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Timing of Resumption of Anticoagulation After Polypectomy and Frequency of Post-procedural Complications: A Post-hoc Analysis

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An Editorial to this article was published on 20 January 2022

Abstract

Background

Optimal timing for anticoagulation resumption after polypectomy is unclear. We explored the association between timing of anticoagulation resumption and occurrence of delayed post-polypectomy bleeding (PPB) and thromboembolic (TE) events.

Methods

We performed a post-hoc analysis of patients in an earlier study whose anticoagulants were interrupted for polypectomy. We compared rates of clinically important delayed PPB and TE events in relationship to timing of anticoagulant resumption. Late resumption was defined as > 2 days after polypectomy.

Results

Among 437 patients, 351 had early and 86 late resumption. Compared to early resumers, late resumers had greater polypectomy complexity. PPB rate was higher (but not significantly) in the late versus early resumers (2.3% vs. 0.9%, 1.47% greater, 95% CI [− 2.58 to 5.52], p = 0.26). TE events were more frequent in late versus early resumers [0% vs. 1.2% at 30 days, 0% vs. 2.3%, 95% CI 0.3–8, (p = 0.04) at 90 days]. On multivariate analysis, timing of restarting anticoagulation was not a significant predictor of PPB (OR 0.97, 95% CI 0.61–1.44, p = 0.897). Significant predictors were number of polyps ≥ 1 cm (OR 4.14, 95% CI 1.27–13.66, p = 0.014) and use of fulguration (OR 11.43, 95% CI 1.35–80.80, p = 0.014).

Conclusions

Physicians delayed anticoagulation resumption more commonly after complex polypectomies. The timing of restarting anticoagulation was not a significant risk factor for PPB and late resumers had significantly higher rates of TE events within 90 days. Considering the potentially catastrophic consequences of TE events and the generally benign outcome of PPBs, clinicians should be cautious about delaying resumption of anticoagulation after polypectomy.

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Abbreviations

DVT:

Deep vein thrombosis

DOAC:

Direct acting oral anticoagulant

GI:

Gastrointestinal

NSAID:

Non-steroidal anti-inflammatory drug

PPB:

post-polypectomy bleeding

PE:

Pulmonary embolus

TE:

Thromboembolic

References

  1. Zauber AG, Winawer SJ, O’Brien MJ et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366:687–696.

    Article  CAS  Google Scholar 

  2. Feagins LA. Colonoscopy, polypectomy, and the risk of bleeding. Med Clin North Am. 2019;103:125–135.

    Article  Google Scholar 

  3. Abraham NS. Antiplatelets, anticoagulants, and colonoscopic polypectomy. Gastrointest Endosc. 2020;91:257–265.

    Article  Google Scholar 

  4. Committee ASoP, Acosta RD, Abraham NS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83:3–16.

  5. Timothy SK, Hicks TC, Opelka FG, Timmcke AE, Beck DE. Colonoscopy in the patient requiring anticoagulation. Dis Colon Rectum. 2001;44:1845–8; discussion, 8–9.

  6. Feagins LA, Smith AD, Kim D, et al. Efficacy of prophylactic hemoclips in prevention of delayed post-polypectomy bleeding in patients with large colonic polyps. Gastroenterology. 2019;157:967–76 e1.

  7. Lip GY, Frison L, Halperin JL, Lane DA. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol. 2011;57:173–180.

    Article  CAS  Google Scholar 

  8. Lip GY, Frison L, Halperin JL, Lane DA. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke. 2010;41:2731–2738.

    Article  CAS  Google Scholar 

  9. Lin D, Soetikno RM, McQuaid K et al. Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications. Gastrointest Endosc. 2018;87:1106–1113.

    Article  Google Scholar 

  10. Sawhney MS, Salfiti N, Nelson DB, Lederle FA, Bond JH. Risk factors for severe delayed postpolypectomy bleeding. Endoscopy. 2008;40:115–119.

    Article  CAS  Google Scholar 

  11. Kelly-Hayes M, Beiser A, Kase CS, Scaramucci A, D’Agostino RB, Wolf PA. The influence of gender and age on disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis. 2003;12:119–126.

    Article  Google Scholar 

  12. Derbyshire E, Hungin P, Nickerson C, Rutter MD. Post-polypectomy bleeding in the English National Health Service Bowel Cancer Screening Programme. Endoscopy 2017;49:899–908.

