{"entity":{"id":"idea-pu-lmwh-plan-around-endoscopy","kind":"idea","name":"Guidance on treatment-dose low molecular weight heparin for a cancer clot around endoscopy","aka":[],"tldr":"Many people with cancer inject a blood thinner called low molecular weight heparin every day to treat a clot, especially those with bowel or stomach cancers, who are also the people most often needing an endoscopy. The main endoscopy guideline only covers this drug as a short bridge for people coming off warfarin, so teams have no agreed plan for when to stop and restart it.","summary":"The gap. The BSG and ESGE guideline on endoscopy in people on antiplatelet or anticoagulant therapy (2021) covers low molecular weight heparin (LMWH) as a bridge while warfarin is stopped: start a therapeutic dose two days after stopping warfarin, give the last dose at least 24 hours before the procedure, restart it the day after. It gives no separate advice for people on long-term treatment-dose LMWH for cancer-associated thrombosis.\n\nWhy it matters for cancer. NICE NG158 (2020) recommends considering a direct oral anticoagulant for people with active cancer and a confirmed clot, and LMWH alone or with a vitamin K antagonist if a DOAC is unsuitable (1.3.17, 1.3.18). Its committee found a higher rate of gastrointestinal and genitourinary bleeding with DOACs than with LMWH in active cancer and agreed DOACs may be unsuitable \"such as people with gastrointestinal malignancies\". So the people steered towards LMWH are disproportionately those having endoscopies for diagnosis, stenting or bleeding.\n\nWhat is unknown. The timing of the last dose before high-risk procedures, whether a reduced dose should be given in the days around them, and when to restart after polypectomy or sphincterotomy are left to local practice; no study OnCo found compares approaches in this group.","asOf":"2026-11-11","links":[{"label":"Veitch et al., Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guideline update (Gut 2021)","url":"https://doi.org/10.1136/gutjnl-2021-325184"},{"label":"NICE guideline NG158, Venous thromboembolic diseases: diagnosis, management and thrombophilia testing, recommendations 1.3.15 to 1.3.18 and rationale (2020)","url":"https://www.nice.org.uk/guidance/ng158/chapter/Recommendations"}],"tags":["protocol-upgrade","upgrade:untested","evidence:insufficient"],"related":[],"cancers":["colorectal","gastric","pancreatic"],"sections":["supportive-care"],"technologies":["cancer-associated-thrombosis"],"targets":[],"drugs":[],"companies":[],"institutions":["nice"],"pathways":[],"terms":["endoscopy"],"trials":[],"people":[],"bottlenecks":["b-care-fragmentation","b-toxicity-qol"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"A stated periprocedural plan for therapeutic LMWH in cancer-associated thrombosis (last dose and restart timed by procedure bleeding risk and clot recency) reduces both post-procedure bleeding and early recurrent clots compared with ad hoc local practice.","rationale":"The drug, the population and the procedures are common together; the guideline that governs endoscopy names LMWH only as a bridge, and the guideline that governs the clot steers gastrointestinal cancers towards LMWH.","test":"A prospective multicentre registry of people on therapeutic LMWH for cancer-associated thrombosis undergoing endoscopy, recording timing and outcomes, to inform a consensus statement and then a pragmatic comparison of two timing rules for high-risk procedures.","maturity":"speculative","actor":"clinic","cost":"small","horizonYears":3},"route":"/ideas/idea-pu-lmwh-plan-around-endoscopy/","neighbours":{"cancer":[{"id":"colorectal","kind":"cancer","name":"Colorectal cancer","route":"/cancers/colorectal/"},{"id":"gastric","kind":"cancer","name":"Gastric & gastro-oesophageal junction cancer","route":"/cancers/gastric/"},{"id":"pancreatic","kind":"cancer","name":"Pancreatic ductal adenocarcinoma","route":"/cancers/pancreatic/"}],"section":[{"id":"supportive-care","kind":"section","name":"Supportive Care & Survivorship","route":"/fronts/supportive-care/"}],"technology":[{"id":"cancer-associated-thrombosis","kind":"technology","name":"Cancer-associated thrombosis prevention and treatment","route":"/technologies/cancer-associated-thrombosis/"}],"institution":[{"id":"nice","kind":"institution","name":"National Institute for Health and Care Excellence","route":"/institutions/nice/"}],"term":[{"id":"endoscopy","kind":"term","name":"Endoscopy (EGD, EUS, ERCP)","route":"/terms/endoscopy/"}],"bottleneck":[{"id":"b-care-fragmentation","kind":"bottleneck","name":"Fragmented care and guideline gaps","route":"/bottlenecks/b-care-fragmentation/"},{"id":"b-toxicity-qol","kind":"bottleneck","name":"Toxicity and quality of life are undervalued","route":"/bottlenecks/b-toxicity-qol/"}],"protocol":[{"id":"anticoagulants-and-antiplatelets-before-endoscopy","kind":"protocol","name":"Anticoagulants and antiplatelet drugs around elective endoscopy and endoscopic biopsy","route":"/protocols/anticoagulants-and-antiplatelets-before-endoscopy/"}]}}