Should Plavix (clopidogrel) be discontinued 5 days before a colonoscopy and substituted with Lovenox (enoxaparin)?

Discontinuing Plavix Before Colonoscopy: Bridging with Lovenox is NOT Recommended

For colonoscopy with polypectomy, discontinue clopidogrel 5-7 days before the procedure but do NOT bridge with Lovenox—bridging antiplatelet therapy with heparin products is not indicated and may actually increase bleeding risk. 1, 2

Risk Stratification for Your Procedure

Colonoscopy falls into different bleeding risk categories depending on what is performed:

• Low-risk procedure: Diagnostic colonoscopy with biopsies only—clopidogrel can be continued 1
• High-risk procedure: Colonoscopy with polypectomy, EMR, or ESD—clopidogrel must be stopped 1

Management Algorithm Based on Thrombotic Risk

For Patients at LOW Thrombotic Risk:

• Stop clopidogrel 7 days (or at minimum 5 days) before colonoscopy 1, 2
• Continue aspirin throughout the perioperative period if the patient is already on it 1
• Do NOT bridge with Lovenox or any heparin product 2
• Resume clopidogrel 1-2 days after the procedure depending on hemostatic stability 1, 2

For Patients at HIGH Thrombotic Risk:

High thrombotic risk conditions include: 1, 2

• Recent coronary stent (especially <6-12 months for drug-eluting stents, <1 month for bare metal stents)
• Recent acute coronary syndrome
• Cerebrovascular disease with recent stroke/TIA
• Peripheral vascular disease

For these high-risk patients, you MUST consult with an interventional cardiologist before stopping clopidogrel (strong recommendation, high quality evidence). 1, 2 The cardiologist will help weigh the risk of thrombotic events versus bleeding complications. Continue aspirin regardless. 1

Why Lovenox Bridging is NOT Appropriate

Bridging with LMWH (Lovenox) is only recommended for patients on warfarin undergoing high-risk procedures, NOT for patients on antiplatelet agents like clopidogrel. 1 The guidelines explicitly state that heparin bridging should not be used when stopping P2Y12 inhibitors. 2 This is a critical distinction—antiplatelet therapy and anticoagulation therapy require completely different perioperative management strategies.

The Society of Interventional Radiology guidelines for GI procedures specify that therapeutic LMWH should be withheld only one dose before moderate-risk procedures, but this applies to patients already on anticoagulation, not as bridging therapy for antiplatelet agents. 1

Common Pitfalls to Avoid

• Do NOT bridge with heparin when stopping clopidogrel—this is not indicated and may increase bleeding risk 2
• Do NOT stop aspirin in patients on dual antiplatelet therapy who require clopidogrel cessation; aspirin should continue throughout 1, 2
• Do NOT unnecessarily stop clopidogrel for diagnostic colonoscopy without polypectomy—it can be safely continued for low-risk procedures 1
• Do NOT fail to consult cardiology in patients with recent coronary stents or high thrombotic risk before making any changes to antiplatelet therapy 1, 2

Post-Procedure Management

• Resume clopidogrel 1-2 days after colonoscopy if there are no bleeding complications 1, 2
• Counsel patients that they have an increased risk of post-procedure hemorrhage compared to patients not on antiplatelet therapy 1, 2
• Research shows that resuming anticoagulation/antiplatelet agents within 1-3 days post-polypectomy is safe and does not significantly increase hemorrhage rates 3

Evidence Quality Note

The 2021 BSG/ESGE guidelines provide the most current recommendations (strong recommendation, moderate quality evidence for stopping clopidogrel 5-7 days before high-risk procedures). 1 The 2016 version of these same guidelines provided similar recommendations. 1 A 2019 randomized controlled trial found that continuing clopidogrel resulted in slightly higher but not statistically significant bleeding rates (3.8% vs 3.6%), supporting the guideline approach of stopping it for high-risk procedures. 4