David R. Lichtenstein, MD, FACG

David R. Lichtenstein, MD, FACG Managing the GI Bleeder on Anticoagulants David R. Lichtenstein, MD, FACG Director of Endoscopy Boston University Me...
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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 XIIXIIa XIXIa IXIXa

Tissue factor released by injured cells Tissue thromboplastin (III)

VIIVIIIa XXa Takes place on the surface of activated platelets

Va

Prothrombin (II)(IIa) Thrombin

VIIaVII

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) FibrinogenFibrin (Ia) Fibrin stabilizing factor XIIIXIIIa 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

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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

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