How long should a patient come off Plavix (clopidogrel) before undergoing an Esophagogastroduodenoscopy (EGD)?

From the Guidelines

Plavix (clopidogrel) should be discontinued at least 5 days before undergoing an Esophagogastroduodenoscopy (EGD) in patients at low thrombotic risk, as recommended by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1. This recommendation is based on moderate quality evidence and a strong recommendation from the guidelines. When considering discontinuation of Plavix, it is crucial to weigh the risks of bleeding against the risks of thrombosis. Key factors to consider include:

• The patient's thrombotic risk profile
• The type of EGD procedure being performed (diagnostic vs. therapeutic)
• The presence of any comorbid conditions that may affect bleeding or thrombotic risk In patients with high thrombotic risk, such as those with recent coronary stents or stroke, the decision to discontinue Plavix should be made in consultation with a cardiologist or other relevant specialist, as the risks of stopping the medication may outweigh the benefits 1. After the EGD procedure, Plavix can typically be resumed once any bleeding risk has passed, usually within 24-72 hours, but the exact timing should be determined by the patient's healthcare provider. It is essential to note that individualized decision-making is critical in these situations, and patients should always consult with their healthcare provider before making any changes to their medication regimen.

From the FDA Drug Label

Talk with your doctor about stopping your clopidogrel tablets before you have surgery. Your doctor may tell you to stop taking clopidogrel tablets at least 5 days before you have surgery to avoid excessive bleeding during surgery.

The patient should stop taking clopidogrel at least 5 days before undergoing an Esophagogastroduodenoscopy (EGD), as it may be considered a surgical procedure with a risk of bleeding. However, the decision to stop clopidogrel should be made by the doctor who prescribed it, taking into account the individual patient's risk of bleeding and other factors 2.

From the Research

Recommendations for Clopidogrel Cessation Before EGD

• The British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend discontinuing P2Y12 receptor antagonists, such as clopidogrel, five days before high-risk endoscopic procedures in patients at low thrombotic risk 3.
• For low-risk endoscopic procedures, the guidelines recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy 3.
• A study published in 2019 found no significant difference in hemoglobin drop between patients who stopped clopidogrel 3 days prior to coronary artery bypass grafting (CABG) and those who stopped it 5 days before surgery 4.
• Another study published in 2003 suggests that it is not necessary to adjust anticoagulation for low-risk procedures, such as upper endoscopy with biopsy, but recommends discontinuing warfarin four to five days beforehand for high-risk procedures 5.
• A 2013 study found that the risk of bleeding complications in patients undergoing endoscopic procedures while on uninterrupted clopidogrel/dual antiplatelet therapy was low (1%) and suggests that clinical decision making should take place on an individual basis 6.

Considerations for Clopidogrel Cessation

• The risk of thromboembolism due to discontinuation of clopidogrel should be weighed against the risk of procedure-related bleeding 3, 5.
• The nature of the underlying condition and the patient's individual risk factors should be taken into account when deciding whether to discontinue clopidogrel before an EGD 3, 4, 6.
• The type of endoscopic procedure being performed, whether high-risk or low-risk, should also be considered when making decisions about clopidogrel cessation 3, 5.