From the Guidelines
For a patient with a drug-eluting stent who is on aspirin and needs a colonoscopy, the recommendation is to continue aspirin therapy throughout the periendoscopic period, as the risk of stent thrombosis outweighs the small increased risk of bleeding during colonoscopy, as supported by the most recent guidelines from the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 1. The guidance for managing patients with drug-eluting stents undergoing colonoscopy prioritizes minimizing the risk of stent thrombosis while considering the risk of bleeding associated with the procedure.
Key Considerations
- The risk of stent thrombosis is significantly higher if antiplatelet therapy is discontinued, with an approximate 40% risk of acute myocardial infarction or death 1.
- Aspirin should not be discontinued due to its crucial role in preventing stent thrombosis.
- If the patient is on dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor like clopidogrel), the P2Y12 inhibitor may be temporarily discontinued 7 days before the procedure if the stent was placed more than 12 months ago, in consultation with the patient's cardiologist, to minimize the bleeding risk while still protecting against stent thrombosis 1.
Procedure-Specific Guidance
- For patients with more recently placed stents (less than 12 months), elective procedures should be delayed if possible to reduce the risk of stent thrombosis.
- If the colonoscopy is urgent and includes high-risk interventions like polypectomy, a cardiologist should be consulted to determine the safest approach, considering the use of bridging therapy if necessary 1.
- After the procedure, any discontinued antiplatelet therapy should be resumed within 24-48 hours to maintain protection against stent thrombosis. This approach is supported by the latest guidelines and balances the risk of stent thrombosis against the risk of bleeding during colonoscopy, prioritizing the patient's safety and outcomes 1.
From the Research
Guidance for Patients with Drug-Eluting Stents Undergoing Colonoscopy
- The management of patients with drug-eluting stents who require colonoscopy involves careful consideration of the risk of stent thrombosis and bleeding complications 2.
- Dual antiplatelet therapy with aspirin and a thienopyridine (such as clopidogrel) is recommended for at least 12 months after drug-eluting stent placement to reduce the risk of stent thrombosis and cardiac complications 3.
- The risk of bleeding complications during colonoscopy may be increased in patients taking dual antiplatelet therapy, and the decision to continue or discontinue antiplatelet therapy should be made on a case-by-case basis, taking into account the individual patient's risk factors and the potential benefits and risks of the procedure 2.
- If antiplatelet therapy is discontinued, it is recommended to restart it as soon as possible after the procedure to minimize the risk of stent thrombosis 4.
- Some studies suggest that the use of proton pump inhibitors (PPIs) in combination with clopidogrel may be safe and not associated with an increased risk of major adverse cardiac events or bleeding complications 5.
Considerations for Colonoscopy Procedure
- The colonoscopy procedure should be performed by an experienced gastroenterologist or surgeon who is aware of the patient's medical history and the potential risks and complications associated with the procedure 2.
- The use of bleeding prophylaxis, such as tranexamic acid, may be considered in patients at high risk of bleeding complications 6.
- The patient should be closely monitored for signs of bleeding or stent thrombosis during and after the procedure, and appropriate treatment should be initiated promptly if any complications occur 3, 6.