David R. Lichtenstein, MD, FACG
Managing the GI Bleeder on Anticoagulants
David R. Lichtenstein, MD, FACG Director of Endoscopy Boston University Medical Center Email:
[email protected] Web: www.bmc.org/ www.bmc.org/digestivedisorders digestivedisorders
Learning Objectives Understand risk of GI bleeding and thromboembolic risk when taking and withholding antithrombotics • Antiplatelet agents (aspirin, thienopyridines) • Anticoagulants (warfarin and NOACs) • TOAT ((T Triple Oral Antithrombotic Therapy ) Antithrombotic management in the bleeding patient •
When to stop and start
•
How and when to reverse
ACG 2015 Boston Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
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David R. Lichtenstein, MD, FACG
Antithrombotics in Endoscopy: Current Societal Guidelines ASGE Guideline: Anderson MA, BenBen-Menachem T, Gan SI, Appalaneni V, Banerjee S, Cash BD, Fisher L, Harrison ME, Fanelli RD, Fuakami N, Ikenberry SO, Jain R, Kahan K, Krinsky ML, Lichtenstein DR, Shen B, Strohmeyer L, Baron T, Dominitz JA. Management of Antithrombotic Agents for Endoscopic Procedures. Procedures. Gastrointest Endosc 2009;70:10602009;70:1060-70 70.. ACG Guideline: Management of anticoagulation before and after gastrointestinal endoscopy.. Am J Gastroenterol 2009;3085endoscopy 2009;3085-3097. BSG Guideline: Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. procedures. Gut 2008;57:13222008;57:1322-1329
Case Scenario 65 year old man arrives for his colonoscopy to have a 3cm flat adenoma of the cecum removed. PMH: MI with PCI and BMS 5 months ago on ASA 81mg and clopidogrel 75 mg daily. Chronic nonnon-valvular afib on dabigatran 150mg BID for stroke prevention. He is treated with insulin for diabetes and metoprolol both for hypertension and rate control. He has no prior history of stroke or heart failure. Only other med is pantoprazole for NSAID prophylaxis. He states that no one told him to hold his “blood thinners” for the procedure. What should you do now? A. Proceed with the colonoscopy B. Transfuse 2 units FFP and then do colonoscopy C. Reschedule colonoscopy and hold dabigatran and clopidogrel D. Reschedule colonoscopy and bridge with LMWH
ACG 2015 Boston Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
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David R. Lichtenstein, MD, FACG
• Timing of withholding • Bridge? • When to restart?
PeriPeri-Procedural Antithrombotic Decisions and AEs: The Balancing Act
Endoscopy-induced Endoscopybleeding on antithrombotic agent
Risk of thromboembolic events if hold antithrombotic agent
Anticoagulation for Elective Colonoscopy: Factors Drug
Procedure Risk of Bleeding (High vs. Low)
ACG 2015 Boston Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
Thromboembolic Risk (High vs. Low)
Recommended Action
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PROPAGATION
Injury to blood vessel Contact activation XIIXIIa XIXIa IXIXa
Tissue factor released by injured cells Tissue thromboplastin (III)
VIIVIIIa XXa Takes place on the surface of activated platelets
Va
Prothrombin (II)(IIa) Thrombin
VIIaVII
xtrinsic System Ex
INITIATION
Intrinsic System
David R. Lichtenstein, MD, FACG
Direct factor Xa inhibitors: • Rivaroxaban (Xarelto) Xarelto) • Apixaban (Eliquis) Eliquis) • Edoxaban (Savaysa) Savaysa) Direct thrombin inhibitors: • Dabigatran (Pradaxa) • Bi Bivalirudin li di (Angiomax A i Angiomax) ) • Lepirudin (Refludan) Refludan) • Argatroban (Acova) Acova)
(I) FibrinogenFibrin (Ia) Fibrin stabilizing factor XIIIXIIIa Stable fibrin clot, fibrin strands crosslinked
NOACs: Comparison of Pharmacologic and Clinical Characteristics to Warfarin
Desai J et al. Gastrointest Endosc 2013;78:227 2013;78:227--39
ACG 2015 Boston Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
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David R. Lichtenstein, MD, FACG
Polyps Found in Anticoagulated Patients: What Should I Do Now? Resect or Repeat? Study design
Colonoscopy and Polypectomy (bleeds)
Risk
Polyp size of bleeders
Hui, 2004
Case control (warfarin w/in 1 week of colon)
1,657 pts (37 bleeds w/4 on warfarin)
AOR 13.37 P1cm)**
ERCP without sphincterotomy
Pneumatic or bougie dilation
EUS without FNA
Endoscopic hemostasis
Enteroscopy & diagnostic balloonassisted enteroscopy
Treatment of varices
Capsule Endoscopy Enteral stent deployment
Biliary or pancreatic sphincterotomy
Tumor ablation by any technique placement* PEG p EUS with FNA* Cystgastrostomy* Therapeutic balloon-assisted enteroscopy*
**not ASGE or ACG guideline
ACG 2015 Boston Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
*bleeding may be inaccessible or uncontrollable by endoscopic means
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David R. Lichtenstein, MD, FACG
Anticoagulation for Elective Colonoscopy Drug
Procedure Risk (Bleeding)
Thromboembolic Risk
Continue
Low
Anticoagulant (warfarin or NOAC)
Recommended Action
Low
Interrupt
Hig h
Bridge?
