyridones; Rivaroxaban; Warfarin

The usage of direct oral anticoagulants (DOACs) to prevent and treat thromboembolic events is gradually increasing. We aimed to evaluate the outcomes of patients taking DOACs after polypectomy. We retrospectively reviewed 131 patients taking DOACs and 270 taking clopidogrel who underwent polypectomy between November 2010 and December 2017. The risk of delayed postpolypectomy bleeding (PPB) was evaluated and compared. A total of 989 polyps were removed (320 polyps in the DOAC and 669 polyps in the clopidogrel group). DOACs and clopidogrel were discontinued for 2.8 ± 1.7 days and 5.8 ± 2.5 days before polypectomy, respectively. DOACs and clopidogrel were restarted on 1.6 ± 2.9 days and 1.7 ± 1.1 days after polypectomy, respectively. According to per polyp analysis, delayed PPB rate was 1.6% in both groups (p = 0.924). Logistic regression analysis was performed after propensity score matching and revealed that DOACs did not increase the delayed PPB risk compared to clopidogrel (OR 0.929, 95% CI 0.436-1.975, p = 0.847). With the majority following the antithrombotic discontinuation guidelines, the incidence of delayed PPB was 3.1% in the patients taking DOACs. The delayed PPB risk was not greater in those taking DOACs than in those taking clopidogrel.

Topics: Administration, Oral; Aged; Anticoagulants; Clopidogrel; Colonic Polyps; Colonoscopy; Female; Gastrointestinal Hemorrhage; Hemorrhage; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Risk Factors; Thromboembolism; Ticlopidine; Warfarin

Newly published guidelines of the Japanese Gastroenterological Endoscopy Society (JGES) suggest to consider endoscopic procedures with high risk of bleeding without stopping warfarin and with stopping direct oral anticoagulants (DOACs) only on the day of the procedure. In this study, we aimed to test the validity of these recommendations.. We retrospectively reviewed medical records of 344 patients with anticoagulant therapy who underwent hot-snare polypectomy between January 2012 and October 2018. Patients (n = 132) with interruption of anticoagulants (3-7 days for warfarin and 2-3 days for DOACs before the procedure) and without heparin-bridging were excluded. Among the remaining 212 patients, the incidence of post-polypectomy bleeding was compared between the following 2 patient groups: patients who had interruption of anticoagulants with heparin-bridging (HB group, n = 139) and patients treated according to the new JGES guideline (FG group, n = 73).. The rate of post-polypectomy bleeding (PPB) in FG group (9.6%) was not significantly different from that in HB group (12.9%, p = 0.5). In subgroup analysis, the incidence of bleeding in patients with warfarin (12.2%) and with DOAC (6.3%) in FG group was not significantly different from corresponding figures in HB group (14.2%, 0%). In multivariate analysis, number of resected polyps was associated with PPB, but the administration of anticoagulants according to the new guidelines was not a significant risk factor for PPB (p = .98).. Our study affirms the recommendations of JGES for the management of anticoagulants in patients who undergo colonic polypectomy regarding post-polypectomy bleeding.

Topics: Administration, Oral; Aged; Anticoagulants; Colonic Polyps; Female; Gastrointestinal Hemorrhage; Humans; Incidence; Male; Multivariate Analysis; Risk Factors; Treatment Outcome; Warfarin

Heparin bridging therapy (HBT) is indeed related to a high frequency of bleeding after endoscopic mucosal resection (EMR). In this study, our aim was to investigate clinical impact of management of oral anticoagulants without HBT in bleeding after colonic EMR.. From data for patients who underwent consecutive colonic EMR, the relationships of patient factors and procedural factors with the risk of bleeding were analysed. Our management of antithrombotic agents was based on the shortest cessation as follows: the administration of warfarin was generally continued within the therapeutic range, and direct oral anticoagulants (DOACs) were not administered on the day of the procedure. We calculated bleeding risks after EMR in patients who used antithrombotic agents and evaluated whether perioperative management of anticoagulants without HBT was beneficial for bleeding.. A total of 1734 polyps in 825 EMRs were analysed. Bleeding occurred in 4.0% of the patients and 1.9% of the polyps. The odds ratios for bleeding using multivariate logistic regression analysis were 3.67 in patients who used anticoagulants and 4.95 in patients who used both anticoagulants and antiplatelet agents. In patients with one-day skip of DOACs, bleeding occurred in 6.5% of the polyps, and there were no significant differences in bleeding risk between HBT and continuous warfarin or one-day skip DOACs.. The use of oral anticoagulants was related to bleeding after colonic EMR, and perioperative management of oral anticoagulants based on the shortest cessation without HBT would be clinically acceptable.

