Is it advisable to resume DOAC use 1 day after colorectal ESD?

Resumption of direct oral anticoagulants (DOACs) a day after undergoing colorectal endoscopic submucosal dissection (ESD) results in fewer thromboembolic events without elevating the risk of delayed bleeding compared with 2 or 3 days after ESD, reports a study.

"Moreover, this study also shows that the risk of delayed bleeding varies with the type of DOAC, with dabigatran having the highest association with delayed bleeding,” the investigators said. 

This retrospective cohort study used the Diagnosis Procedure Combination database from 2012 to 2023, identifying patients who resumed DOACs within 3 days following colorectal ESD. Those who used anticoagulants other than DOACs were excluded.

The investigators then divided all eligible patients into early (the day after ESD) and delayed (2–3 days after ESD) resumption groups. They examined the delayed bleeding and thromboembolic events within 30 days using inverse probability of treatment weighting. Delayed bleeding was characterized by bleeding that requires endoscopic haemostasis or blood transfusion after ESD.

A total of 176,139 colorectal ESDs were identified, of which 3,550 involved DOAC users. Among these users, 2,698 (76 percent) belonged to the early resumption group and 852 (24 percent) to the delayed resumption group. [Am J Gastroenterol 2025;120:623-631]

After inverse probability of treatment weighting adjustment, delayed bleeding did not significantly increase in the early resumption group compared with the delayed resumption group (odds ratio [OR], 1.05, 95 percent confidence interval [CI], 0.78–1.42; p=0.73). However, the likelihood of thromboembolic events was markedly reduced with early DOAC resumption (OR, 0.45, 95 percent CI, 0.25–0.82; p<0.01).

“Given the impracticality of performing large-scale randomized controlled trials or prospective studies due to the required sample size, our retrospective observational study still provides pivotal insights for managing DOACs following colorectal ESD,” the investigators said.

Recommendations

International guidelines on anticoagulation have varying recommendations regarding the timing of DOAC resumption following colorectal ESD. 

For instance, the 2017 Japanese guidelines suggest resuming DOACs a day after ESD, while multiple guidelines exist from various societies in the US. However, recent guidelines set by the American College of Gastroenterology do not specifically address the timing of DOAC resumption. [Dig Endosc 2018;30:433-440; Am J Gastroenterol 2022;117:542-545]

On the other hand, guidelines in the UK and Europe recommend pausing DOAC use 3 days prior to a high-risk procedure and continuing them 2 or 3 days after the procedure. [Gut 2021;70:1611-1628]

"However, UK and European guideline recommendations are not based on studies comparing resumption the day after treatment with 2 or 3 days later but rather on the PAUSE trial design, which assumed DOAC resumption at 2 or 3 days postprocedure with a thromboembolic event rate of less than 1 percent,” the investigators said. [JAMA Intern Med 2019;179:1469-1478]

“Our study is the first to evaluate early vs delayed DOAC resumption specifically, showing that resuming DOACs the day after ESD is associated with a reduction in thromboembolic events without significantly increasing the risk of delayed bleeding compared with resuming 2 or 3 days after ESD,” they added.