What is the perioperative management of aspirin and Plavix (clopidogrel) dual antiplatelet therapy (DAPT) for secondary stroke prevention in patients undergoing colonoscopy?

From the Guidelines

For patients on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel (Plavix) for secondary stroke prevention who need a colonoscopy, the management should prioritize continuing aspirin and considering temporary discontinuation of clopidogrel 5-7 days before high-risk procedures, with resumption 24-48 hours after if hemostasis is adequate, as supported by the most recent guidelines 1. The decision to manage DAPT in patients undergoing colonoscopy involves balancing the risk of bleeding against the risk of thrombotic events, such as stroke.

• For low-risk colonoscopy procedures (diagnostic without biopsies), continuing both aspirin and clopidogrel without interruption is generally recommended, as the risk of bleeding is low and the benefit of continuing antiplatelet therapy to prevent thrombotic events outweighs this risk.
• For high-risk procedures (polypectomy, biopsy), aspirin can typically be continued due to its essential role in preventing thrombotic events, but clopidogrel should be temporarily discontinued to minimize the risk of bleeding, as suggested by guidelines from the British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy 1.
• In patients with very high thrombotic risk (recent stroke within 90 days or recent stent placement), it is crucial to consider delaying elective colonoscopy if possible, or consulting with the patient's neurologist or cardiologist about the best approach, which may include continuing DAPT throughout the procedure or implementing a bridge therapy with shorter-acting antiplatelet agents, as recommended by the American Heart Association/American Stroke Association 1. The management strategy should be individualized based on the patient's specific risk factors for bleeding and thrombosis, and the type of colonoscopy procedure being performed.
• After the procedure, DAPT should be resumed as soon as hemostasis is adequate to minimize thrombotic risk, typically within 24-48 hours for most patients, as emphasized by the Journal of the American College of Cardiology 1. It is essential to weigh the risks and benefits of continuing or discontinuing DAPT in the context of colonoscopy, considering the latest evidence and guidelines to optimize patient outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Perioperative Management of Aspirin and Plavix DAPT for Secondary Stroke Prevention

• The management of anticoagulants and antiplatelet agents during colonoscopy is a complex issue, requiring careful consideration of the risks of bleeding and thromboembolic complications 2.
• For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is less than 0.5%, but this risk is increased in patients taking anticoagulants, especially warfarin and thienopyridines 2.
• The risk of postpolypectomy bleeding in patients who continue aspirin or other nonsteroidal anti-inflammatory drugs is not significantly different from that of patients who do not take these medications 2, 3.
• However, for patients who continue thienopyridines, such as Plavix, and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4% 2.

Aspirin and Plavix Use in Secondary Stroke Prevention

• Aspirin is commonly used for secondary stroke prevention, and its continuation during colonoscopy is generally considered safe 3, 4.
• Plavix, a thienopyridine, is also used for secondary stroke prevention, often in combination with aspirin, and its management during colonoscopy requires careful consideration of the risks and benefits 2, 5, 6.
• The choice of antiplatelet agent and the decision to continue or discontinue it during colonoscopy should be individualized based on the patient's risk factor profile and treatment tolerance 5.

Clinical Judgment and Decision-Making

• The decision to interrupt or continue anticoagulants and antiplatelet agents during colonoscopy involves considerable exercise of clinical judgment, taking into account the patient's underlying medical conditions, the type of procedure being performed, and the potential risks and benefits of continuing or discontinuing these medications 2, 4.