From the Guidelines
For patients on clopidogrel who need a polypectomy, it is generally recommended to stop clopidogrel 5-7 days before the procedure, as this duration allows for sufficient platelet recovery and minimizes the risk of bleeding complications, as supported by the most recent guideline update from the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 1.
Key Considerations
- The risk of postpolypectomy bleeding (PPB) is a significant concern in patients on antiplatelet therapy, with studies indicating a risk range of 0.07%–1.7% for colonoscopic polypectomy 1.
- Factors influencing the risk of PPB include polyp size, use of pure cutting current, and the technique used for endoscopic mucosal resection (EMR) 1.
- The use of endoscopic clips or submucosal injection of diluted epinephrine may reduce the risk of PPB, but caution is advised due to potential complications 1.
Management Recommendations
- For elective polypectomy procedures in patients with low to moderate thrombotic risk, discontinuing clopidogrel 7 days prior to the procedure is recommended, after consultation with a cardiologist 1.
- In high-risk cardiac patients, such as those with recent stent placement or acute coronary syndrome, the procedure may need to be delayed or performed without stopping clopidogrel, depending on the polyp size and type 1.
- Clopidogrel can typically be resumed 24-48 hours after polypectomy if there are no bleeding complications, balancing the risk of bleeding with thrombotic risk from medication discontinuation 1.
Coordination of Care
- It is essential to coordinate medication management between the gastroenterologist and cardiologist to create an individualized plan based on the patient's specific cardiac and bleeding risk factors 1.
- The decision to stop or continue clopidogrel should be made on a case-by-case basis, considering the latest evidence and guidelines to minimize risks and optimize outcomes for the patient.
From the FDA Drug Label
5.3 Discontinuation of Clopidogrel Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.
The recommended duration to stop clopidogrel before a procedure like polypectomy is 5 days 2.
From the Research
Polypectomy and Clopidogrel
- The management of clopidogrel in patients undergoing polypectomy is a topic of interest, with various studies investigating the optimal timing of cessation and resumption of the medication 3, 4, 5, 6, 7.
Current Guidelines and Recommendations
- Current guidelines recommend temporary cessation of clopidogrel for 7-10 days for patients on clopidogrel undergoing colonoscopy with polypectomy 3.
- However, recent prospective randomized controlled trials have advocated for uninterrupted clopidogrel, due to similar post-polypectomy bleeding (PPB) rates with and without continued clopidogrel therapy 6.
Risk of Postpolypectomy Bleeding
- The risk of PPB is increased in patients on continued clopidogrel therapy, with a risk ratio of 1.96 (95% CI, 1.36-2.83) 3.
- The rate of delayed PPB is also increased in patients on continued clopidogrel therapy, with a risk ratio of 3.10 (95% CI, 1.60-5.98) 3.
- Concomitant use of clopidogrel and aspirin/other nonsteroidal anti-inflammatory drugs is a significant risk factor for PPB, with an odds ratio of 3.7 (95% CI, 1.6-8.5) 5.
Resumption of Clopidogrel
- The optimal timing of resumption of clopidogrel after polypectomy is not well established, with some studies suggesting that resumption immediately after polypectomy is safe 4.
- However, other studies recommend exercising clinical judgment when deciding to interrupt or continue clopidogrel for endoscopy 7.