Antithrombotics Around Elective Endoscopy in 2026: What to Continue, What to Hold

These rows follow the 2022 ACG-CAG periendoscopic guideline. They apply to elective cases. They do not apply to a patient who is actively bleeding.

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Start with bleed risk of the procedure, not the brand name of the pill

Most cancelled lists happen because someone applied a "hold everything 5 days" rule to a diagnostic EGD. ACG-CAG split the problem into two rooms: acute GI bleeding, and elective endoscopy. This page is the elective room.

Low-risk procedures: diagnostic EGD or colonoscopy, including standard mucosal biopsies, and ERCP without sphincterotomy. High-risk procedures: polypectomy of large lesions, EMR, ESD, biliary sphincterotomy, PEG, tumor ablation, and any case where you expect a large mucosal defect. If the planned case can turn high-risk in the room, treat it as high-risk on the intake call.

Aspirin

For secondary cardiovascular prevention, continue aspirin 81-325 mg. Do not hold it for elective endoscopy. If someone already stopped it, restart the day hemostasis is confirmed. Primary-prevention aspirin is a different conversation with the referring clinician; it is not a reason to cancel a diagnostic exam.

Warfarin

ACG-CAG suggest continuing warfarin for elective endoscopy rather than a 1-7 day hold. If you do hold it because the procedure is high-risk, do not bridge with LMWH unless the patient has a mechanical heart valve. Bridging is where the bleeds come from.

Check an INR only when the result would change the plan. A therapeutic INR is acceptable for biopsy-level work. A supratherapeutic INR is not a reason to reverse for a routine elective case. Defer the case instead.

DOACs

Temporarily interrupt DOACs for elective endoscopy. That is the opposite of the warfarin suggestion, and it is the row people mix up. Typical holds are 1 day for standard-risk procedures with normal renal function, and 2 days (sometimes longer for dabigatran) when CrCl is reduced or the case is high-risk. Do not bridge. There is no ACG-CAG recommendation that forces same-day restart versus a 1-7 day delay; restart when hemostasis looks durable and the thrombotic risk is not extreme.

P2Y12 inhibitors and DAPT

On dual antiplatelet therapy for secondary prevention, hold the P2Y12 inhibitor and keep aspirin. After a recent coronary stent, this is a cardiology call, not a default 7-day hold on both agents. For P2Y12 monotherapy, ACG-CAG could not make a recommendation. Say that out loud. Do not invent a rule.

What not to do on the morning of the case

• Do not reverse warfarin with FFP or vitamin K for an elective, non-bleeding patient.
• Do not give andexanet alfa or idarucizumab for elective endoscopy.
• Do not transfuse platelets solely because the patient took clopidogrel last week.
• Do not treat a diagnostic EGD like an ESD.

GLP-1 agonists and NPO status are a separate airway problem. See Aspiration risk, NPO, and GLP-1s before endoscopy.

Selected references

1. Abraham NS, Barkun AN, Sauer BG, et al. ACG-CAG Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute GI Bleeding and the Periendoscopic Period. Am J Gastroenterol. 2022;117:542-558.
2. ASGE Standards of Practice Committee. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83:3-16.

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Last reviewed September 20, 2026. Written for clinicians making periendoscopic medication calls. This is not a substitute for procedure-specific judgment or cardiology input after recent coronary intervention.