Management of Plavix (Clopidogrel) Before Colonoscopy from a Cardiovascular Perspective
For patients undergoing colonoscopy, Plavix (clopidogrel) should be discontinued 7 days before the procedure to minimize bleeding risk while balancing cardiovascular safety. 1
Risk Stratification Approach
Low Thrombotic Risk Patients
- Discontinue Plavix (clopidogrel) 7 days before colonoscopy
- Continue aspirin if the patient is on dual antiplatelet therapy (DAPT)
- Resume Plavix 1-2 days after the procedure if no post-procedural bleeding
High Thrombotic Risk Patients
- Continue aspirin therapy without interruption
- Consult with an interventional cardiologist regarding the risk/benefit of discontinuing Plavix
- High thrombotic risk conditions include:
- Recent coronary stent placement (drug-eluting stent within 6-12 months or bare metal stent within 1 month)
- Recent acute coronary syndrome
- Recent stroke or transient ischemic attack
Colonoscopy Classification and Management
Colonoscopy is considered a high-risk endoscopic procedure when polypectomy is anticipated. The 2021 British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guidelines provide clear recommendations for managing antiplatelet therapy before colonoscopy 1:
For diagnostic colonoscopy without polypectomy (low-risk procedure):
- Plavix can be continued without interruption
- Morning dose on the day of procedure can be taken
For colonoscopy with anticipated polypectomy (high-risk procedure):
- Discontinue Plavix 7 days before the procedure
- Continue aspirin if on dual therapy
- Resume Plavix 1-2 days after the procedure
Balancing Bleeding vs. Thrombotic Risks
The management of Plavix before colonoscopy requires careful consideration of both bleeding and thrombotic risks:
- Bleeding risk: Continuing Plavix during polypectomy increases the risk of post-polypectomy bleeding
- Thrombotic risk: Discontinuing Plavix increases the risk of cardiovascular events, particularly in high-risk patients
The FDA label for clopidogrel warns that discontinuation increases the risk of cardiovascular events and recommends restarting as soon as possible after temporary discontinuation 2.
Special Considerations
For patients with drug-eluting coronary stents placed within the past 6-12 months or bare metal stents placed within the past month, consultation with an interventional cardiologist is strongly recommended before discontinuing Plavix 1
If colonoscopy must be performed urgently in patients on Plavix, consider:
- Performing diagnostic colonoscopy without polypectomy
- Deferring polypectomy to a later date when Plavix can be safely discontinued
- Using cold snare polypectomy techniques for small polyps (<1 cm) if polypectomy cannot be deferred
After the procedure, Plavix should be resumed within 1-2 days depending on the perceived hemorrhagic and thrombotic risks 1
Potential Pitfalls
- Discontinuing Plavix too close to the procedure (less than 7 days) may not allow sufficient time for platelet function to normalize, increasing bleeding risk
- Delaying Plavix resumption beyond 2-3 days post-procedure unnecessarily increases thrombotic risk
- Failing to continue aspirin in patients on dual antiplatelet therapy when Plavix is discontinued increases thrombotic risk
- Not consulting with a cardiologist for high-risk patients may lead to adverse cardiovascular outcomes
While some research suggests that continuing Plavix during colonoscopy with polypectomy might be safe in certain circumstances 3, the current guidelines strongly recommend discontinuation 7 days before high-risk procedures like colonoscopy with polypectomy 1.