Brilinta Management Prior to Colonoscopy
For colonoscopy with polypectomy (high-risk procedure), hold Brilinta (ticagrelor) for 7 days prior to the procedure. 1
Risk Stratification Framework
The decision depends on two key factors:
1. Procedure Risk Classification
Low-risk procedures (diagnostic colonoscopy with biopsy only):
- No need to hold Brilinta
- Continue therapy through the procedure
High-risk procedures (colonoscopy with polypectomy, EMR, ESD):
- Requires 7-day interruption of Brilinta
2. Patient Thrombotic Risk Assessment
Low thrombotic risk patients:
- Ischemic heart disease without coronary stent
- Cerebrovascular disease
- Peripheral vascular disease
- Action: Stop ticagrelor 7 days before endoscopy; continue aspirin if on dual antiplatelet therapy (DAPT) 1
High thrombotic risk patients:
- Within 6-12 months after drug-eluting stent
- Within 1 month after bare metal stent
- Action: Continue aspirin and discuss with interventional cardiologist regarding risk/benefit of stopping ticagrelor 1
Practical Management Algorithm
For most colonoscopies with anticipated polypectomy:
- Stop Brilinta: 7 days before procedure
- Continue aspirin: If patient is on DAPT (do not stop aspirin) 1
- Restart Brilinta: 1-2 days after procedure, depending on bleeding risk and hemostasis 1
Critical Caveats
The FDA label states to hold Brilinta for 5 days prior to surgery with major bleeding risk 2, but the 2021 BSG/ESGE guidelines specifically recommend 7 days for P2Y12 inhibitors including ticagrelor before high-risk endoscopic procedures 1. The guideline recommendation takes precedence here as it is procedure-specific and represents the most recent expert consensus for endoscopic procedures.
Never hold aspirin in patients on DAPT - this is a common error that significantly increases thrombotic risk. The aspirin should be continued throughout the periprocedural period 1.
For patients with recent coronary stents (especially <6 months for drug-eluting stents), the decision to hold ticagrelor carries substantial thrombotic risk. These cases require mandatory cardiology consultation before proceeding 1. The risk of stent thrombosis may outweigh bleeding risk, and the procedure may need to be deferred.
Post-procedure resumption timing should balance bleeding versus thrombotic risk. Generally restart 1-2 days after the procedure once adequate hemostasis is confirmed 1. For patients at very high thrombotic risk, consider restarting as soon as hemostasis is achieved.