Topics: Administration, Oral; Aged; Anticoagulants; Colonic Polyps; Drug Administration Schedule; Endoscopic Mucosal Resection; Female; Fibrinolytic Agents; Gastrointestinal Hemorrhage; Heparin; Humans; Japan; Male; Middle Aged; Perioperative Care; Platelet Aggregation Inhibitors; Retrospective Studies; Warfarin

Use of direct-acting oral anticoagulants (DOACs) is increasing, but little is known about the associated risks in patients undergoing colonoscopy with polypectomy. We aimed to determine the risk of post-polypectomy complications in patients prescribed DOACs.. We performed a retrospective analysis using Optum's de-identified Clinformatics Data Mart Database (2003-2016) (a de-identified administrative database from a large national insurance provider) to identify adults who underwent colonoscopy with polypectomy or endoscopic mucosal resection (EMR) from January 1, 2011, through December 31, 2015. We collected data from 11,504 patients prescribed antithrombotic agents (1590 DOAC, 3471 warfarin, and 6443 clopidogrel) and 599,983 patients not prescribed antithrombotics of interest (controls). We compared 30-day post-polypectomy complications, including gastrointestinal bleeding (GIB), cerebrovascular accident (CVA), myocardial infarction (MI), and hospital admissions, of patients prescribed DOACs, warfarin, or clopidogrel vs controls.. Post-polypectomy complications were uncommon but occurred in a significantly higher proportion of patients receiving any antithrombotic vs controls (P < .001). The percentage of patients in the DOAC group with GIB was 0.63% (95% CI, 0.3%-1.2%) vs 0.2% (95% CI, 0.2%-0.3%) in controls. The percentage of patients with CVA in the DOAC group was 0.06% (95% CI, 0.01%-0.35%) vs 0.04% (95% CI, 0.04%-0.05%) in controls. After we adjusted for bridge anticoagulation, EMR, Charlson comorbidity index (CCI), and CHADS. In our retrospective analysis of a large national dataset, we found that patients prescribed DOACs did not have significantly increased adjusted odds of post-polypectomy GIB, MI, CVA, or hospital admission. Bridge anticoagulation, higher CHADS

Topics: Aged; Anticoagulants; Case-Control Studies; Clopidogrel; Colonic Polyps; Colonoscopy; Endoscopic Mucosal Resection; Factor Xa Inhibitors; Female; Gastrointestinal Hemorrhage; Hospitalization; Humans; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Complications; Postoperative Hemorrhage; Retrospective Studies; Risk Factors; Stroke; Warfarin

Balancing the risks for thromboembolism and postpolypectomy bleeding in patients requiring anticoagulation and antiplatelet agents is challenging. We investigated the incidence and risk factors for postpolypectomy bleeding on anticoagulation, including heparin bridge and other antithrombotic therapy.. We performed a retrospective cohort and case control study at 2 tertiary-care medical centers from 2004 to 2012. Cases included male patients on antithrombotics with hematochezia after polypectomy. Nonbleeding controls were matched to cases 3 to 1 by antithrombotic type, study site, polypectomy technique, and year of procedure. Our outcomes were the incidence and risk factors for postpolypectomy bleeding.. There were 59 cases and 174 matched controls. Postpolypectomy bleeding occurred in 14.9% on bridge anticoagulation. This was significantly higher than the overall incidence of bleeding on antithrombotics at 1.19% (95% confidence interval, 0.91%-1.54%) (59/4923). We identified similarly low rates of bleeding in patients taking warfarin (0.66%), clopidogrel (0.84%), and aspirin (0.92%). Patients who bled tended to have larger polyps (13.9 vs 7.3 mm; P < .001) and more polyps ≥2 cm (41% vs 10%; P < .001). Bleeding risk was increased with restarting antithrombotics within 1 week postpolypectomy (odds ratio [OR] 4.50; P < .001), having polyps ≥2 cm (OR 5.94; P < .001), performing right-sided cautery (OR 2.61; P = .004), and having multiple large polyps (OR 2.92; P = .001). Among patients on warfarin, the presence of bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12.27; P = .0001).. We conclude that bridge anticoagulation is associated with a high incidence of postpolypectomy bleeding and is an independent risk factor for hemorrhage compared with patients taking warfarin alone. A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk.

