As I was reading through the SGNA Discussion Forum, I noted some questions about stopping Coumadin in endoscopy procedures. This is an interesting topic as there are many points of view.

First, let's look at the reasons we give blood thinners such as Coumadin. According to Prentice Hall Nurse's Drug Guide (Wilson, Shannon, Shields, & Stang, 2007), Coumadin is used for prophylaxis and treatment of deep vein thrombosis and its extension pulmonary embolism as well as for treatment of atrial fibrillation with embolization. Coumadin is also used as an adjunct in treatment of coronary occlusion, cerebral transient ischemic attacks, and as a prophylactic in patients with prosthetic cardiac valves.

In the Discussion Forum comments, one nurse noted that a gastroenterologist she works with usually stops Coumadin 5 days prior to a procedure. She also worked with another physician, however, who did not stop Coumadin at all and wondered what everyone else was doing. Another person said they stop all blood thinners 5 days prior to procedures, unless there is too much risk.

This is an interesting topic not only in regard to Coumadin, but also in relation to the many drugs that can affect clotting or platelet aggregation. We are seeing more and more people on various combinations of medications that can affect these drugs. Coumadin has been a concern for some time, but with cardiac stenting being more prevalent, we are seeing more concerns with endoscopy patients on drugs such as Plavix. In my region, when the cardiologists are placing stents, they typically do not want to stop these drugs for 1 year after stent placement.

Other drugs of concern may be Aggrenox (aspirin + dipyridamole), Persantine (dipyridamole), Ticlid (ticlopidine), nonsteroidal anti-inflammatory drugs (NSAIDs), or even aspirin (that everyone seems to be taking daily, though the patients often forget to mention this). I have known physicians who do not want to do procedures when patients are on any of these medications unless the medications are stopped 5 days before. I know of others who will do patients on these medications. What is best?

In an emergency, you don't have the same choices. Coumadin may be changed to a short-acting heparin, and fresh frozen plasma and vitamin K may be given to correct clotting. Keep in mind, however, Coumadin's onset is 2-7 days with a half-life of 0.5-3 days. Where I work, if we have an elective procedure and the patient must be on a blood thinner, we stop Coumadin and start Lovenox days prior to the procedure. Lovenox is already typically used with patients who have prosthetic heart valves. The patient continues on Lovenox for 2 days after the procedure, and the Coumadin is restarted the evening of the procedure with a validating international normalized ratio to ensure that the patient is at the correct level.

Many patients do not like to take Lovenox because it is an injection. This can be a little inconvenient, though the patient or a family member can be taught to administer the drug for the two injections taken each day for approximately 5 days. Lovenox dosing is calculated by weight and, although usually covered by insurance, is costly.

When you look at other conditions, there may be options. Often people are on Coumadin for atrial fibrillation. If the fibrillation has been well controlled, the patient may be allowed to stop his or her Coumadin for a few days prior to the procedure. We always place a call to the primary care provider or cardiologist who is managing the patient's Coumadin to ensure that this is acceptable.

A group that has been affecting the increased use of Coumadin in recent years is neurologists who deal with stroke victims. Many do not want to stop any type of thinner because of the patient's increased risk of stroke. These situations require decisions regarding risk versus benefit to the individual patient. Sometimes patients must be counseled regarding these issues and given the opportunity to decide or given the advice to discuss this with their neurologist or primary care provider. The risk of stroke in these patients may even extend for longer than 1 week after the procedure, so it is very important to consider the decision carefully in these patients.

Many people take prescription NSAIDs or over-the-counter (OTC) medications at prescription strength. Ibuprofen is one example of this type of medication; many patients take three to four 200-mg tables at a time three to four times a day for arthritis or joint complaints. Patients do not frequently list these as routine medications when they are filling out forms, so specific questioning about these drugs is warranted. If the patient is there for a procedure, would it be canceled as a result of taking these medications? I know of physicians who would cancel. There are also many people who take an aspirin a day (or more), sometimes on a physician's recommendation, but not always-some patients think that this is something that everyone should be doing.

We need to be working closely with cardiology for recommendations on drug management when doing procedures on patients who take these medications. Is it worth the risk of a myocardial infarction to stop these drugs for a screening colonoscopy? If the patient has iron deficiency anemia and you are screening for cancer, is it worth the risk? These are tough decisions, and discussions regarding the risks need to include patients.

The use of Coumadin in endoscopic patients has many different points of view and not one that is clearly accepted by all. It is important to work with those members of the healthcare community who work in primary care or specialty practice in order to have the best possible outcome for patients undergoing endoscopic procedures taking medications that may slow the clotting process.

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