Management of Aspirin and Plavix Before Colonoscopy
For colonoscopy with polypectomy (high-risk procedure), discontinue Plavix (clopidogrel) 5 days before the procedure while continuing aspirin, unless the patient has high thrombotic risk requiring cardiology consultation. 1
Risk Stratification of Colonoscopy Procedures
The first critical step is determining whether your colonoscopy is low-risk or high-risk:
Low-risk procedures (diagnostic colonoscopy with biopsies only):
High-risk procedures (polypectomy, EMR, ESD):
- Requires medication management based on thrombotic risk 1
- Polypectomy is explicitly classified as high-risk 1
Management Algorithm for High-Risk Colonoscopy
Step 1: Assess Thrombotic Risk
Low thrombotic risk patients include:
- Ischemic heart disease without coronary stents 1
- Cerebrovascular disease 1
- Peripheral vascular disease 1
3 months after venous thromboembolism 1
High thrombotic risk patients include:
- Drug-eluting stents placed within 12 months 1
- Bare metal stents placed within 1 month 1
- Acute coronary syndrome or PCI within 6 months 1
- Prosthetic metal heart valve in mitral position 1
Step 2: Medication Management Based on Risk
For LOW thrombotic risk patients on dual antiplatelet therapy:
- Stop Plavix (clopidogrel) 5 days before colonoscopy 1
- Continue aspirin throughout the periprocedural period 1
- Resume Plavix within 24-48 hours after procedure once adequate hemostasis achieved 1, 2
For HIGH thrombotic risk patients on dual antiplatelet therapy:
- Continue aspirin 1
- Liaise with cardiology immediately regarding risk/benefit of discontinuing Plavix 1
- If procedure is within 6 weeks of PCI, defer the colonoscopy if possible 1
- If procedure is 6 weeks to 6 months post-PCI and cannot be deferred, continue both medications and accept higher bleeding risk, or defer until >6 months 1
Step 3: Timing Specifications
Plavix discontinuation:
- Stop exactly 5 days before the procedure (not 5-7 days) 1
- The platelet inhibition effect lasts 7-10 days, but 5 days provides adequate platelet recovery while minimizing thrombotic risk 2
- Do not exceed 7 days total interruption due to stent thrombosis risk 1
Aspirin management:
- Never discontinue aspirin in patients on dual therapy undergoing high-risk procedures, unless ultra-high bleeding risk 1
- Aspirin monotherapy can be safely continued for polypectomy 1
Critical Pitfalls to Avoid
Stopping both antiplatelet agents simultaneously:
- This dramatically increases stent thrombosis risk, with median time to thrombosis as short as 7 days 1
- Continuing one agent (aspirin) extends median time to thrombosis to 122 days 1
Holding Plavix for longer than necessary:
- The total duration of interruption should not exceed 7 days 1, 2
- Each additional day off therapy increases cardiovascular event risk 1
Resuming Plavix too early after polypectomy:
- Wait for adequate hemostasis, typically 24-48 hours 1
- Recent evidence shows continuing clopidogrel significantly increases major bleeding (18.2% vs 0%) in EMR procedures 3
Not distinguishing between aspirin and clopidogrel:
- Clopidogrel carries significantly higher bleeding risk than aspirin for polypectomy 3
- Aspirin continuation is safe even for high-risk procedures 1, 4
Special Considerations
For patients on aspirin monotherapy:
- Continue aspirin for both diagnostic and therapeutic colonoscopy 1
- Postpolypectomy bleeding risk with continued aspirin is low and manageable 1, 4
Restarting anticoagulation:
- Resume Plavix as soon as hemostasis is achieved, ideally within 24-48 hours 1, 2
- Restart aspirin immediately if it was held (though it typically should not be) 5
Documentation requirements: