Endoscopic Procedures in Patients under Clopidogrel or Dual Antiplatelet Therapy: A Survey among German Gastroenterologists and Current Guidelines

Abstract

Background: Because of the higher risk of bleeding, guidelines recommend cessation of clopidogrel seven days prior to high-risk endoscopic procedures. However, premature cessation of clopidogrel may lead to catastrophic cardiovascular sequelae due to stent thrombosis. We aimed to assess the current clinical practice among German gastroenterologists regarding endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy.

Methods: A 10-item questionnaire on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy was sent by e-mail to all 220 members of the ALGK.

Results: 73 (33 %) chief gastroenterologists returned completed questionnaires, 35 (48 %) of whom conduct high-volume endoscopic units performing more than 4000 procedures per annum. 62 (85 %) endoscopic units perform endoscopic biopsies under clopidogrel alone, while just in 30 (41 %) departments biopsies are carried out under dual antiplatelet therapy. In 36 (49 %) GI-units endoscopic polypectomy under clopidogrel monotherapy is performed, in contrast to only 4 (5.5 %) in the case of combined antiplatelet therapy. However, in emergency situations more than 60 % of all participants do perform endoscopic sphincterotomy in patients under clopidogrel/dual antiplatelet therapy. Percutaneous endoscopic gastrostomy is carried out in 32 endoscopic units (44 %) under clopidogrel monotherapy, but only in 4 (5.5 %) under dual antiplatelet therapy.

Conclusion: Current guidelines on endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy are mainly based on expert opinion and therefore, backed by only weak evidence. Our survey shows that in this setting the clinical decision making takes place on an individual basis, as there are no data to support the recommendations of the present guidelines.

Zusammenfassung

Hintergrund: Aufgrund des erhöhten Blutungsrisikos empfehlen die aktuellen Leitlinien die Beendigung einer Clopidogrel-Therapie mind. 7 Tage vor high-risk endoskopischen Prozeduren. Allerdings kann die vorzeitige Beendigung einer Clopidogrel-Therapie aufgrund von Stentthrombosen katastrophale kardiovaskuläre Folgen nach sich ziehen. Ziel dieser Arbeit ist, das aktuelle Vorgehen unter deutschen Gastroenterologen bez. endoskopischer Prozeduren unter Clopidogrel/dualer Thrombozytenaggregationshemmung zu evaluieren.

Methoden: Ein Fragebogen bestehend aus 10 Fragen über endoskopische Prozeduren unter Clopidogrel/dualer Thrombozytenaggregationshemmung wurde an alle 220 Mitglieder der ALGK per E-Mail verschickt.

Ergebnisse: 73 (33 %) leitende Gastroenterologen sendeten den ausgefüllten Fragebogen zurück. 35 (48 %) der an unserer Umfrage beteiligten Gastroenterologen leiten große endoskopische Einheiten, die über 4000 endoskopische Prozeduren jährlich erbringen. 62 (85 %) der endoskopischen Einheiten führen endoskopische Biopsien unter Clopidogrel durch, während nur 30 (41 %) Kliniken endoskopische Biopsien unter dualer Thrombozytenaggregationshemmung vornehmen. In 36 (49 %) Kliniken werden endoskopische Polypektomien unter Clopidogrel-Monotherapie vorgenommen, im Gegensatz zu nur 4 (5,5 %) Einheiten, die diese Prozedur unter dualer Thrombozytenaggregationshemmung durchführen. In Notfallsituationen hingegen werden in 60 % aller beteiligten Kliniken endoskopische Sphinkterotomien unter Clopidogrel/dualer Thrombozytenaggregationshemmung durchgeführt. Eine perkutane endoskopische Gastrostomie wird in 32 endoskopischen Einheiten (44 %) unter Clopidogrel-Monotherapie vorgenommen, allerdings nur in 4 (5,5 %) Kliniken unter dualer Thrombozytenaggregationshemmung durchgeführt.

Schlussfolgerung: Die aktuellen Leitlinien über endoskopische Prozeduren unter Clopidogrel/dualer Thrombozytenaggregationshemmung basieren überwiegend auf Expertenmeinungen und werden deshalb nur von einer schwachen Evidenz untermauert. Unsere Umfrage zeigt, dass in diesem Setting die klinische Entscheidung auf individueller Basis getroffen wird, da es keine Daten gibt, die die aktuellen Leitlinienempfehlungen unterstützen.

Schlüsselwörter

Thrombozytenaggregationshemmung - Clopidogrel - endoskopischen Prozeduren - Fragebogen

Key words

dual antiplatelet therapy - clopidogrel - endoscopic procedures - questionnaire

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