Topics: Aged; Anticoagulants; Aspirin; Case-Control Studies; Clopidogrel; Colonic Polyps; Colonoscopy; Colorectal Neoplasms; Female; Gastrointestinal Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Incidence; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Retrospective Studies; Risk Factors; Thromboembolism; Ticlopidine; Time Factors; Warfarin

To verify the validity of the endoscopy guidelines for patients taking warfarin or direct oral anticoagulants (DOAC).. We collected data from 218 patients receiving oral anticoagulants (73 DOAC users, 145 warfarin users) and 218 patients not receiving any antithrombotics (age- and sex-matched controls) who underwent polypectomy. (1) We evaluated post-polypectomy bleeding (PPB) risk in patients receiving warfarin or DOAC compared with controls; (2) we assessed the risks of PPB and thromboembolism between three AC management methods: Discontinuing AC with heparin bridge (HPB) (endoscopy guideline recommendation), continuing AC, and discontinuing AC without HPB.. PPB rate was significantly higher in warfarin users and DOAC users compared with controls (13.7% and 13.7%. PPB risk was similar between patients taking warfarin and DOAC. Thromboembolism was observed in warfarin users only. The guideline recommendations for HPB should be re-considered.

Topics: Administration, Oral; Aged; Anticoagulants; Colonic Polyps; Colonoscopy; Female; Heparin; Humans; Japan; Male; Postoperative Hemorrhage; Practice Guidelines as Topic; Retrospective Studies; Risk Assessment; Thromboembolism; Warfarin

Few large studies have evaluated the adverse events associated with therapeutic colonoscopy for colorectal neoplasia, including bleeding and bowel perforation. Our aim was to investigate factors associated with these events, using a Japanese national inpatient database.. We extracted data from the nationwide Japan Diagnosis Procedure Combination database for patients who underwent therapeutic colonoscopy for colorectal neoplasia between 2013 and 2014. Therapeutic colonoscopy included endoscopic submucosal dissection (ESD), EMR, and polypectomy. Outcomes included bleeding, perforation, cerebro-cardiovascular events, and in-hospital death. A multivariable logistic regression model was used to evaluate factors associated with bleeding and bowel perforation.. We analyzed 345,546 patients, including 16,812 (4.9%) who underwent ESD, 219,848 (63.6%) who underwent EMR, and 108,886 (31.5%) who underwent polypectomy. The rates of bleeding, bowel perforation, cardiovascular events, cerebrovascular events, and death were 32.5, 0.47, 0.05, 0.88, and 1.32 per 1000 patients, respectively. In the multivariate analysis, a higher bleeding rate was associated with being male, comorbid diseases, ESD, tumor size ≥2 cm, and use of drugs including low-dose aspirin, thienopyridines, non-aspirin antiplatelet drugs, novel oral anticoagulants, warfarin, non-steroidal anti-inflammatory drugs (NSAIDs), and steroids. A higher bowel perforation rate was associated with being male, renal disease, ESD, tumor size ≥2 cm, and drugs including warfarin, NSAIDs, and steroids.. Although the incidence of adverse events after therapeutic colonoscopy was low, several patient-related factors were significantly associated with bleeding and bowel perforation.

