For a patient on clopidogrel (Plavix) needing a colonoscopy, how many days should the drug be held before a routine diagnostic versus a therapeutic procedure, and when can it be resumed, especially if the patient has a recent coronary stent or acute coronary syndrome?

Clopidogrel Management Before Colonoscopy

For routine diagnostic colonoscopy without polypectomy, continue clopidogrel; for colonoscopy with polypectomy, discontinue clopidogrel 7 days before the procedure in patients at low thrombotic risk, and resume 1-2 days after if hemostasis is adequate. 1

Risk Stratification by Procedure Type

Diagnostic colonoscopy with biopsies only:

• Continue clopidogrel without interruption, as this is classified as a low-risk procedure with minimal bleeding risk 2, 1
• No medication adjustment is required regardless of thrombotic risk status 1

Colonoscopy with polypectomy:

• Classified as a high-risk endoscopic procedure requiring medication management 2, 1
• Management depends on patient's thrombotic risk profile (see below) 1

Management Algorithm Based on Thrombotic Risk

Low Thrombotic Risk Patients

Definition: Remote myocardial infarction (>1 year), ischemic heart disease without stent, cerebrovascular disease, or peripheral vascular disease 2, 1

Management:

• Discontinue clopidogrel 7 days before colonoscopy (strong recommendation, moderate quality evidence) 2, 1
• If on dual antiplatelet therapy (DAPT), continue aspirin throughout the perioperative period 2, 3, 1
• Resume clopidogrel 1-2 days after the procedure if no bleeding complications occur 3, 1

High Thrombotic Risk Patients

Definition includes:

• Drug-eluting coronary stent placed ≤6-12 months ago 1
• Bare metal coronary stent placed ≤1 month ago 1
• Acute coronary syndrome (ACS) within the preceding 6 weeks 1

Management options:

1. Defer elective colonoscopy until >6 weeks post-ACS or until safer to interrupt clopidogrel 1
2. Mandatory cardiology consultation before making any decision about stopping clopidogrel (strong recommendation, high quality evidence) 2, 3, 1
3. For small polyps (<1 cm), consider cold snare polypectomy technique while continuing clopidogrel, which does not significantly increase bleeding risk 1
4. Continue aspirin throughout and consult interventional cardiologist about risk/benefit of discontinuing clopidogrel 2, 3

Evidence on Bleeding Risk

Quantified bleeding risk with continued clopidogrel:

• Meta-analysis demonstrates a 1.96-fold increased risk of post-polypectomy bleeding (95% CI 1.36-2.83) when clopidogrel is continued 1
• Delayed post-polypectomy bleeding rate: 3.5% with clopidogrel vs 1.0% without (p=0.02) 4
• Bleeding requiring hospitalization/intervention: 2.1% with clopidogrel vs 0.4% without (p=0.04) 4

Important nuance from recent high-quality RCT:

• A 2019 double-blind randomized trial found no statistically significant difference in delayed bleeding between continued clopidogrel (3.8%) versus placebo (3.6%, p=0.945) 5
• However, this study was likely underpowered, and guideline recommendations remain to discontinue clopidogrel for high-risk procedures 2, 1

Concomitant aspirin/NSAID use:

• Dual antiplatelet therapy (clopidogrel + aspirin/NSAID) significantly increases bleeding risk (OR 3.7,95% CI 1.6-8.5) 4
• Clopidogrel alone was not an independent risk factor for post-polypectomy bleeding in one study 4

Post-Procedure Management

Resumption timing:

• Resume clopidogrel 1-2 days after colonoscopy if no bleeding complications occur 3, 1, 6
• For high thrombotic risk patients with recent coronary stents, prioritize earlier resumption (within 12-24 hours if hemostasis is secure) 1
• Never delay resumption beyond 5 days in high-risk patients 3

Patient counseling:

• Advise patients of increased risk of delayed bleeding compared to those not on antiplatelet therapy 3, 1
• Delayed bleeding can occur up to 2 weeks post-polypectomy 1

Critical Pitfalls to Avoid

Never stop clopidogrel without cardiology consultation in:

• Patients with drug-eluting stents placed within 12 months 1
• Patients with bare metal stents placed within 1 month 1
• Patients with ACS within 6 weeks 1
• Abrupt cessation can precipitate stent thrombosis with ~10% increase in cardiovascular events 1

Do not bridge with heparin:

• Heparin bridging when stopping clopidogrel is not recommended and increases bleeding risk without proven benefit 3, 1

Do not stop aspirin in DAPT patients:

• When clopidogrel must be discontinued in patients on DAPT, continue aspirin throughout the perioperative period 2, 3, 1