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as per our guideline.

Letter to the Editor

Editor, – Thank you for the informative and detailed article on antiplatelets, anticoagulants and elective surgery (Aust Prescr 2011;34:139-43).

The authors noted that patients requiring a biopsy during an elective endoscopy should follow the recommendations for those having general surgery. However, patients who do not require a biopsy during an endoscopy should follow the recommendations for dental, dermatological and ophthalmological procedures. In practice, it is usually not known before a colonoscopy whether or not a polypectomy will be required, and some gastroenterologists perform biopsies on most or all patients having elective endoscopies. I therefore presume the take-home message is to treat most patients according to the recommendations applying to general surgery.

I was also interested to read that warfarin could be resumed on the evening of the procedure, but at the usual maintenance dose with no loading dose. Why is a loading dose not advised? Having a patient at a sub-therapeutic INR level for a relatively prolonged period after a procedure can complicate the logistics of their care, particularly if they are unable or unwilling to self-administer low molecular weight heparin, and live in a rural area.

Kylie Fardell
General practitioner
Cooma, NSW

Authors' comments

Dr Merriman and Dr Tran, authors of the article, comment:

Thank you for your comment on our article. You are correct – if it is likely that a biopsy is to be taken or a polyp removed during an endoscopic procedure, then we would advise following the recommendations for general surgery.

When resuming warfarin after such procedures, for atrial fibrillation one would usually commence this at the usual maintenance dose as these patients are not generally loaded with higher doses even when first started on warfarin. For patients at higher risk, such as atrial fibrillation with prior thrombosis, mechanical heart valves or previous deep vein thrombosis or pulmonary embolism, one could start with a higher loading dose using a warfarin nomogram and bridge with low molecular weight heparin