Topics: Adult; Aged; Aged, 80 and over; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Cerebrovascular Disorders; Colonic Polyps; Colonoscopy; Colorectal Neoplasms; Comorbidity; Endoscopic Mucosal Resection; Female; Gastrointestinal Hemorrhage; Hospital Mortality; Humans; Incidence; Intestinal Perforation; Japan; Kidney Diseases; Male; Middle Aged; Platelet Aggregation Inhibitors; Retrospective Studies; Risk Factors; Sex Factors; Steroids; Tumor Burden; Warfarin

Managing antiplatelet and anticoagulant drugs before endoscopy may be challenging.. To assess whether the pre-endoscopic management of antiplatelet/anticoagulant drugs is adherent to current guidelines and the influence of patients' characteristics, referring physician's specialty, type of endoscopic procedure and therapeutic regimen on adherence.. Two hundred and twenty patients taking aspirin, thienopyridines or warfarin and scheduled for upper endoscopy (± biopsies), variceal band ligation, colonoscopy (± biopsies or polypectomy), were prospectively analyzed.. In 109 patients (49.5%) the management of antiplatelet/anticoagulant drugs was thoroughly compliant with guidelines. Neither demographic characteristics, nor in/outpatient status, nor type of endoscopic procedure, nor physician's specialty influenced the adherence but the therapeutic regimen had a significant impact (p < 0.0001) as compliance was less likely in patients on warfarin. Unwarranted drugs withholding was more frequent before colonoscopy than upper endoscopy (p = 0.0001). Warfarin was stopped longer than recommended more frequently than aspirin (p = 0.009). The International Normalized Ratio was properly checked before endoscopy in 47.7% of patients. Among the 55 patients who withheld warfarin, the decision about bridging to low molecular weight heparin was appropriate in 21 (38.2%).. Compliance with guidelines is low especially in the management of warfarin, both among gastroenterologists and other physicians.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Biopsy; Cohort Studies; Colonic Polyps; Colonoscopy; Endoscopy, Digestive System; Endoscopy, Gastrointestinal; Esophageal and Gastric Varices; Female; Gastroenterology; Guideline Adherence; Humans; Ligation; Male; Middle Aged; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Practice Patterns, Physicians'; Preoperative Care; Prospective Studies; Thienopyridines; Warfarin

Endoscopic procedures are commonly performed in patients taking antithrombotic agents.. To examine the correlation between the management of antithrombotic drugs for colonoscopic polypectomies and the published guidelines.. A structured survey delivered to gastroenterologists in 15 major Israeli hospitals and three central HMO clinics.. We collected 100 filled out surveys. Polypectomies on aspirin were performed by 78%. Most physicians did not perform polypectomies on clopidogrel. None of the physicians performed polypectomies on warfarin. Cessation of aspirin for ≥ 3 days post-polypectomy was recommended by 60%. Renewal of LMWH or warfarin was recommended ≥ 2 days post-polepectomy in 91% and 71%, respectively. The greatest variation in recommendations was found for clopidogrel, where the majority of gastroenterologists advised renewal after 1-2 days (38%). Years in practice and increasing colonoscopy volume work had no significant association with management of antithrombotic agents. Working in a HMO clinic was associated with lower rates of polypectomies on aspirin (P=0.036).. When the guidelines are clear, most gastroenterologists practice according to the existing recommendation. However, lack of prospective studies limits the ability to publish evidence-based recommendation and guidelines. We found that the practice of our cohort study varies in these situations.

Topics: Aspirin; Clopidogrel; Colonic Polyps; Colonoscopy; Fibrinolytic Agents; Gastroenterology; Guideline Adherence; Health Maintenance Organizations; Heparin, Low-Molecular-Weight; Hospitals; Humans; Israel; Logistic Models; Practice Guidelines as Topic; Practice Patterns, Physicians'; Surveys and Questionnaires; Ticlopidine; Warfarin

Topics: Aged; Aged, 80 and over; Anticoagulants; Colonic Polyps; Colonoscopy; Female; Follow-Up Studies; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Retrospective Studies; Time Factors; Warfarin

