How long before a scheduled colonoscopy and EGD should Plavix (clopidogrel) be stopped and aspirin continued for a patient 1 year post-CVA?

From the Guidelines

For a patient who is 1 year post-CVA and scheduled for a colonoscopy and EGD, Plavix (clopidogrel) should be stopped at least 5 days before the procedure while aspirin can be continued. This recommendation is based on the most recent guidelines, such as the 2024 ESC guidelines for the management of chronic coronary syndromes 1, which suggest stopping clopidogrel at least 5 days before procedures to minimize bleeding risk. The decision to stop Plavix and continue aspirin balances the risk of bleeding during the endoscopic procedure with the risk of thromboembolic events. Aspirin provides some ongoing protection against thrombotic events, and its continuation is generally recommended, as seen in guidelines such as the 2011 ACCF/AHA guideline for coronary artery bypass graft surgery 1.

The patient's history of CVA (cerebrovascular accident) is a significant consideration, but being more than 12 months post-event, the risk associated with temporary discontinuation of Plavix for the procedure is considered manageable. It's crucial for the patient to consult with both their neurologist or cardiologist and the gastroenterologist performing the procedure to assess their specific risk factors and the potential need for any adjustments in their antiplatelet therapy regimen. After the procedure, Plavix should be resumed as soon as possible, typically within 24 hours, once hemostasis is assured, as directed by the proceduralist. This approach aligns with recommendations for managing antithrombotic therapy in patients undergoing procedures, as outlined in guidelines like the 2012 ACCF/AHA focused update on the management of patients with unstable angina/non-ST-elevation myocardial infarction 1.

Key considerations include:

• The timing of Plavix discontinuation to ensure minimal risk of bleeding during the procedure
• The continuation of aspirin to maintain some level of protection against thrombotic events
• Personalization of the recommendation based on the patient's specific risk factors and the nature of the procedures to be performed
• Close communication and coordination among the patient's healthcare providers to ensure safe management of their antiplatelet therapy during this period.

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.

For a patient 1 year post-CVA with a scheduled colonoscopy and EGD, it is recommended to stop Plavix (clopidogrel) 5 days before the procedure and continue aspirin. This is based on the guidance provided in the drug label regarding the discontinuation of clopidogrel for surgery with a major risk of bleeding 2.

From the Research

Stopping Plavix and Continuing Aspirin Before Colonoscopy and EGD

• The decision to stop Plavix (clopidogrel) and continue aspirin before a scheduled colonoscopy and EGD for a patient 1 year post-CVA should be based on the patient's individual risk factors and medical history.
• According to the study 3, clopidogrel (Plavix) should be stopped 7 days prior to colonoscopy that may require polypectomy.
• The study 4 suggests that, except for low-risk settings, the practice of withdrawing antiplatelet drugs 5-10 days prior to surgical procedures should be changed, and most surgical procedures may be performed while on low-dose aspirin treatment.
• The American College of Cardiology (ACC) guidelines, as mentioned in the study 5, suggest clopidogrel suspension for 5 days before non-emergent cardiac surgery.
• However, the study 5 also found that there was no significant difference in the hemoglobin drop of patients who had clopidogrel stopped 3 days prior to the major procedure like CABG in comparison to the patients who stopped clopidogrel 5 days before surgery.

Recommendations

• Based on the available evidence, it is recommended to stop Plavix (clopidogrel) at least 5-7 days before the scheduled colonoscopy and EGD, as suggested by studies 3 and 5.
• Aspirin can be continued, as it is generally considered safe to perform most surgical procedures while on low-dose aspirin treatment, according to study 4.
• The decision to stop or continue antiplatelet therapy should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history, as emphasized by studies 4 and 6.