Management of patients with antiplatelet and anticoagulation...
Transcript of Management of patients with antiplatelet and anticoagulation...
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Management of patients with antiplatelet and
anticoagulation before and after endoscopy
IM R3 고영선 IM1 pf. 민양원
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Guidelines..
1. 내시경 검사 또는 시술 종류에 따른 출혈 위험성
2. 환자의 기저질환에 따른 혈전 또는 색전의 위험성
3. 사용하고 있는 약제의 종류에 따라
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Procedure risk for bleeding
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Risk of thrombosis
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Antiplatelet agents
• For all endoscopic procedures : continuing aspirin
– Exception : ESD, large colonic EMR (>2cm), upper GI EMR, ampullectomy
• For high-risk endoscopic procedures
– Low thrombotic risk : P2Y12 receptor antagonists(clopidogrel) 5일전 중단
dual antiplatelet 치료 중엔 aspirin만 유지
– High thrombotic risk : aspirin 유지, P2Y12 receptor antagonists는
risk/benefit 을 고려하여 순환기 내과 의견 문의
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Aspirin
• Be safe in colonoscopic polypectomy and endoscopic sphincterotomy
• ESD, large(>20mm) colonic EMR : increased risk of hemorrhage
• upper GI EMR : high risk of hemorrhage
• Secondary prevention 으로 aspirin 복용하는 경우 primary prevention 으로 복용하는 환자보다 aspirin 중단 시 thrombotic risk 증가
– Cardiovascular or cerebrovascular event의 risk가 3배로 증가
– 70% 는 aspirin 중단 7-10일 이내 발생
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Clopidogrel
• The interlinked processes of platelet deposition, adherence, and aggregation are
central to the initiation of the process of thrombus formation in the arterial
system.
• antiplatelet action of clopidogrel is irreversible and platelet function has been
demonstrated to return to normal 5–7days after withdrawal of clopidogrel, based
on the regenerative production of clopidogrel-naive platelets
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Prasugrel and ticagrelor
• Newer, more potent and more rapidly acting agents than clopidogrel
• Prasugrel : thienopyridine, like clopidogrel
• Ticagrelor : different class agent, reversible
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Ischaemic heart disease and coronary artery stents
• To prevent stent thrombosis DAPT
– Drug-eluting stent(DES) : 12 mo
– Bare metal stent : 1 mo
Lifetime aspirin should be prescribed
• The risk of stent thrombosis increases after 5 days without antiplatelet therapy
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Recommendations for DAPT
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Anticoagulant
• Warfarin : 5일간 중단한 경우 93% 에서 INR 1.5 이하로 감소
• The absolute risk of an embolic event in patients whose anticoagulation is
interrupted for 4 to 7 days is approximately 1%.
• Warfarin 중단 시 4-7일 이내 반드시 재복용 시작
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Bridging therapy
• UFH IV
– half-life 60-90min, 중단 3-4 시간 후 anticoagulant effect 사라짐
– 시술 2-6 시간 내 restart
• LMWH(enoxaparin, dalteparin) SC
– 시술 48 시간 후 restart (2012 ACCP guidelines)
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Bridging therapy - indication
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Discontinuing warfarin for gastric ESD
3 2 1 0 -1 -2 -3 -4
Skip warfarin
Enoxaparin 1mg/kg
(outpatient, if possible)
Restart warfarin
Gastric ESD
Discharge
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Direct oral anticoagulants • Direct thrombin inh. (Dabigatran)
• Direct factor Xa inh. (Rivaroxaban, apixaban, edoxaban)
• For low-risk endoscopic procedures : 시술 당일 아침에만 중단
– 개인차가 있으나 복용 후 2-6시간에 peak level을 갖기 때문에 아침에 skip 하면 trough level 에서 biopsy sample이 가능함
• For high-risk endoscopic procedures
: 적어도 시술 48시간 전에 중단
: dabigatran : CCr 30-50mL/min 은 72시간 전에 중단
: 복용 후 3시간 이내 therapeutic dose 에 도달하기 때문에 시술 24-48시간 후에 재복용 시작
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• VKA 와 비교하여 overall risk of major hemorrhage (특히 intracranial bleeding) 50% 감소
• Dabigatran, rivaroxaban
: warfarin 과 비교하여 GI bleeding incidence 가 증가
• Bridging therapy : bleeding event 증가, thromboembolic event 에는 차이 없음.
• Triple antithrombotic therapy
: endoscopoy 에 대한 data 없음. 내시경이 꼭 필요한 경우 순환기 내과, 신경과 등 협진 필요
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Management of bleeding patients treated with DOACs
• Not severe bleeding : 일시적 중단
• Severe bleeding (resuscitation intervention 필요한 경우)
: 마지막 DOACs 복용시간 확인, CCr 고려하여 반감기 계산
: Protamine sulphate, vit K : no effect
: tranexamic acid : would be reasonable in some patients
: prothrombin complex concentrate (PCC) : life-threatening bleeding 있
는 경우
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감사합니다