Topics: Aged; Anticoagulants; Clopidogrel; Colonic Polyps; Colonoscopy; Contraindications; Drug Administration Schedule; Guideline Adherence; Humans; Male; Practice Guidelines as Topic; Surveys and Questionnaires; Ticlopidine; Warfarin

Topics: Adenoma; Adenomatous Polyps; Anticoagulants; Aspirin; Coffee; Colonic Polyps; Colonoscopy; Colorectal Neoplasms; Female; Heart Failure; Humans; Male; Mortality; Platelet Aggregation Inhibitors; Warfarin

An increasing number of patients are treated with anticoagulation for many medical conditions. Our practice is to suspend warfarin 5-7 days, aspirin 3 days, and clopidogrel (Plavix) 7 days prior to colonoscopy that may require polypectomy. Generally, we accept an INR of ≤1.5 as safe. However, there are no published case series documenting when it is safe to resume these medications after polypectomy. Therefore, the management of anticoagulation after polypectomy varies. We sought to evaluate the safety of our practice with regard to anticoagulation and polypectomy.. We conducted a retrospective review of all patients over the age of 18 who underwent colonoscopy with polypectomy while on anticoagulation for various medical comorbidities at our institution over a 15-month period (July 2007 to September 2008). All morbidity and mortality that occurred for the first 3 weeks post-polypectomy was recorded. The Mann-Whitney test was performed using SPSS 15.5.. From July 2007 to September 2008, we performed 579 colonoscopies with polypectomy on patients who were on anticoagulation therapy during the study period. Seven (1.2%) patients presented to the Emergency Room or were hospitalized within 3 weeks after polypectomy for lower gastrointestinal bleeding. Distribution of anticoagulants was listed: 2 (28.6%) patients on warfarin, 4 (57.1%) on aspirin, and 1 (14.3%) on clopidogrel. Warfarin was held for, on average, 4 days pre-polypectomy and 1 day post-polypectomy. Aspirin was held, on average, 3 days both pre- and post-polypectomy. Clopidogrel was held, on average 6.5 days pre-polypectomy but restarted immediately post-polypectomy. No statistically significant difference was found between the number of days that anticoagulation was held pre- or post-polypectomy in individuals who did and did not bleed.. We found that our practice of resuming anticoagulation or antiplatelet agents (warfarin, aspirin, and clopidogrel) post-polypectomy was safe and did not prove to significantly affect the post-polypectomy rate of hemorrhage.

Topics: Anticoagulants; Aspirin; Clopidogrel; Colonic Polyps; Colonoscopy; Female; Gastrointestinal Hemorrhage; Humans; Platelet Aggregation Inhibitors; Postoperative Period; Retrospective Studies; Ticlopidine; Warfarin

To review our experience performing polypectomy in anticoagulated patients without interruption of anticoagulation.. Retrospective chart review at the Veterans Affairs Palo Alto Health Care System. Two hundred and twenty five polypectomies were performed in 123 patients. Patients followed a standardized protocol that included stopping warfarin for 36 h to avoid supratherapeutic anticoagulation from the bowel preparation. Patients with lesions larger than 1 cm were generally rescheduled for polypectomy off warfarin. Endoscopic clips were routinely applied prophylactically.. One patient (0.8%, 95% CI: 0.1%-4.5%) developed major post-polypectomy bleeding that required transfusion. Two others (1.6%, 95% CI: 0.5%-5.7%) had self-limited hematochezia at home and did not seek medical attention. The average polyp size was 5.1 +/- 2.2 mm.. Polypectomy can be performed in therapeutically anticoagulated patients with lesions up to 1 cm in size with an acceptable bleeding rate.

