How long should Plavix (clopidogrel) be held prior to a colonoscopy?

Clopidogrel (Plavix) Management Before Colonoscopy

For patients undergoing colonoscopy with potential polypectomy, clopidogrel (Plavix) should be discontinued 7 days before the procedure to minimize bleeding risk. 1

Risk Assessment and Management Algorithm

For Low-Risk Endoscopic Procedures (diagnostic colonoscopy without polypectomy):

• Continue clopidogrel without interruption 1
• Low-risk procedures include:
  • Diagnostic colonoscopy with or without biopsies 1
  • Procedures without tissue removal or significant mucosal disruption 1

For High-Risk Endoscopic Procedures (colonoscopy with polypectomy):

• Discontinue clopidogrel 7 days before the procedure 1
• This timing allows for adequate recovery of platelet function 1
• If patient is on dual antiplatelet therapy (DAPT):
  • Continue aspirin throughout the perioperative period 1
  • Only discontinue the clopidogrel component 1

Special Considerations for High Thrombotic Risk Patients

For patients with high thrombotic risk:

• Consult with the patient's cardiologist before stopping clopidogrel 1
• High thrombotic risk conditions include:
  • Recent coronary stent placement (especially drug-eluting stents within 6-12 months) 1
  • Bare metal stents placed within the last month 1
  • Recent acute coronary syndrome 1

Management options for high thrombotic risk:

1. Defer elective colonoscopy until safer to interrupt clopidogrel 1
2. For small polyps (<1 cm), consider:
   • Cold snare polypectomy technique if proceeding on clopidogrel 1
   • Temporarily substituting aspirin for clopidogrel 7 days prior to colonoscopy 1

Evidence on Bleeding Risk

• Meta-analysis data shows increased risk of post-polypectomy bleeding (PPB) with continued clopidogrel therapy (risk ratio 1.96; 95% CI 1.36-2.83) 1, 2
• The risk is particularly high for delayed bleeding (RR 3.10; 95% CI 1.60-5.98) rather than immediate bleeding 2
• A randomized controlled trial found slightly higher rates of delayed PPB in the continued clopidogrel group (3.8%) compared to placebo (3.6%), though not statistically significant 3

Post-Procedure Management

• Resume clopidogrel 1-2 days after the procedure if no bleeding complications 1
• Some studies suggest that immediate resumption of clopidogrel post-polypectomy is safe 4, 5, but guidelines recommend 1-2 days delay 1
• Advise patients of increased bleeding risk compared to those not on antiplatelet therapy 1

Caveats and Pitfalls

• Never stop clopidogrel without consulting the prescribing physician, especially in patients with recent coronary stents 1
• Avoid bridging with heparin for clopidogrel, as this is not recommended and may increase bleeding risk 1
• For very small polyps (<1 cm), some evidence suggests polypectomy may be safe on continued clopidogrel, but this remains controversial and guidelines still recommend discontinuation 1, 5
• The FDA label for clopidogrel notes that it increases bleeding risk and inhibits platelet aggregation for 7-10 days (the lifetime of the platelet) 6