Can patients continue taking their maintenance medications, such as antihypertensives (blood pressure medications), antidiabetics (diabetes medications), and anticonvulsants (seizure medications), including anticoagulants (blood thinners) like warfarin (coumadin), aspirin, or clopidogrel (plavix), while on bowel preparation for colonoscopy?

Management of Maintenance Medications During Colonoscopy Bowel Preparation

Most maintenance medications including antihypertensives, antidiabetics (with specific exceptions), and anticonvulsants should be continued during bowel preparation, while anticoagulants and antiplatelet agents require risk-stratified management based on the procedure type and patient's thrombotic risk.

General Maintenance Medications

Antihypertensives and Anticonvulsants

• Continue all antihypertensive and anticonvulsant medications without interruption during bowel preparation 1
• These medications do not interfere with bowel preparation quality and stopping them poses significant risks of hypertensive crisis or seizures 1
• Patients should take these medications with small sips of water even during the fasting period 1

Diabetes Medications - Specific Management Required

SGLT-2 Inhibitors (e.g., Jardiance):

• Hold on the morning of colonoscopy to avoid dehydration and electrolyte imbalances during bowel preparation 2
• Resume after the procedure once normal eating has resumed and kidney function has been verified 2
• Check kidney function before restarting, especially in high-risk patients 2

DPP-4 Inhibitors (e.g., Januvia):

• Continue through the colonoscopy preparation period without interruption 2
• Unlike GLP-1 receptor agonists, DPP-4 inhibitors do not significantly delay gastric emptying and do not increase risk of inadequate bowel preparation 2

Long-acting Insulin (e.g., Lantus):

• Reduce dose but do not completely discontinue to minimize hypoglycemia risk 2
• Monitor blood glucose more frequently during the preparation period, especially during the fasting phase 2

Sulfonylureas (e.g., Glipizide):

• Hold on the day of the procedure to minimize hypoglycemia risk during fasting 2
• Resume normal medication schedule once eating has resumed after the procedure 2

Anticoagulants and Antiplatelet Agents - Risk-Stratified Approach

Aspirin Management

For Diagnostic Colonoscopy (Low-Risk Procedure):

• Continue aspirin without interruption for all diagnostic procedures including biopsies 3
• Aspirin monotherapy has been found safe in colonoscopic polypectomy and does not require discontinuation 3

For High-Risk Procedures (Polypectomy, EMR, ESD):

• Continue aspirin for most polypectomies, as the risk of thrombotic events from discontinuation outweighs bleeding risk 3
• Consider discontinuation only for large colonic EMR (>2 cm), upper GI EMR, ESD, and ampullectomy on an individual patient basis depending on thrombotic versus hemorrhagic risk 3
• In patients on aspirin for secondary prevention, discontinuation carries a three-fold increased risk of cardiovascular or cerebrovascular events, with 70% occurring within 7-10 days 3

Clopidogrel (Plavix) Management

For Diagnostic Colonoscopy Without Polypectomy:

• Continue clopidogrel without interruption 4
• Diagnostic colonoscopy with or without biopsies is considered low-risk and does not require clopidogrel discontinuation 4

For Colonoscopy With Anticipated Polypectomy (High-Risk Procedure):

Low Thrombotic Risk Patients:

• Discontinue clopidogrel 7 days (5 days minimum) before the procedure 3, 4
• Continue aspirin if on dual antiplatelet therapy 3
• Resume clopidogrel 1-2 days after the procedure if no bleeding complications occur 4

High Thrombotic Risk Patients (Recent Stents, Acute Coronary Syndrome):

• Continue aspirin and consult with cardiologist before stopping clopidogrel 3, 4
• High-risk conditions include: drug-eluting stents within 12 months, bare metal stents within 1 month, recent acute coronary syndrome 3, 4
• Management options include: defer elective colonoscopy until safer to interrupt clopidogrel, use cold snare technique for small polyps (<1 cm) while continuing clopidogrel, or temporarily substitute aspirin for clopidogrel 7 days prior 4
• Never stop clopidogrel without consulting the prescribing cardiologist in patients with recent coronary stents 4

Warfarin (Coumadin) Management

For Diagnostic Colonoscopy (Low-Risk Procedure):

• Continue warfarin and check INR during the week before endoscopy 3
• If INR is within therapeutic range, continue usual daily dose 3
• If INR is above therapeutic range but <5, reduce daily dose until INR returns to therapeutic range 3
• If INR >5, defer the endoscopy and contact anticoagulation clinic for advice 3

For High-Risk Procedures (Polypectomy, EMR) - Low Thrombotic Risk:

• Stop warfarin 5 days before the procedure 3
• Check INR prior to procedure to ensure <1.5 3
• Restart warfarin on the day of the procedure with usual dose that night 3
• Check INR one week later to ensure adequate anticoagulation 3
• Do not bridge with LMWH for non-valvular atrial fibrillation, as this increases bleeding risk without reducing thrombotic events 3

For High-Risk Procedures - High Thrombotic Risk (Metal Heart Valves, AF with Mitral Stenosis):

• Stop warfarin 5 days before procedure and bridge with therapeutic LMWH 3
• Start LMWH 2 days after stopping warfarin 3
• Administer last dose of LMWH at least 24 hours prior to procedure 3
• Check INR prior to procedure to ensure <1.5 3
• Restart warfarin evening of procedure with usual dose 3
• Restart therapeutic LMWH on day after procedure and continue until satisfactory INR achieved 3

Important Caveat:

• All patients on warfarin have increased risk of post-procedure bleeding compared to non-anticoagulated patients, even when temporarily discontinued 3

Critical Pitfalls to Avoid

• Never discontinue anticonvulsants or antihypertensives during bowel preparation, as the risks far outweigh any theoretical benefits 1
• Never stop clopidogrel in patients with recent coronary stents without cardiology consultation 4
• Never bridge warfarin with LMWH for non-valvular atrial fibrillation undergoing high-risk procedures, as this increases bleeding without reducing thrombotic events 3
• Never restart SGLT-2 inhibitors without verifying kidney function after colonoscopy 2
• Never assume aspirin needs to be stopped for routine polypectomy, as thrombotic risk from discontinuation typically exceeds bleeding risk 3

Post-Procedure Resumption

• Resume antiplatelet or anticoagulant therapy within 1-2 days after the procedure depending on perceived bleeding and thrombotic risks 3
• Resume diabetes medications once normal eating has resumed 2
• Continue all other maintenance medications without interruption throughout the entire peri-procedural period 1