Management of Brilinta (Ticagrelor) Before Colonoscopy in Post-PCI Patient
For a patient 6 months post-PCI on Brilinta planning colonoscopy in one month (7 months post-PCI), you should discontinue Brilinta 5-7 days before the procedure and transition to aspirin monotherapy, which can be continued through the colonoscopy. 1, 2
Rationale for Discontinuation Timing
At 7 months post-PCI, this patient is well beyond the critical 6-month DAPT window recommended by ESC guidelines for chronic coronary syndrome patients. 1, 2 The default DAPT duration is up to 6 months after PCI-stenting, after which lifelong single antiplatelet therapy is indicated. 1, 2
- The patient has already completed the recommended DAPT duration, making it safe to transition to single antiplatelet therapy before the procedure. 1, 2
- Ticagrelor has a relatively short half-life (approximately 12 hours for active metabolites), with platelet function recovering within 5 days of discontinuation, though 7 days provides additional safety margin. 1
Specific Periprocedural Management
Before Colonoscopy:
- Stop Brilinta 5-7 days before the procedure to allow adequate platelet function recovery. 1
- Continue aspirin 75-100 mg daily throughout the periprocedural period, as aspirin monotherapy does not significantly increase post-polypectomy bleeding risk. 3, 4
- The patient should remain on aspirin alone during this bridging period. 1, 2
After Colonoscopy:
- Resume aspirin 75-100 mg daily lifelong as single antiplatelet therapy—do not restart Brilinta. 1, 2
- Alternatively, clopidogrel 75 mg daily is equally acceptable as lifelong single antiplatelet therapy if aspirin is contraindicated. 1, 2
Evidence Supporting This Approach
Bleeding Risk Considerations:
- Uninterrupted P2Y12 inhibitor therapy (like ticagrelor/clopidogrel) significantly increases post-polypectomy bleeding risk, with odds ratios of 4.43 for immediate bleeding and 10.80 for delayed bleeding. 3
- A randomized trial showed that continuing clopidogrel through colonoscopy resulted in 3.8% delayed bleeding versus 3.6% with placebo (not statistically significant but trending higher). 4
- Aspirin monotherapy, in contrast, shows minimal to no increased bleeding risk during colonoscopy with polypectomy. 3
Thrombotic Risk Considerations:
- The highest risk period for stent thrombosis is within the first 3 months post-PCI, with risks substantially declining after 6 months. 1
- At 7 months post-PCI, the patient is in the chronic stable phase where single antiplatelet therapy is the standard of care. 1, 2
- Premature DAPT discontinuation within 30 days carries catastrophic risk (20-40% mortality from stent thrombosis), but this concern does not apply at 7 months. 1, 2
Critical Pitfalls to Avoid
- Do not restart dual antiplatelet therapy after colonoscopy—the patient should remain on aspirin monotherapy indefinitely. 1, 2
- Do not hold aspirin unless there are specific high-risk bleeding features during the colonoscopy itself (large polyps >2cm, multiple polypectomies). 3
- Ensure coordination with the interventional cardiologist if there were any high-risk features at the time of PCI (left main stenting, bifurcation stenting, prior stent thrombosis), though at 7 months these would not typically change management. 1
Special Circumstances That Would Alter This Plan
If the patient had undergone complex high-risk PCI (left main, two-stent bifurcation, chronic total occlusion), some data suggest extended DAPT beyond 12 months may provide net benefit. 5, 6 However, even in these cases, temporary interruption at 7 months for a necessary procedure is reasonable with aspirin continuation. 1