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©2013 UpToDate ® Print Email ASGE recommendations for adjusting warfarin prior to elective endoscopic procedures Low-risk procedure No adjustments in anticoagulation need to be made irrespective of the underlying condition. However, elective procedures should be avoided when the level of anticoagulation is above the therapeutic range. High-risk procedures in patients with low-risk conditions Warfarin therapy should be discontinued 3 to 5 days before the scheduled procedure. The decision to obtain a preprocedure prothrombin time should be individualized. High-risk procedures in patients with high-risk conditions Warfarin therapy should be discontinued 3 to 5 days before the procedure. The decision to administer intravenous heparin once the INR falls below the therapeutic level should be individualized. Preliminary experience suggest there may be a role for monitored reduction in the INR without the use of heparin. Heparin, if used, should be discontinued 4 to 6 hours before the scheduled procedure and may be resumed 2 to 6 hours after the procedure. Warfarin therapy may generally be resumed the night of the procedure. Heparin infusion and warfarin should overlap for a period of 4 to 5 days or until the INR has achieved the target therapeutic range for 2 to 3 days. However, the risk of major hemorrhage after sphincterotomy is between 10 and 15 percent if anticoagulation is reinstituted within three days of the sphincterotomy. Therefore, the benefits of immediate anticoagulation should be carefully weighed against the risks and would be advisable only in a situation where the risk of thromboembolic events significantly exceeds the risk of hemorrhage from sphincterotomy. Data from: Eisen, GM, Baron, TH, Dominitz, JA, et al. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc 2002; 55:775.