Topics: Aged; Aged, 80 and over; Anticoagulants; Colonic Polyps; Colonoscopy; Contraindications; Female; Humans; Male; Middle Aged; Retrospective Studies; Warfarin

To assess the effect of warfarin anticoagulation therapy (AC) on the incidence of colon bleeding after elective colonoscopy with polypectomy and to identify independent predictors of post-polypectomy colon bleeding.. This was a retrospective cohort analysis. Patients interrupting warfarin AC therapy for polypectomy (AC group) were matched on age (+/- 3 years) with up to two patients who underwent polypectomy but were not receiving AC (non-AC group). Data were extracted from electronic medical, pharmacy and laboratory claims and records and manual medical chart review. Incidence rates of colon bleeding requiring hospitalization, other gastrointestinal bleeding, thrombosis and death in the 30 days post-polypectomy were compared between groups. Multivariate regression techniques were used to identify independent predictors of post-polypectomy colon bleeding.. A total of 425 AC group patients were matched to 800 non-AC group patients. Post-polypectomy colon bleeding occurred more often in AC group patients (2.6% vs. 0.2%, P = 0.005). There were no differences in the rates of other outcomes (P > 0.05). Independent predictors of colon bleeding included AC group status [adjusted odds ratio (AOR) = 11.6; 95% confidence interval (CI) = 2.3-57.3], number of polyps removed (AOR = 1.2; 95% CI = 1.1-1.4) and male gender (AOR = 9.2, 95% CI = 1.1-74.9).. The incidence of post-polypectomy colon bleeding was higher in patients receiving AC even although warfarin was interrupted for the procedure. Independent predictors of colon bleeding were identified as: receiving AC, removal of multiple polyps and male gender. Our findings suggest that additional methods to reduce the likelihood of post-polypectomy colon bleeding in AC patients should be investigated.

Topics: Aged; Aged, 80 and over; Anticoagulants; Cohort Studies; Colonic Polyps; Colonoscopy; Female; Hemorrhage; Humans; Incidence; Male; Middle Aged; Predictive Value of Tests; Retrospective Studies; Sex Factors; Thrombosis; Warfarin

According to current practice guidelines for performance of colonoscopy in patients requiring long-term anticoagulation, polypectomy is considered a high-risk procedure for which anticoagulation must temporarily be discontinued. However, these guidelines are based on expert opinion, and the bleeding risk after polypectomy in anticoagulated patients is not known.. Measure the risk of postpolypectomy bleeding in patients who undergo colonoscopic polypectomy while anticoagulated.. Retrospective review of patients who underwent polypectomy without discontinuation of anticoagulation.. Veterans Administration Palo Alto Health Care System.. Forty-one polypectomies were performed in 21 patients. All patients had been receiving long-term anticoagulation with warfarin; the average international normalized ratio was 2.3 (range 1.4-4.9; normal 0.9-1.2). To prevent supratherapeutic anticoagulation, warfarin was withheld for 36 hours before the procedure while the patients were on a liquid diet. The average polyp size was 5 mm (range 3-10 mm).. All patients underwent polypectomy followed immediately by prophylactic application of one or two clips to prevent bleeding.. Rate of postpolypectomy bleeding.. There were no episodes of postpolypectomy bleeding. The 95% CI for the risk of bleeding was 0% to 8.6% when analyzed per polypectomy and 0% to 15% when analyzed per patient.. Small single-center retrospective study.. Our experience suggests that small polyps can be removed with a very low risk of bleeding when clips are applied immediately after polypectomy. If these results can be confirmed in a larger multicenter study, our protocol may become an alternative to withholding anticoagulation in patients at high risk of thrombosis.

Topics: Anticoagulants; Colonic Polyps; Colonoscopy; Comorbidity; Hemostasis, Endoscopic; Humans; Postoperative Hemorrhage; Retrospective Studies; Thromboembolism; Warfarin

Anticoagulants and antiplatelet agents commonly are used to treat patients with cardiovascular and cerebrovascular diseases. Data on the safety of the use of these drugs before colonoscopic polypectomy are scanty.. An audit was conducted for a 2-year period of consecutive patients undergoing colonoscopy and polypectomy. Patient demographics, site and size of polyps, and the use of anticoagulants and antiplatelet agents were documented from a hospital on-line database. Bleeding episodes were classified as immediate or delayed and were graded as mild, moderate, or severe. Risk factors associated with postendoscopy bleeding were analyzed by multivariate logistic regression analysis.. A total of 5593 cases were reviewed. Polypectomy was performed in 1657 patients. There were 37 cases of polypectomy-associated bleeding (2.2%); bleeding was immediate in 32 and delayed in 5. Multivariate analysis showed that warfarin use, after adjustment for the effects of each of the other factors, was an independent risk factor for bleeding, with an odds ratio 13.37: 95% CI[4.10, 43.65]. Age; the location and size of polyp; and the use of aspirin, non-steroidal anti-inflammatory drugs, and other antiplatelet agents were not associated with a higher risk of polypectomy-associated bleeding.. The use of antiplatelet agents during polypectomy was not associated with an increase in post-polypectomy bleeding. In contrast, treatment with warfarin should be discontinued, because this was associated with a significant increase in post-polypectomy bleeding.

