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If you take a blood thinner or a drug like aspirin or clopidogrel, tell the team well before an endoscopy or colonoscopy. For a simple look with small biopsies most people carry on, perhaps missing one morning dose. For riskier procedures, such as removing polyps, the team will say which drug to stop, for how long, and when to restart. Never stop a heart or clot medicine on your own.
BSG/ESGE 2021 (GRADE) sorts procedures by bleeding risk (low: diagnostic endoscopy with or without biopsy, stenting, EUS without sampling; high: polypectomy, endoscopic resection, ERCP with sphincterotomy, EUS-guided sampling, PEG and others) and patients by thrombotic risk. Everyone is told both the thrombotic risk of stopping and the bleeding risk of continuing (strong, low). Aspirin continues for all procedures except ampullectomy (strong, low). Low-risk procedures: continue P2Y12 inhibitors, single or dual (strong, low); continue warfarin with an INR within range in the week before (weak, low); omit the morning DOAC dose (weak, low). High-risk procedures, low thrombotic risk: stop P2Y12 inhibitors 7 days before (strong, moderate) keeping aspirin; stop warfarin 5 days before with INR below 1.5 (strong, high); last DOAC dose 3 days before (strong, low), 5 days for dabigatran with clearance 30 to 50 ml/min. High thrombotic risk: keep aspirin and discuss P2Y12 interruption with an interventional cardiologist (strong, high); bridge warfarin with LMWH (strong, low). Restart within 2 to 3 days (strong, moderate). ACG-CAG 2022 (GRADE, all conditional) differs: it suggests continuing warfarin for elective endoscopy generally and suggests against heparin bridging when warfarin is held, suggests interrupting DOACs rather than continuing them, suggests not interrupting aspirin for secondary prevention, interrupting the P2Y12 inhibitor but not aspirin on dual therapy, and could not recommend on resumption timing.
Why: Whether to stop depends on both: how likely the procedure is to bleed, and how dangerous a pause is for the heart or a clot.
“We recommend that all patients are advised of the thrombotic risks of discontinuing antiplatelets or anticoagulants, as well as the haemorrhagic risks of continuing therapy (strong recommendation, low quality evidence).”
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · strong recommendation, low quality evidence
Why: Aspirin adds little bleeding risk to endoscopy, and stopping it can trigger a heart attack or stroke.
“For all endoscopic procedures we recommend continuing aspirin (strong recommendation, low quality evidence), with the exception of ampullectomy (weak recommendation, low quality evidence).”
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · strong recommendation, low quality evidence
Why: Ordinary biopsies rarely bleed enough to matter.
“For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (DAPT) (strong recommendation, low quality evidence).”
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · strong recommendation, low quality evidence
Why: Warfarin can be kept going for simple procedures as long as the blood is not thinner than intended.
“It should be ensured that the international normalised ratio (INR) does not exceed the therapeutic range in the week prior to the procedure (strong recommendation, low quality evidence).”
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · strong recommendation, low quality evidence
Why: Skipping one dose lowers the drug level at the time of the biopsy without leaving a long gap in protection.
“For low-risk endoscopic procedures we suggest omitting the morning dose of direct oral anticoagulants (DOACs) on the day of the procedure (weak recommendation, low quality evidence).”
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · weak recommendation, low quality evidence
Why: These drugs affect platelets for about a week, and procedures such as polyp removal can bleed.
“For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists 7 days before the procedure (strong recommendation, moderate quality evidence).”
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · strong recommendation, moderate quality evidence
Why: Warfarin takes several days to wear off; the INR confirms it has.
“For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing warfarin for 5 days before the procedure (strong recommendation, high quality evidence).”
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · strong recommendation, high quality evidence
Why: These drugs clear in a few days, faster or slower depending on the kidneys.
“For high-risk endoscopic procedures in patients on DOACs, we recommend that the last dose of DOACs be taken 3 days before the procedure (strong recommendation, low quality evidence).”
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · strong recommendation, low quality evidence
Why: For them a pause in treatment can cause a stent to block or a clot to form, which may be worse than bleeding.
“For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a consultant interventional cardiologist about the risk/benefit of discontinuing P2Y12 receptor antagonists (strong recommendation, high quality evidence).”
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · strong recommendation, high quality evidence
Why: The longer the pause, the higher the risk of a clot; the timing balances that against bleeding from the site.
“If antiplatelet or anticoagulant therapy is discontinued, then we recommend this should be resumed up to 2–3 days after the procedure depending on the perceived haemorrhagic and thrombotic risks (strong recommendation, moderate quality evidence).”
