Which medications, such as warfarin (anticoagulant), aspirin (acetylsalicylic acid), clopidogrel (antiplatelet), nonsteroidal anti-inflammatory drugs (NSAIDs), fish oil, and vitamin E, should be held prior to colonoscopy?

Medication Management Prior to Colonoscopy

For colonoscopy with potential polypectomy, clopidogrel, warfarin, and other anticoagulants should be held, while aspirin can be safely continued in most patients. 1, 2

Medications That Should Be Held

Anticoagulants

• Warfarin: Should be held 5-7 days before colonoscopy with polypectomy

  • Target INR ≤1.5 for procedure 1, 3
  • Risk of delayed post-polypectomy bleeding is 0.8-14% when continued 1
  • Can resume 1-7 days after polypectomy depending on bleeding risk 3

• Direct Oral Anticoagulants (DOACs):

  • Should be held at least 48 hours before colonoscopy with polypectomy
  • Associated with high bleeding risk (4.7-12%) when continued 1
  • No bridging with heparin is generally necessary due to rapid onset/offset 4

Antiplatelets

• Clopidogrel:

  • Should be held 5-7 days before colonoscopy with polypectomy 3
  • Continued clopidogrel increases risk of post-polypectomy bleeding by 4.66 times 1
  • Can resume immediately to 1 day post-procedure if no immediate bleeding 3

• Dual Antiplatelet Therapy:

  • Should be held when possible, particularly for large polyps (>1 cm)
  • Higher risk of bleeding compared to single antiplatelet therapy 1
  • Consider cardiology consultation for patients with recent coronary stents

Medications That Can Be Continued

Antiplatelet Agents

• Aspirin:

  • Can be safely continued for colonoscopy with polypectomy 2
  • Multiple studies show no significant increase in clinically relevant bleeding 1, 5
  • Benefit of continuing aspirin outweighs bleeding risk, especially for secondary prevention 2

• NSAIDs:

  • Can be continued for colonoscopy with polypectomy 5, 6
  • Associated with minor self-limited bleeding (6.3% vs 2.1% in controls) but not major bleeding 6

• Fish Oil and Vitamin E:

  • No strong evidence requiring discontinuation
  • Generally considered low bleeding risk and can be continued

Risk Stratification for Polypectomy

Higher Risk Factors (Consider More Conservative Approach)

• Polyp size >1 cm (major risk factor) 1
• Multiple polyps (risk increases with number of polyps removed) 5
• Use of hot snare technique (14-23% bleeding risk vs 0-5.7% with cold snare) 1, 2
• Renal disease 2

Risk Mitigation Strategies

• Use cold snare technique for small polyps (<1 cm) when possible 1, 2
• Consider prophylactic clip placement after removing large polyps (>1 cm) 2
• Limit number of polyps removed in single session for high-risk patients
• For patients with high thrombotic risk who cannot stop anticoagulants, consider staged procedures

Special Considerations

Coronary Stents

• Highest risk of thrombotic events is within 6 weeks of stent placement 1
• Risk remains elevated from 6 weeks to 6 months 1
• For patients with recent stent placement (<6 months), consider deferring elective colonoscopy or consult cardiology

Emergency Colonoscopy

• For urgent/emergent colonoscopy, risk-benefit assessment is crucial
• Consider reversal agents for anticoagulants if immediate intervention is needed
• Aspirin can generally be continued even in emergency settings 2

Common Pitfalls

1. Stopping aspirin unnecessarily (increases thrombotic risk without significant benefit)
2. Inadequate holding period for clopidogrel (requires 5-7 days for platelet function recovery)
3. Failing to consider polyp size and technique in risk assessment
4. Not using cold snare technique for patients on antithrombotics when appropriate
5. Restarting anticoagulants too soon after removing large polyps

By following these evidence-based recommendations, clinicians can minimize both bleeding and thrombotic complications associated with colonoscopy and polypectomy in patients on antithrombotic medications.