Appendix C. Holding Antithrombotics for Outpatient Endoscopy Procedures How to Use this Appendix This appendix provides additional details regarding how UW Digestive Health Center (DHC) providers categorize the bleeding risk of specific outpatient endoscopic procedures, and their corresponding recommendations for stopping oral antithrombotics prior to the procedure. This appendix is meant to facilitate communication of recommendations between DHC providers and providers managing the patient’s antithrombotic therapy. Outpatient Endoscopic Procedure Bleeding Risk Categories4,10 MINIMAL BLEED RISK 30 day bleed risk: ~0% LOW/MODERATE BLEED RISK 30 day bleed risk: 0-2% HIGH BLEED RISK 30 day bleed risk: > 2% • Video capsule endoscopy • Argon plasma coagulation (APC) • Balloon dilation of luminal stenoses • Colonoscopy +/- biopsy • Enteral stent deployment • Esophagogastroduodenoscopy (EGD) +/- biopsy • Flexible sigmoidoscopy +/- biopsy • Marking (including clipping, electrocoagulation, tattooing) • Push enteroscopy and diagnostic balloon-assisted enteroscopy • Ampullary resection • Colonic polyp resectiona • Cystogastrostomy • Endoscopic hemostasis (excluding argon plasma coagulation) • Endoscopic mucosal resection (EMR)/ endoscopic submucosal dissection (ESD) • Endoscopic retrograde cholangiopancreatography (ERCP)b • Endoscopic ultrasound (EUS) with fine needle aspiration (FNA)c • Laser ablation and coagulation • Percutaneous endoscopic gastrotomy (PEG) placement • Percutaneous endoscopic jejunostomy (PEJ) placement • Peroral endoscopic myotomy (POEM) • Pneumatic or bougie dilation for achalasia or esophageal strictures • Radiofrequency ablation • Therapeutic balloon-assisted enteroscopy • Treatment of varices (including variceal band ligation) • Tumor ablation aPolypectomy < 1 cm may be considered low/moderate bleed risk; polyp size may not be known prior to procedure bERCP without sphincterotomy may be considered low/moderate bleed risk cEUS without FNA may be considered low/moderate bleed risk Step 1. Identify the bleeding risk category of the patient’s procedure Step 2. Identify the recommendation for stopping the antithrombotic prior to the procedure Step 3. The provider managing the antithrombotic therapy should determine whether they agree with the DHC recommendations for stopping antithrombotics prior to the procedure, based on their knowledge of the patient’s thromboembolic risk and past medical history • If Yes  please confirm instructions with the patient or their caregiver • If No (or if further discussion is needed)  please contact DHC at 608-890-5000 or (for UW Health providers) via Health Link In Basket: DHC ENDOSCOPY CLINICAL ALL Step 4. Decisions about restarting antithrombotic therapy after the procedure should be made by the provider managing the antithrombotic therapy; DHC providers may provide updated post-procedure instructions, based on what occurred during the procedure Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 05/2023 Effective 5/18/2023. Contact CCKM@uwhealth.org for previous versions When to Stop Oral Antithrombotics Prior to Procedure4,5 • For minimal bleed risk procedures, antithrombotics may be continued uninterrupted • For low/moderate bleed risk and high bleed risk procedures, see recommendations below • This table is not all-inclusive; for more information, see Step 2 of the full guideline Antithrombotic Medication Patient-Specific Criteria Low/Moderate Bleed Risk Procedure High Bleed Risk Procedure Warfarin (Coumadin) INR 2.0-3.5 Stop 5 days prior INR > 3.5 Stop 6 or more days prior Apixaban (Eliquis) Stop 1 day prior Stop 2 days prior Dabigatran (Pradaxa) CrCl ≥ 50 ml/min Stop 1 day prior Stop 2 days prior CrCl < 50 ml/min Stop 2 days prior Stop 4 days prior Edoxaban (Savaysa) Stop 1 day prior Stop 2 days prior Rivaroxaban (Xarelto) Stop 1 day prior Stop 2 days prior Aspirin (ASA) Continue ASA uninterrupted Cilostazol (Pletal) Stop 1 to 2 days prior Clopidogrel (Plavix) Stop 5 days priord Prasugrel (Effient) Stop 7 days priord Ticagrelor (Brilinta) Stop 5 days priord d For patients taking dual antiplatelet therapy (DAPT) with stents in place, ANY interruption in antiplatelets should be coordinated between the proceduralist, anesthesiologist (if applicable), and the prescribing provider (e.g., cardiologist, neurosurgeon, vascular surgeon); elective procedures should be delayed at least 30 days after bare metal stent and at least 6 months after drug-eluting stent 1 day = all doses on the calendar day prior to the procedure Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 05/2023 Effective 5/18/2023. Contact CCKM@uwhealth.org for previous versions Appendix C. Holding Antithrombotics for Outpatient Endoscopy Procedures