Holding Prasugrel (Effient) After Esophagogastroduodenoscopy (EGD)
Prasugrel should be discontinued for 7 days before an EGD if it is a high-risk endoscopic procedure, and can be resumed 1-2 days after the procedure if hemostasis is achieved. 1
Classification of EGD Procedures by Risk
Low-Risk EGD Procedures
- Diagnostic EGD with or without biopsy 1
- For low-risk procedures, prasugrel can be continued without interruption 1
High-Risk EGD Procedures
- EGD with interventions such as EMR (endoscopic mucosal resection), ESD (endoscopic submucosal dissection), or therapy of varices 1
- Endoscopic ultrasound (EUS) with sampling or interventional therapy 1
- Esophageal or gastric radiofrequency ablation 1
Management Algorithm for Prasugrel Around EGD
Before High-Risk EGD
- Discontinue prasugrel 7 days before the procedure for patients at low thrombotic risk 1
- For patients at high thrombotic risk, consult with an interventional cardiologist about the risk/benefit of discontinuing prasugrel 1
- Continue aspirin therapy if the patient is on dual antiplatelet therapy (DAPT) 1
After EGD
- Resume prasugrel 1-2 days after the procedure depending on the perceived hemorrhagic and thrombotic risks 1
- Advise patients that there is an increased risk of post-procedure hemorrhage compared with patients not on antiplatelet therapy 1
Thrombotic Risk Assessment
High Thrombotic Risk Conditions
- Recent coronary stent placement (especially drug-eluting stents within 6-12 months or bare metal stents within 1 month) 1, 2
- History of myocardial infarction 2
- Diabetes with coronary artery disease 2
Pharmacodynamic Considerations
- Platelet aggregation gradually returns to baseline values over 5-9 days after discontinuation of prasugrel 3
- This recovery time reflects new platelet production rather than pharmacokinetics of prasugrel 3
- At least 75% of patients return to baseline platelet reactivity by day 7 after prasugrel discontinuation 4
Special Considerations
- For patients weighing <60 kg, consider a reduced maintenance dose of 5 mg (instead of standard 10 mg) due to increased exposure to the active metabolite and higher bleeding risk 2, 3
- Prasugrel is generally not recommended in patients ≥75 years of age due to increased risk of fatal and intracranial bleeding 2
- Prasugrel is contraindicated in patients with a history of TIA or stroke 2
Common Pitfalls to Avoid
- Failing to distinguish between low-risk and high-risk endoscopic procedures when deciding whether to discontinue prasugrel 1
- Not consulting with a cardiologist for patients at high thrombotic risk before discontinuing prasugrel 1
- Resuming prasugrel too early after a high-risk procedure, which may increase bleeding risk 1
- Not considering individual bleeding risk factors such as low body weight, age ≥75 years, or concomitant use of medications that increase bleeding risk 2, 3