Current status of gastrointestinal endoscopy in antithrombotic drug users: Questionnaire-based survey in the Hokuriku region of Japan

The “Gastrointestinal Endoscopic Clinical Guidelines for Antithrombotic Drug Users,” published by the Japan Gastroenterological Endoscopy Society in 2012, considers the risk of thromboembolic complications accompanying the discontinuation of antithrombotic drugs, as well as the risk of bleeding accompanying endoscopic treatment. However, future prospective studies are necessary because each situation including the antithrombotic drug that the patient is taking, type of endoscopic treatment and the patients status, has a low evidence level. Because of the variable bleeding risk of each situation, it is difficult to determine whether to manage them similarly. To confirm the present condition of digestive endoscopy in antithrombotic drug users, here we investigated the status of acceptance of the current guidelines and the present situation of antithrombotic drug withdrawal during endoscopic biopsy or treatment at hospitals and clinics in the Hokuriku region. We sent a questionnaire to board-certified endoscopist members of the Japan Gastroenterological Endoscopy Society about the current situation of digestive endoscopy in antithrombotic drug users at their institutions. Endoscopists at 78 institutions (48 hospitals, 30 clinics) answered the questionnaire; overall, 79.2% of hospitals and 48.3% of clinics followed the guidelines (p=0.007). Among the endoscopists who performed endoscopic biopsies on antithrombotic drug users, 71.4% reported performing endoscopic biopsies on patients who continued taking aspirin; 62.3% on patients who continued taking thienopyridine derivatives; 54.5% on patients who continued taking warfarin; 57.1% on patients who continued taking direct oral anticoagulants (DOAC); and 14.3-20.8% on patients who continued taking various combinations of these drugs. The rate of endoscopists performing endoscopic treatment in patients with both a high bleeding risk and high thromboembolism risk due to continuation of antithrombotic drug use during endoscopy varied widely depending on the type of endoscopic treatment: of the respondents, 17.5-78.4% reported performing endoscopic treatment on patients who continued taking aspirin; 0.0-78.4% on patients who continued taking thienopyridine derivatives; 0.0-64.9% on patients who continued taking warfarin; and 0.0-64.9% on patients who continued taking DOAC. In conclusion, endoscopists in clinics were more cautious than those in hospitals with regard to performing endoscopies in antithrombotic drug users. Among the endoscopic treatments with high bleeding risk, a large gap exists in the decision of antithrombotic drug withdrawal. It is necessary to accumulate further evidence so that all endoscopists can be convinced of the safety of endoscopy in patients who continue to take antithrombotic drugs during endoscopic procedures.