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · strong recommendation, moderate quality evidence
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
BSG/ESGE 2021 for UK and European practice: classify the procedure's bleeding risk and the patient's thrombotic risk; continue aspirin; for low-risk procedures continue P2Y12 inhibitors and warfarin (INR in range) and omit the morning DOAC dose; for high-risk procedures at low thrombotic risk stop P2Y12 inhibitors 7 days, warfarin 5 days (INR below 1.5) and DOACs 3 days before; at high thrombotic risk involve cardiology and bridge warfarin; restart within 2 to 3 days. The North American ACG-CAG guideline (2022) disagrees on two points, both on conditional recommendations: it suggests continuing warfarin for elective endoscopy rather than interrupting it, and suggests against heparin bridging when warfarin is held. Both agree on continuing aspirin for secondary prevention and on interrupting DOACs, rather than continuing them, for procedures that need it.
BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 · ACG and CAG (Abraham et al., American Journal of Gastroenterology) 2022
Where it differs: Suggests continuing warfarin for elective endoscopic procedures rather than interrupting it for 1 to 7 days, and, where it is held, suggests against heparin bridging; it excludes patients at high thromboembolic risk, for whom elective procedures should be deferred.
Evidence: Conditional recommendations: very low certainty for continuing warfarin, low certainty against bridging. BSG/ESGE itself notes studies showing more post-polypectomy bleeding with LMWH bridging without fewer clots, while still advising bridging for those at high thromboembolic risk.
ACG and CAG (Abraham et al., American Journal of Gastroenterology) 2022 · BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021
Where it differs: For patients on a P2Y12 inhibitor alone, ACG-CAG could not recommend for or against interruption, and it could not recommend a time to resume warfarin, a DOAC or a P2Y12 inhibitor (same day versus 1 to 7 days). BSG/ESGE gives 7 days off before high-risk procedures and restart within 2 to 3 days.
Evidence: ACG-CAG found one randomised trial and one cohort study for P2Y12 interruption and no comparative studies of resumption timing.
ACG and CAG (Abraham et al., American Journal of Gastroenterology) 2022 · BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021
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.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Bridge warfarin with LMWH for high-risk procedures in people at high thrombotic risk “For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend that warfarin should be temporarily discontinued and substituted with low molecular weight heparin (LMWH) (strong recommendation, low quality evidence).” | strong recommendation, low quality evidence | BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 |
| Check INR below 1.5 before a high-risk procedure after stopping warfarin “Check INR prior to the procedure to ensure <1.5 (strong recommendation, low quality evidence).” | strong recommendation, low quality evidence | BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 |
| Dabigatran with creatinine clearance 30 to 50 ml/min: last dose 5 days before “For patients on dabigatran with a creatinine clearance (CrCl) (or estimated glomerular filtration rate (eGFR)) of 30–50 mL/min we recommend that the last dose be taken 5 days prior to the procedure (strong recommendation, low quality evidence).” | strong recommendation, low quality evidence | BSG and ESGE (Veitch et al., Gut; also published in Endoscopy, 10.1055/a-1547-2282) 2021 |
| Continue warfarin rather than interrupt it for elective endoscopy (US and Canada) “For patients on warfarin undergoing elective/planned endoscopic GI procedures, we suggest warfarin be continued, as opposed to temporarily interrupted (1–7 days) (conditional recommendation, very low certainty of evidence).” | conditional recommendation, very low certainty of evidence | ACG and CAG (Abraham et al., American Journal of Gastroenterology) 2022 |
| No heparin bridging when warfarin is held (US and Canada) “For patients on warfarin, who hold warfarin in the periprocedural period for elective/planned endoscopic GI procedures, we suggest against bridging anticoagulation (conditional recommendation, low certainty of evidence).” | conditional recommendation, low certainty of evidence | ACG and CAG (Abraham et al., American Journal of Gastroenterology) 2022 |
| Interrupt DOACs rather than continue them (US and Canada) “For patients on direct oral anticoagulants (DOACs) who are undergoing elective/planned endoscopic GI procedures, we suggest temporarily interrupting DOACs rather than continuing DOACs (conditional recommendation, very low certainty of evidence).” | conditional recommendation, very low certainty of evidence | ACG and CAG (Abraham et al., American Journal of Gastroenterology) 2022 |
| Do not interrupt aspirin for secondary prevention (US and Canada) “For patients on ASA 81–325 mg/d (monotherapy) for secondary cardiovascular prevention, we suggest against interruption of ASA (conditional recommendation, very low certainty of evidence).” | conditional recommendation, very low certainty of evidence | ACG and CAG (Abraham et al., American Journal of Gastroenterology) 2022 |
Shares Venous thromboembolism (VTE), Cancer-associated thrombosis prevention and treatment, Aspirin.
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Shares Venous thromboembolism (VTE), Cancer-associated thrombosis prevention and treatment.
Shares Venous thromboembolism (VTE), Cancer-associated thrombosis prevention and treatment.
Shares Venous thromboembolism (VTE), Cancer-associated thrombosis prevention and treatment.
Shares Venous thromboembolism (VTE), Cancer-associated thrombosis prevention and treatment.
Shares Venous thromboembolism (VTE), Cancer-associated thrombosis prevention and treatment.
Shares Venous thromboembolism (VTE), Cancer-associated thrombosis prevention and treatment.