Delaying DOAC after colonoscopy: Weighing the risks
"The lack of an evidence base has prevented several gastroenterology societies from offering recommendations."
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03/27/2026
Delayed resumption of direct oral anticoagulants following outpatient colonoscopy was associated with higher thromboembolic risk without a reduction in gastrointestinal (GI) bleeding, according to a cohort study published in Clinical Gastroenterology and Hepatology.
Management of anticoagulation around colonoscopy remains a common clinical challenge. Temporary interruption reduces post-procedural bleeding risk, but prolonged interruption may increase the risk of stroke and other thromboembolic events, noted Lawrence Jun Leung, MD, MPH, and colleagues.
"Currently, little is known about the optimal timing for DOAC resumption after colonoscopy to minimize the risks of both gastrointestinal bleeding and thromboembolic events, and the lack of an evidence base has prevented several gastroenterology societies from offering recommendations on the timing of DOAC resumption following colonoscopy," wrote Dr. Leung, of the Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, and fellow researchers.
Study design and population
They analyzed 7,798 patients receiving DOAC therapy who underwent outpatient colonoscopy between 2013 and 2022 within a large integrated US health care system. Patients were grouped based on documented timing of DOAC resumption instructions: early (less than 2 days) or delayed (2 days or more).
The cohort had a mean age of about 70 years, and most patients had multiple comorbidities and elevated thromboembolic risk. Colonoscopic interventions were common, including polypectomy in more than 70% of procedures.
The primary outcomes were GI bleeding requiring emergency department evaluation or hospitalization and thromboembolic events within 30 days following colonoscopy. Researchers used inverse probability weighting to account for baseline differences between groups.
Thromboembolic risk vs GI bleeding
"After elective colonoscopy, delayed DOAC resumption was associated with increased thromboembolic risk without a corresponding reduction in GI bleeding, suggesting thromboembolism risk may warrant greater consideration when determining resumption timing," noted researchers.
Thromboembolic event rates were consistently higher with delayed resumption (0.9% vs 0.6%). Point estimates for transient ischemic attack, deep vein thrombosis, and myocardial infarction were also higher in the delayed group, though these differences did not reach statistical significance.
Rates of overall and clinically significant bleeding were similar between groups in adjusted analyses. Absolute bleeding rates remained modest, occurring in 2.1% of patients with delayed resumption and 1.4% of patients with early resumption. Findings were generally consistent across procedural subgroups, including polypectomy and endoscopic mucosal resection.
Clinical relevance
Guidelines for peri-procedural DOAC management vary, in part because of limited direct evidence on when to resume therapy. Prior studies have focused on anticoagulant interruption rather than timing of resumption. This analysis adds real-world data across a range of colonoscopy indications and interventions commonly performed in outpatient practice.
The absence of a bleeding reduction with delayed resumption is particularly relevant in patients undergoing colonoscopic interventions, where concerns about post-procedural bleeding often influence clinical decision-making. "These findings suggest that thromboembolic risk may warrant greater consideration than bleeding risk when determining the optimal timing of DOAC resumption following elective colonoscopy," noted Dr. Leung and colleagues.
Limitations
This observational study may be subject to residual confounding despite statistical adjustment. Timing of DOAC resumption was based on documented instructions, and adherence was assumed. Detailed procedural factors, such as resection technique, were not fully captured, and the relatively small number of thromboembolic events limited precision for some outcomes and the ability to define duration-related risk.
The study was funded by the National Cancer Institute and Kaiser Permanente Northern California Graduate Medical Education, with no involvement of the sponsors in the study design, data collection, analysis, interpretation, or reporting. The researchers reported no conflicts of interest.