GI Medication Quick Guide

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GI NOTES

GI Medication Quick Guide

Key points

Take PPIs 30 to 60 minutes before a meal; review every long-term prescription for a clear indication.
Around endoscopy, stopping or continuing antithrombotics depends on both bleeding risk of the procedure and clot risk of the patient.
Patients on GLP-1 receptor agonists may have retained food; a liquid diet the day before is a common approach.
Before starting biologics or JAK inhibitors, screen for TB and hepatitis B and update vaccines.
In cirrhosis, avoid NSAIDs, and use non-selective beta-blockers, lactulose and rifaximin where indicated.

1. Acid suppression

Clear long-term indications: erosive esophagitis LA grade C or D, Barrett’s esophagus, eosinophilic esophagitis responding to PPI, ulcer prevention in high-risk NSAID or antiplatelet users, idiopathic peptic ulcer.
Deprescribing: for uncomplicated GERD that has resolved, taper or stop and use on-demand dosing. Rebound symptoms are common for 2 to 4 weeks.
Potassium-competitive acid blockers (vonoprazan) are approved for erosive esophagitis and as part of H. pylori regimens.
Reported associations with long-term PPIs (fractures, kidney disease, dementia) are mostly from observational data; the strongest real risks are C. difficile infection and low magnesium or B12.

2. Antithrombotics around elective endoscopy

FIGURE: PLANNING ANTITHROMBOTICS BEFORE ENDOSCOPY

Elective procedure: what is the bleeding risk?

Low risk
Diagnostic EGD or colonoscopy, biopsies, small polyp cold snare
→ Usually continue

High risk
Large polypectomy, sphincterotomy, EUS-FNA, PEG, dilation
→ Plan holds with cardiology

Aspirin for secondary prevention: continue. Recent stent (DES under 6 to 12 months): delay elective procedure if possible.

Original diagram based on the ACG-CAG 2022 periendoscopic antithrombotic guideline.

Drug	Typical hold before high-risk procedure	Notes
Warfarin	5 days; check INR	Bridging heparin is generally not recommended except in selected very high-risk patients (such as mechanical mitral valves)
Apixaban, rivaroxaban, edoxaban	1 to 2 days (longer with reduced kidney function)	No bridging; restart once hemostasis is secure
Dabigatran	2 to 4 days depending on kidney function	Mostly cleared by the kidneys
Clopidogrel, prasugrel, ticagrelor	5 days (prasugrel 7)	Continue aspirin; never stop dual therapy early after a coronary stent without cardiology

3. Before procedures and treatment

GLP-1 receptor agonists (semaglutide, tirzepatide, others): slow gastric emptying. Current multisociety guidance favors continuing in most patients, with a liquid diet for 24 hours before the procedure; consider holding in those with GI symptoms or at high risk of retained food.
Bowel preparation: split dosing (half the evening before, half 4 to 6 hours before the procedure) gives the best results; finish at least 2 hours before sedation. Avoid sodium phosphate in kidney disease.
Before biologics or JAK inhibitors: TB screening (interferon-gamma release assay), hepatitis B serology, HIV and varicella status, update vaccines (no live vaccines once treatment starts), check TPMT before thiopurines.

4. Cirrhosis medicines at a glance

Medicine	Use	Common starting dose
Carvedilol	Prevent first variceal bleed; portal hypertension	6.25 mg daily, up to 12.5 mg daily
Spironolactone with furosemide	Ascites	100 mg and 40 mg daily (ratio 100:40)
Lactulose	Hepatic encephalopathy	Titrate to 2 to 3 soft stools a day
Rifaximin	Prevent recurrent encephalopathy, added to lactulose	550 mg twice daily
Ceftriaxone	Prophylaxis during GI bleeding in cirrhosis	1 g daily up to 7 days
Albumin	Large-volume paracentesis; SBP; hepatorenal syndrome	6 to 8 g per liter removed when over 5 L

Avoid in cirrhosis: NSAIDs, ACE inhibitors and ARBs in ascites, aminoglycosides, benzodiazepines where possible.
Acetaminophen up to 2 g a day is generally considered safe.

Self-check questions

A patient on apixaban with normal kidney function needs a large polypectomy. How long to hold, and is bridging needed?
When should a PPI be taken?
What screening is needed before starting infliximab?
A patient with cirrhosis and ascites has knee pain. Which painkiller is preferred?

Answers: (1) About 1 to 2 days; no bridging. (2) 30 to 60 minutes before a meal. (3) TB (IGRA), hepatitis B serology, vaccine review. (4) Acetaminophen at a reduced daily dose; avoid NSAIDs.

References

Targownik LE, Fisher DA, Saini SD. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors. Gastroenterology. 2022;162(4):1334-1342.
Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol. 2022;117(4):542-558.
Kindel TL, Wang AY, Wadhwa A, et al. Multisociety Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024 (published online October 29, 2024). doi:10.1016/j.cgh.2024.10.003.
Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the AASLD. Hepatology. 2021;74(2):1014-1048.
Saltzman JR, Cash BD, Pasha SF, et al. Bowel preparation before colonoscopy. Gastrointest Endosc. 2015;81(4):781-794.

For educational purposes only. This note does not replace clinical judgment or local protocols. Check doses against current labeling and institutional guidance.