Safety of uninterrupted anticoagulation in the setting of routine colonoscopy

Data are lacking regarding the optimal periprocedural management of anticoagulation before an elective endoscopy. The aim of this study was to compare the safety of interrupted versus uninterrupted anticoagulation among patients undergoing routine colonoscopy.

A comparative effectiveness study was performed among patients aged 45 to 75 years. These patients were taking warfarin or a direct oral anticoagulant and underwent outpatient elective colonoscopy between January 1, 2016, and December 31, 2022, in a large integrated health care system comprising 13 gastroenterology groups in Southern California. One of the high-volume medical centers initiated an uninterrupted anticoagulation protocol on March 20, 2019. An interrupted time series and comparative cohort analysis was used to compare 30-day postprocedural bleeding and thromboembolic risk in patients managed with interrupted versus uninterrupted anticoagulation both within the high-volume medical center and across other medical centers. Multivariable logistic regression was performed with adjusted covariates, including patient age, sex, race/ethnicity, Elixhauser comorbidity index, CHA₂DS₂-VASc score, anticoagulation type, indication, and intervention (ie, biopsy, snare).

A total of 20,284 patients met eligibility criteria, and 13,011 were included in analyses. The mean ages ranged from 66.3 to 66.6 years, and the majority of patients were male (63%) and white (56%). In the single-center interrupted time series, there was no difference in pre-implementation versus postimplementation of the uninterrupted anticoagulation protocol for either postprocedural bleeding (crude rate interrupted vs uninterrupted, 2.52% vs 1.51%; P = .06) or thromboembolic event (.78% vs .91%; P = .72). In the comparative cohort analysis (n = 1654 at the uninterrupted anticoagulation protocol center; n = 10,204 from the 12 other medical service areas), there was no difference in postprocedural bleeding (1.5% vs 1.1%; P = .25) or thromboembolic event (.8% vs .7%; P = .61). Of note, all postprocedural bleeds within the uninterrupted anticoagulation protocol center occurred in patients who had anticoagulant agents discontinued before colonoscopy. The findings were consistent in multivariable analysis. Snare polypectomy (odds ratio, 7.92; 95% CI, 4.84-12.97) and black race (odds ratio, 1.77; 95% CI, 1.08-2.91) were associated with postprocedural bleeding while an Elixhauser comorbidity index score ≥6 (odds ratio, 2.45; 95% CI, 1.09-5.51) was associated with a thromboembolic event.

Continuous or interrupted anticoagulation both seem to be acceptable approaches for routine colonoscopy in the setting of a systematic protocol for anticoagulation management.