Is it necessary to discontinue clopidogrel (Plavix) prior to undergoing a gastroscopy?

From the Guidelines

Clopidogrel typically does not need to be stopped for a routine diagnostic gastroscopy, but it should be discontinued 5-7 days before high-risk procedures such as polypectomy or endoscopic mucosal resection. For patients undergoing a standard gastroscopy without planned biopsies or interventions, continuing clopidogrel is generally considered safe, as the bleeding risk is low 1. However, the decision to discontinue clopidogrel should be individualized based on the patient's thrombotic risk versus bleeding risk.

Some key points to consider when making this decision include:

• The type of procedure being performed: high-risk procedures such as polypectomy or endoscopic mucosal resection may require discontinuation of clopidogrel, while low-risk procedures such as diagnostic endoscopy may not 1.
• The patient's thrombotic risk: patients with recent coronary stent placement, acute coronary syndrome, or other high thrombotic risk conditions may require consultation with a cardiologist before stopping clopidogrel 1.
• The patient's bleeding risk: patients with a high risk of bleeding, such as those with a history of bleeding disorders or taking other medications that increase the risk of bleeding, may require closer monitoring or alternative management strategies 1.

After therapeutic endoscopic procedures, clopidogrel can typically be resumed 24-72 hours following the procedure, depending on the intervention performed and whether adequate hemostasis was achieved 1. This recommendation balances the risk of procedure-related bleeding against the risk of thrombotic events from antiplatelet discontinuation. It is essential to weigh the risks and benefits of discontinuing clopidogrel on a case-by-case basis, considering the latest evidence and guidelines, such as those from the French working group on perioperative haemostasis (GIHP) and the French study group on thrombosis and haemostasis (GFHT) 1.

From the FDA Drug Label

Talk with your doctor about stopping your clopidogrel tablets before you have surgery. Your doctor may tell you to stop taking clopidogrel tablets at least 5 days before you have surgery to avoid excessive bleeding during surgery.

It is recommended to discontinue clopidogrel (Plavix) prior to undergoing a surgery, including a gastroscopy, to avoid excessive bleeding. The doctor may instruct to stop taking clopidogrel tablets at least 5 days before the procedure. However, the decision to discontinue clopidogrel should be made by the healthcare provider, considering the individual patient's risk of bleeding and cardiovascular events 2.

From the Research

Discontinuation of Clopidogrel Prior to Gastroscopy

• The decision to discontinue clopidogrel prior to undergoing a gastroscopy depends on various factors, including the type of procedure, the patient's thrombotic risk, and the risk of bleeding associated with the procedure 3, 4.
• For low-risk endoscopic procedures, guidelines recommend continuing P2Y12 receptor antagonists, such as clopidogrel, as single or dual antiplatelet therapy 4.
• For high-risk endoscopic procedures in patients at low thrombotic risk, guidelines recommend discontinuing P2Y12 receptor antagonists, including clopidogrel, five days before the procedure 4.
• However, in patients at high thrombotic risk, guidelines recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists, including clopidogrel 4.
• A survey among German gastroenterologists found that the majority of respondents perform endoscopic biopsides and polypectomies under clopidogrel monotherapy, but fewer perform these procedures under dual antiplatelet therapy 3.
• Emerging evidence suggests that anticoagulant and/or antiplatelet therapy may be safe to be continued in certain endoscopic procedures, such as cold snare polypectomy for small polyps (< 10 mm) 5.
• The American College of Gastroenterology-Canadian Association of Gastroenterology clinical practice guideline recommends temporary interruption of the P2Y12 receptor inhibitor, including clopidogrel, for patients on dual antiplatelet therapy for secondary prevention, while continuing aspirin 6.
• The British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guideline update emphasizes the importance of risk assessment and individualized decision-making when managing patients on antiplatelet or anticoagulant therapy undergoing endosscopy 7.