Effect and outcomes of the ASGE guidelines on the periendoscopic management of patients who take anticoagulants

OBJECTIVE: In December 1997, the American Society of Gastrointestinal Endos copy (ASGE) issued guidelines regarding periendoscopic management of patien ts who take anticoagulants. They recommended that physicians substitute hep arin for warfarin in their patients who have highly thrombotic conditions ( e.g., a mechanical valve in the mitral position), and who will undergo high -risk procedures (e.g., polypectomy). The purpose of this study was to asse ss whether patient outcomes and anticoagulant management changed after the publication of the 1997 guidelines. METHODS: We collected utilization data on all 104 patients at the Veterans Affairs Pale Alto Health Care System who were taking chronic warfarin thera py and who underwent endoscopic procedures during the study period (1996-19 99). These patients underwent 99 colonoscopies, 63 upper endoscopies, and n ine endoscopic retrograde cholangiopancreatographies. According to the ASGE guidelines, 18 of these patients had highly thrombotic conditions, whereas the remaining 86 patients had relatively low thrombotic conditions. We cal culated their costs for intravenous or subcutaneous heparin therapy from th e perspective of society. We followed-up all patients for 3 months, to dete rmine the incidence of thrombotic and hemorrhagic outcomes. RESULTS: No patient suffered a thromboembolism or a hemorrhage; thus, the a dverse-event rate (95% confidence interval) was 0% (0-3%). As recommended b y the ASGE guidelines, all five (100%) patients who had highly thrombotic c onditions had heparin substituted for warfarin before undergoing high-risk procedures. This strategy was also followed in 44 (27%) of the 166 procedur es in other patients: 16 high-risk procedures in low-risk patients, and 28 low-risk procedures tin 20 low-thrombotic patients and in eight high-thromb otic patients). There was no significant difference between the management of any patients before and after the publication of the guidelines. The ave rage cost per course of heparin therapy (typically 2 days intravenous hepar in preprocedure, and 3 days heparin administered sub-cutaneously postendosc opy) was $1684. In all, 44 (90%) of 49 courses of heparin substituted for w arfarin therapy were not recommended by the guidelines. CONCLUSIONS: Patients treated by the ASGE guidelines had the same 0% rate o f thrombosis as patients who received periendoscopic heparin outside of the guidelines. Following the ASGE guidelines in all patients would have reduc ed the use of heparin therapy by 90%, for a net savings of $74,100. (C) 200 0 by Am. Cell. of Gastroenterology.