    Article  Google Scholar 

  13. Garcia D, Alexander JH, Wallentin L et al. Management and clinical outcomes in patients treated with apixaban vs warfarin undergoing procedures. Blood. 2014;124:3692–3698.

    Article  CAS  Google Scholar 

  14. Healey JS, Eikelboom J, Douketis J et al. Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) randomized trial. Circulation. 2012;126:343–348.

    Article  CAS  Google Scholar 

  15. Sherwood MW, Douketis JD, Patel MR et al. Outcomes of temporary interruption of rivaroxaban compared with warfarin in patients with nonvalvular atrial fibrillation: results from the rivaroxaban once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation (ROCKET AF). Circulation. 2014;129:1850–1859.

    Article  CAS  Google Scholar 

  16. Witt DM, Delate T, McCool KH et al. Incidence and predictors of bleeding or thrombosis after polypectomy in patients receiving and not receiving anticoagulation therapy. J Thromb Haemost. 2009;7:1982–1989.

    Article  CAS  Google Scholar 

  17. Lau LH, Guo CL, Yip TC, et al. Risks of post-colonoscopic polypectomy bleeding and thromboembolism with warfarin and direct oral anticoagulants: a population-based analysis. Gut. 2021. https://doi.org/10.1136/gutjnl-2020-323600

    Article  Google Scholar 

  18. Feagins LA, Iqbal R, Harford WV et al. Low rate of postpolypectomy bleeding among patients who continue thienopyridine therapy during colonoscopy. Clin Gastroenterol Hepatol. 2013;11:1325–1332.

    Article  Google Scholar 

  19. Lukens FJ, Gomez V, Patel MK, Achem SR, Picco MF. Colonoscopic postpolypectomy bleeding in patients that resumed warfarin: not as frequent as we may think. J Clin Gastroenterol. 2013;47:290–292.

    Article  Google Scholar 

  20. Yu JX, Oliver M, Lin J, et al. Patients prescribed direct-acting oral anticoagulants have low risk of postpolypectomy complications. Clin Gastroenterol Hepatol. 2019;17:2000–7 e3.

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Funding

Funding was provided by VA MERIT (Grant No. 5I01CX00815).

Author information

Author notes

  1. Benjamin R. Chebaa and Brandon Burgman have contributed equally to this work.

Authors and Affiliations

  1. Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Health Discovery Building, 1601 Trinity Street, Building B, Austin, TX, 78712, USA

    Benjamin R. Chebaa & Linda A. Feagins

  2. Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, The University of Texas at Austin, Austin, TX, USA

    Brandon Burgman & S. Stephen Yi

  3. Department of Medicine, VA North Texas Healthcare System, Dallas, TX, USA

    Andrew D. Smith, Daniel S. Kim & Kerry B. Dunbar

  4. Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA

    Tisha Lunsford

  5. Department of Medicine, South Texas Veterans Healthcare System, San Antonio, TX, USA

    Miriam Mara & Leon Kundrotas

  6. Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA

    Kerry B. Dunbar

  7. Department of Medicine and Center for Esophageal Diseases, Baylor University Medical Center, Dallas, TX, USA

    Stuart J. Spechler

Authors
  1. Benjamin R. Chebaa
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Contributions

Benjamin Chebaa, BA—patient recruitment; data collection; analysis of the data Brandon Burgman, BS—statistical analysis Andrew D. Smith, BA—patient recruitment; data collection; analysis of the data Daniel Kim, BA—patient recruitment; data collection; analysis of the data Tisha Lunsford, MD—patient recruitment; data collection Miriam Mara, BS—patient recruitment; data collection; analysis of the data Leon Kundrotas, MD—patient recruitment; data collection Kerry B. Dunbar, MD, PhD—patient recruitment; data collection; critical revision of the article for important intellectual content Stuart J. Spechler, MD—patient recruitment; data collection; critical revision of the article for important intellectual content S. Stephen Yi, PhD—statistical analysis and verification of statistical methodology Linda A. Feagins, MD—conception and design; analysis and interpretation of the data; drafting of the article; final approval of the article.

Corresponding author

Correspondence to Linda A. Feagins.

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An editorial commenting on this article is available at https://doi.org/10.1007/s10620-021-07349-9.

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Chebaa, B.R., Burgman, B., Smith, A.D. et al. Timing of Resumption of Anticoagulation After Polypectomy and Frequency of Post-procedural Complications: A Post-hoc Analysis. Dig Dis Sci 67, 3210–3219 (2022). https://doi.org/10.1007/s10620-021-07341-3

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