What medications should be held prior to colonoscopy?

Medication Management for Colonoscopy

For colonoscopy, medications should be managed based on procedure risk and patient thrombotic risk, with antiplatelet agents and anticoagulants requiring specific protocols for discontinuation before high-risk procedures like polypectomy. 1

Risk Stratification

Procedure Risk

• Low-risk procedures (can continue most medications):

  • Diagnostic colonoscopy with or without biopsy 1, 2

• High-risk procedures (may require medication adjustment):

  • Polypectomy
  • Endoscopic mucosal resection (EMR)
  • Endoscopic submucosal dissection (ESD) 1

Patient Thrombotic Risk

• Low thrombotic risk:

  • Atrial fibrillation without valvular disease
  • Ischemic heart disease without coronary stent 1, 2

• High thrombotic risk:

  • Prosthetic metal heart valve
  • Recent coronary stent placement (especially drug-eluting stents within 6-12 months)
  • Bare metal stents placed within the last month 1, 3

Specific Medication Management

Antiplatelet Agents

Aspirin

• Low-risk procedures: Continue aspirin therapy without interruption 1, 2
• High-risk procedures:
  • Continue aspirin even for high-risk procedures 1
  • Studies show aspirin/NSAIDs do not significantly increase post-polypectomy bleeding risk 4

P2Y12 Receptor Antagonists (Clopidogrel, Prasugrel, Ticagrelor)

• Low-risk procedures: Continue P2Y12 receptor antagonists 1, 3
• High-risk procedures with low thrombotic risk:
  • Discontinue 7 days before the procedure 1, 3
  • Continue aspirin if already prescribed 1
• High-risk procedures with high thrombotic risk:
  • Continue aspirin
  • Consult with interventional cardiologist about risk/benefit of discontinuing P2Y12 receptor antagonists 1, 3
  • For small polyps (<1 cm), cold snare polypectomy may be safer if proceeding on clopidogrel 1, 3

Anticoagulants

Warfarin

• Low-risk procedures:
  • Continue warfarin therapy 1
  • Check INR during the week before endoscopy to ensure it's within therapeutic range 1
• High-risk procedures with low thrombotic risk:
  • Discontinue warfarin 5 days before the procedure 1
  • Check INR prior to procedure to ensure <1.5 1
  • Restart warfarin evening of procedure with usual daily dose 1
• High-risk procedures with high thrombotic risk:
  • Temporarily discontinue warfarin and substitute with LMWH 1
  • Stop warfarin 5 days before endoscopy 1
  • Start LMWH 2 days after stopping warfarin 1
  • Administer last dose of LMWH at least 24 hours prior to procedure 1

Direct Oral Anticoagulants (DOACs)

• Low-risk procedures:
  • Omit the morning dose on the day of procedure 1, 2
• High-risk procedures:
  • Take last dose 3 days before the procedure 1
  • For patients on dabigatran with CrCl (eGFR) of 30-50 mL/min, take last dose 5 days prior 1
  • In patients with rapidly deteriorating renal function, consult a hematologist 1

Post-Procedure Management

• Resume antiplatelet or anticoagulant therapy 1-2 days after the procedure if no bleeding complications 1, 3
• For high thrombotic risk patients, restart therapy as soon as hemostasis is achieved 1
• Advise all patients on antiplatelets or anticoagulants of increased risk of post-procedure bleeding 1

Special Considerations

• Cold snare technique is preferred over hot snare for patients requiring polypectomy while on anticoagulation 2, 3
• The number of polyps removed per patient is a significant risk factor for post-polypectomy bleeding 4, 5
• Concomitant use of clopidogrel and aspirin/NSAIDs increases bleeding risk more than clopidogrel alone 5
• Never stop clopidogrel without consulting the prescribing physician, especially in patients with recent coronary stents 3