Bleeding risk after cold snare polypectomy is reduced when direct-acting oral anticoagulants (DOACs) are withheld only on the day of the procedure rather than continuing use of these agents, data from a new study suggest.
Findings of the study, led by Atsushi Morita, MD, of the Digestive Disease Center, Showa Inan General Hospital in Komagane, Japan, were published in Gastrointestinal Endoscopy.
This prospective, observational single-center study enrolled two consecutive groups of patients receiving antithrombotic medications who were undergoing cold snare polypectomy of colorectal polyps of 10 mm or less.
All colonoscopies were performed by endoscopists who each perform more than 500 endoscopies a year.
During period 1 of the study (2017 and 2018), DOACs were continued, even on the day of polypectomy (DOAC continued group); during period 2 (2019 and 2020), DOACs were withheld only on the day of the procedure (DOAC withheld group).
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The primary outcome was the frequency of delayed bleeding requiring endoscopic treatment within 2 weeks after cold snare polypectomy. Among the secondary outcomes were immediate bleeding and the number of hemostatic clips used.
Clinical features were similar between the two groups. The first group included 204 patients, 34% of whom were female (average age, 75 years); the second group included 264 patients, 34% of whom were female (average age, 74 years). The number of cold snare polypectomies was similar between the groups (47 vs. 66, P = .55), as was the average number of polyps per patient (0.72 vs. 0.70, P = .76).
Delayed bleeding after cold snare polypectomy occurred in 4 out of 47 (8.5%) participants in the continued DOAC group versus 0 out of 66 (0%) participants in the DOAC-withheld group (P < .001). There was similar improvement in immediate postpolypectomy bleeding (secondary outcome) between the two groups.
Immediate bleeding after endoscopy lasting more than 30 seconds occurred about four times as often in continued DOAC group versus the DOAC withheld group (12 out of 47 [25.5%] participants vs. 4 out of 66 [6.1%] participants; P < .008).
Polyps measuring up to 10 mm (excluding tiny hyperplastic polyps in the rectum and distal sigmoid colon), were removed using dedicated cold snares measuring 0.30 mm in diameter.
“This result is consistent with the best practice recommendation of short interruptions of DOACs based on the patient’s creatinine clearance before all polypectomy techniques, including cold snare polypectomy,” the authors wrote.
Countries’ guidelines differ
Guidelines from American Society for Gastrointestinal Endoscopy, the authors noted, currently recommend stopping DOACs before polypectomy, including cold snare procedures, and restarting them only after hemostasis has been achieved. Moreover, since there is no way for a clinician to predict polyp size, the U.S. guidelines further recommend holding warfarin for 5 days and DOACs for 2-3 days before colonoscopy.
In contrast to the U.S. guidelines, the Japanese Gastroenterological Endoscopy Society guidelines suggest clinicians withhold DOACs only on the day of the procedure.
“This policy of withholding DOACs only on the day of colonoscopy should be considered for routine clinical practice,” the authors wrote.
Dr. Rajesh N. Keswani
Rajesh N. Keswani, MD, associate professor of medicine in gastroenterology and hepatology at Northwestern University, Chicago, said in an interview it is difficult to draw firm conclusions from this paper because of its study design but added the authors “appear to have delineated a preferred method for managing DOACs prior to colonoscopy.”
He further noted that most polyps encountered during colonoscopy are less than 10 mm and can be safely managed with cold snare polypectomy.
“The management of DOACs prior to colonoscopy is variable,” Dr. Keswani said, “but ranges from cessation of DOACs multiple days prior to colonoscopy versus uninterrupted use of DOACs throughout the colonoscopy period.”
“The authors suggest that holding DOACs on the day of colonoscopy is the optimal balance between minimizing thromboembolic risk and postpolypectomy bleeding. While this data will need to be validated in larger samples, this provides some guidance to colonoscopists tasked with managing DOACs prior to colonoscopy,” Dr. Keswani said.
Limitations of the study included the small number of patients who received DOACs, conduction of the study at a single hospital in Japan, and the definition of immediate bleeding, which differs based on study design.
No commercial funding or conflicts of interest were reported. Dr. Keswani is a consultant for Boston Scientific and Neptune Medical and receives research support from Virgo.
This article was updated March 24, 2022.