Topics: Aged; Anticoagulants; Clopidogrel; Colonic Polyps; Colonoscopy; Female; Gastrointestinal Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Risk Factors; Ticlopidine; Warfarin

A 63-year-old woman presents to discuss periprocedure anticoagulation management. She has been on oral warfarin with an international normalized ratio between 2 and 3 for the past 3 months because of an idiopathic left popliteal vein thrombosis. A colonic polyp was identified during her purely diagnostic colonoscopy performed as part of her age- and gender-appropriate cancer screening. Immediate repeat colonoscopy with polypectomy is recommended. The clinician is asked to provide periprocedural anticoagulation recommendations.

Topics: Anticoagulants; Colonic Polyps; Colonoscopy; Drug Administration Schedule; Female; Humans; Middle Aged; Popliteal Vein; Preoperative Care; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Colonic Polyps; Heparin; Humans; Postoperative Hemorrhage; Time Factors; Warfarin

In December 1997, the American Society of Gastrointestinal Endoscopy (ASGE) issued guidelines regarding periendoscopic management of patients who take anticoagulants. They recommended that physicians substitute heparin for warfarin in their patients who have highly thrombotic conditions (e.g., a mechanical valve in the mitral position), and who will undergo high-risk procedures (e.g., polypectomy). The purpose of this study was to assess whether patient outcomes and anticoagulant management changed after the publication of the 1997 guidelines.. We collected utilization data on all 104 patients at the Veterans Affairs Palo Alto Health Care System who were taking chronic warfarin therapy and who underwent endoscopic procedures during the study period (1996-1999). These patients underwent 99 colonoscopies, 63 upper endoscopies, and nine endoscopic retrograde cholangiopancreatographies. According to the ASGE guidelines, 18 of these patients had highly thrombotic conditions, whereas the remaining 86 patients had relatively low thrombotic conditions. We calculated their costs for intravenous or subcutaneous heparin therapy from the perspective of society. We followed-up all patients for 3 months, to determine the incidence of thrombotic and hemorrhagic outcomes.. No patient suffered a thromboembolism or a hemorrhage; thus, the adverse-event rate (95% confidence interval) was 0% (0-3%). As recommended by the ASGE guidelines, all five (100%) patients who had highly thrombotic conditions had heparin substituted for warfarin before undergoing high-risk procedures. This strategy was also followed in 44 (27%) of the 166 procedures in other patients: 16 high-risk procedures in low-risk patients, and 28 low-risk procedures (in 20 low-thrombotic patients and in eight high-thrombotic patients). There was no significant difference between the management of any patients before and after the publication of the guidelines. The average cost per course of heparin therapy (typically 2 days intravenous heparin preprocedure, and 3 days heparin administered subcutaneously postendoscopy) was $1684. In all, 44 (90%) of 49 courses of heparin substituted for warfarin therapy were not recommended by the guidelines.. Patients treated by the ASGE guidelines had the same 0% rate of thrombosis as patients who received periendoscopic heparin outside of the guidelines. Following the ASGE guidelines in all patients would have reduced the use of heparin therapy by 90%, for a net savings of $74,100.

Topics: Aged; Anticoagulants; Colonic Polyps; Costs and Cost Analysis; Endoscopy, Digestive System; Heparin; Humans; Male; Practice Guidelines as Topic; Retrospective Studies; Risk Factors; Thrombosis; Treatment Outcome; Warfarin