Plavix (Clopidogrel) Cessation Before EGD and Esophageal Dilation
Stop Plavix (clopidogrel) 7 days before esophagogastroduodenoscopy (EGD) with esophageal dilation, as this is classified as a high-risk endoscopic procedure requiring full discontinuation of P2Y12 receptor antagonists. 1
Risk Classification
Esophageal dilation is categorized as a high-risk endoscopic procedure according to the 2021 British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. 1 This classification places it in the same category as:
- Endoscopic mucosal resection (EMR)
- Endoscopic submucosal dissection (ESD)
- Percutaneous endoscopic gastrostomy (PEG)
- Therapy of varices
- EUS-guided interventional therapy 1
Note that diagnostic EGD without dilation would be considered low-risk and would not require clopidogrel cessation. 1
Management Algorithm Based on Thrombotic Risk
For Patients at LOW Thrombotic Risk:
- Discontinue clopidogrel 7 days before the procedure (strong recommendation, moderate quality evidence) 1
- If the patient is on dual antiplatelet therapy (DAPT), continue aspirin throughout the perioperative period 1
- Resume clopidogrel 1-2 days after the procedure depending on hemostatic stability 1
For Patients at HIGH Thrombotic Risk:
High thrombotic risk conditions include: 1
- Ischemic heart disease without coronary stent
- Cerebrovascular disease
- Peripheral vascular disease
- Drug-eluting coronary stent placed within 6-12 months 2
- Bare metal coronary stent placed within 1 month 2
Management approach:
- Continue aspirin 1
- Consult with an interventional cardiologist before making any decision about stopping clopidogrel (strong recommendation, high quality evidence) 1
- Consider deferring the elective procedure until it is safer to interrupt clopidogrel 2
- If clopidogrel must be stopped, do so for 7 days, but maintain aspirin coverage 1
Critical Safety Considerations
Never stop clopidogrel without consulting the prescribing cardiologist, especially in patients with recent coronary stents. 2 The FDA label explicitly warns that discontinuation of clopidogrel increases the risk of cardiovascular events, and when therapy must be temporarily interrupted, it should be restarted as soon as possible. 3
The guidelines emphasize that stopping clopidogrel in high-risk cardiac patients can lead to stent thrombosis, myocardial infarction, or stroke—outcomes far more serious than procedural bleeding. 1, 3
Post-Procedure Management
- Resume clopidogrel 1-2 days after the procedure if there are no bleeding complications 1
- The timing of resumption should balance the hemorrhagic risk from the procedure against the thrombotic risk from continued clopidogrel cessation 1
- Counsel patients that they have an increased risk of post-procedure hemorrhage compared to patients not on antiplatelet therapy 1
Common Pitfalls to Avoid
Do not bridge with heparin when stopping clopidogrel—this is not recommended and may actually increase bleeding risk. 2 This differs from warfarin management, where bridging with low molecular weight heparin is appropriate for high thrombotic risk patients. 1
Do not stop aspirin in patients on DAPT who require clopidogrel cessation, as aspirin should be continued throughout the perioperative period. 1
Do not assume all EGDs require clopidogrel cessation—only therapeutic procedures like dilation are high-risk; diagnostic EGD with or without biopsies can be performed without stopping clopidogrel. 2
Evidence Quality Note
The recommendation to stop clopidogrel 7 days before high-risk procedures is based on moderate quality evidence with a strong recommendation grade. 1 The 7-day timeframe accounts for the irreversible inhibition of platelet function by clopidogrel, which persists for the lifespan of affected platelets (7-10 days). 3