What is the recommended protocol for stopping aspirin (acetylsalicylic acid) and Plavix (clopidogrel) before a colonoscopy?

Management of Aspirin and Clopidogrel Before Colonoscopy

For patients on aspirin and clopidogrel (Plavix) undergoing colonoscopy, aspirin should be continued while clopidogrel should be discontinued 7 days before the procedure if the patient is at low thrombotic risk. 1

Risk Stratification

Procedure Risk Assessment

Colonoscopy procedures are categorized based on bleeding risk:

• Low-risk procedures:

  • Diagnostic colonoscopy with or without biopsies
  • No interruption of antiplatelet therapy needed

• High-risk procedures:

  • Polypectomy
  • Endoscopic mucosal resection (EMR)
  • Endoscopic submucosal dissection (ESD)
  • Require management of antiplatelet therapy

Patient Thrombotic Risk Assessment

Patients should be stratified based on their thrombotic risk:

• High thrombotic risk:

  • Drug-eluting coronary stents within 12 months
  • Bare metal coronary stents within 1 month
  • Recent acute coronary syndrome (<6 weeks)
  • Prosthetic metal heart valve in mitral position
  • Prosthetic heart valve with atrial fibrillation
  • <3 months after venous thromboembolism

• Low thrombotic risk:

  • Ischemic heart disease without coronary stents
  • Cerebrovascular disease
  • Peripheral vascular disease

  • 3 months after venous thromboembolism

  • Stable coronary artery disease >6 months after stenting

Management Protocol

For Low Thrombotic Risk Patients:

1. Aspirin (ASA):

   • Continue aspirin even for high-risk procedures 1
   • No need to discontinue aspirin before colonoscopy with polypectomy

2. Clopidogrel (Plavix):

   • Discontinue 7 days before high-risk procedures 1
   • Check with patient's cardiologist before discontinuation
   • Resume clopidogrel 1-2 days after procedure if adequate hemostasis is achieved 1

For High Thrombotic Risk Patients:

1. Aspirin:

   • Continue aspirin throughout the periendoscopic period 1

2. Clopidogrel:

   • Consult with a cardiologist about the risk/benefit of discontinuation 1
   • For patients <6 weeks after acute coronary syndrome or stent placement, consider deferring elective colonoscopy 1
   • If colonoscopy cannot be deferred, continue clopidogrel and implement enhanced hemostatic measures during the procedure 1

Post-Procedure Management

• Resume clopidogrel within 1-2 days after the procedure if adequate hemostasis is achieved 1
• Advise patients that there is an increased risk of post-procedure bleeding compared to those not on antiplatelet therapy 1
• Monitor for signs of delayed bleeding (up to 30 days after polypectomy)

Important Considerations

• The risk of coronary thrombosis if antiplatelet drugs are withdrawn is generally higher than the risk of surgical bleeding if they are continued 2
• The overall risk of postpolypectomy bleeding is <0.5% in general population, but increases to approximately 2.4% for patients continuing thienopyridines 3
• Recent evidence suggests that the difference in delayed postpolypectomy bleeding between patients continuing clopidogrel (3.8%) versus those discontinuing it (3.6%) may not be statistically significant 4

Common Pitfalls to Avoid

1. Discontinuing both aspirin and clopidogrel simultaneously in patients with recent coronary stenting, which significantly increases thrombotic risk
2. Delaying resumption of antiplatelet therapy beyond 48 hours after the procedure
3. Failing to consult with the patient's cardiologist before modifying antiplatelet therapy in high-risk patients
4. Substituting antiplatelet agents with heparin or LMWH, which does not provide adequate protection against stent thrombosis

By following these guidelines, clinicians can balance the risks of bleeding against the risks of thrombotic events when managing patients on aspirin and clopidogrel undergoing colonoscopy.