High
Nonvalvular Afib: Afib: CHADS2 and CHA2DS2-VASc Risk Factor
Score
Congestive i heart h f il failure
1
Hypertension
1
Age≥75 y
12
Diabetes mellitus
1
Stroke/TIA/TE
2
Vascular disease (arterial-prior MI, PAD, aortic plaque)
1
Age 65-74 y
1
Sex Category (female gender RF only if ≥ 65 yrs)
1
Lip GY et al. Chest 2010; 137:263137:263-72
ACG 2015 Boston Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
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David R. Lichtenstein, MD, FACG
CHADS2 and CHA2DS2-VASc (Our Patient) Risk Factor
Score
Congestive i heart h f il failure
1
Hypertension
1
Age≥75 y
2
Diabetes mellitus
1
Stroke/TIA/TE
2
Vascular disease (arterial-prior MI, PAD, aortic plaque)
1
Age 65-74 y
1
Sex Category (female gender RF only if ≥ 65 yrs)
1
Lip GY et al. Chest 2010; 137:263137:263-72
Risk Stratification for Perioperative Thromboembolism: A Guide to Bridging Anticoagulation Thromboembolic Risk Category
Atrial Fibrillation
Mechanical Heart Valve
• CVA/TIA w/in 3 mos • Mechanical mitral Very High Annual Risk>10% • Rheumatic valvular dz valve
Venous Thromboembolism (VTE) • Recent VTE (6-12 mo after insertion DES
Continue ASA
Case Scenario 65 year old man arrives for his colonoscopy to have a 3cm flat adenoma of the cecum removed. PMH: MI with PCI and BMS 5 months ago on ASA 81mg and clopidogrel 75 mg daily. Chronic nonnon-valvular afib on dabigatran 150mg BID for stroke prevention. He is treated with insulin for diabetes and metoprolol both for hypertension and rate control. He has no prior history of stroke or heart failure. Only other med is pantoprazole for NSAID prophylaxis. He states that no one told him to hold his “blood thinners” for the procedure. What should you do now? A. Proceed with the colonoscopy B. Transfuse 2 units FFP and then do colonoscopy C. Reschedule colonoscopy and hold dabigatran and clopidogrel D. Reschedule colonoscopy and bridge with LMWH
ACG 2015 Boston Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
11
David R. Lichtenstein, MD, FACG
Postpolypectomy Bleeding: Case Scenario What is the CV risk of withholding antithrombotics tith b ti for f the th colonoscopy l and d polypectomy?
Invasive Procedure or Surgery and Interruption of NOAC Data from RCTs 30 day event rates (%) 30-day Studies
RE-LY dabigatran
ROCKET-AF
warfarin rivaroxaban
ARISTOTLE
warfarin apixaban
warfarin
CVA or Systemic Embolism
0.5%
0.5%
0.3%
0.4%
0.4%
0.6%
Major bleed
5.1%
4.6%
1.0%
0.8%
1.6%
1.9%
Healey et al. Circulation 2012 Sherwood et al. Circulation 2014 Garcia et al. Blood 2014
ACG 2015 Boston Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
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David R. Lichtenstein, MD, FACG
Case Scenario (cont’d) The colonoscopy is rescheduled for the following week Clopidogrel is held for 5 days and dabigatran for 2 days He returns wellwell-prepped and the polyp is removed with EMR technique using saline/indigo carmine and snare electrocautery APC is used to ablate residual adenoma at the resection margin Dabigatran is restarted the following evening
Case Scenario (cont’d) 6 days later you get a late night call from the patient’s ti t’ wife if • She reports her husband just had several large bloody bowel movements and near syncope • You instruct her to call for an ambulance to bring him to the emergency department
ACG 2015 Boston Regional Postgraduate Course Copyright 2015 American College of Gastroenterology
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David R. Lichtenstein, MD, FACG
Postpolypectomy Bleeding: Case Study Why did this patient bleed ?
Greater Bleeding with “Long-Term” DAT Study design
Patient #
Duration
Major Bleeding Results
CURE NEJM (2001)
RCT DAT v. ASA NSTEMI-UA
12,562
3-12 months
All:3.7%v.2.7% P=0.001 GI:1.3% v. 0.7% RR 1.7
ACTIVE NEJM (2009)
RCT DAT v. ASA Afib
7,554
43 months
GI: 1.1% v. 0.5%/yr RR 1.96 [95% CI,1.46-2.63, p