Should aspirin and clopidogrel be held before an ERCP that includes a sphincterotomy in a patient on dual antiplatelet therapy?

Management of Aspirin and Clopidogrel Before ERCP with Sphincterotomy

For patients on dual antiplatelet therapy undergoing ERCP with sphincterotomy, aspirin should be continued throughout the perioperative period while clopidogrel must be stopped 7 days before the procedure in patients at low thrombotic risk; for high thrombotic risk patients, aspirin is continued and cardiology consultation is mandatory before stopping clopidogrel. 1

Risk Stratification Framework

ERCP with sphincterotomy is definitively classified as a high-bleeding-risk endoscopic procedure requiring specific antiplatelet management. 1

Thrombotic Risk Categories

Low thrombotic risk conditions include: 1, 2

• Ischemic heart disease without coronary stent
• Cerebrovascular disease (remote stroke/TIA)
• Peripheral vascular disease
• Stable coronary artery disease >6 months from acute coronary syndrome or percutaneous coronary intervention

High thrombotic risk conditions include: 1, 2

• Drug-eluting coronary stent placed within 6-12 months
• Bare metal coronary stent placed within 1 month
• Acute coronary syndrome or PCI within 6 weeks to 6 months
• Recent stroke or TIA within 3 months

Very high thrombotic risk (defer procedure): 1

• Acute coronary syndrome or PCI within the last 6 weeks

Management Algorithm for Low Thrombotic Risk Patients

Clopidogrel management: 1, 2

• Discontinue clopidogrel 7 days before ERCP with sphincterotomy (strong recommendation, moderate quality evidence)
• The 7-day window reflects updated 2021 guidelines; older 5-day recommendations are now outdated 1, 2

Aspirin management: 1

• Continue aspirin throughout the perioperative period without interruption (strong recommendation, low quality evidence)
• This applies to all patients on dual antiplatelet therapy when clopidogrel is stopped

Post-procedure resumption: 1, 2

• Restart clopidogrel 1-2 days after sphincterotomy once adequate hemostasis is confirmed
• Resume based on perceived hemorrhagic risk balanced against thrombotic protection

Management Algorithm for High Thrombotic Risk Patients

Mandatory cardiology consultation: 1, 2

• Do not stop clopidogrel without discussing with an interventional cardiologist (strong recommendation, high quality evidence)
• The cardiologist must assess the risk-benefit ratio of discontinuing P2Y12 inhibitors

Aspirin management: 1

• Continue aspirin throughout the perioperative period regardless of clopidogrel decision

Procedural timing considerations: 1

• If patient is within 6 weeks of ACS or PCI, defer the elective ERCP until >6 weeks post-event
• If ERCP is deemed necessary within 6 months of cardiac event, continue dual antiplatelet therapy and accept increased bleeding risk with appropriate hemostatic precautions 1

Evidence on Bleeding Risk

Aspirin monotherapy: 3, 4

• Increases post-sphincterotomy bleeding risk modestly (OR 1.53,95% CI 1.03-2.28) 3
• Number needed to harm is 185 patients, indicating the absolute risk increase is small 3
• Withholding aspirin for 1 week does not reduce bleeding risk and eliminates cardiovascular protection 4

Dual antiplatelet therapy: 5, 6

• Small case series suggest ERCP with sphincterotomy can be performed safely on dual antiplatelet therapy when clinically necessary 5
• However, guidelines prioritize stopping clopidogrel when thrombotic risk permits due to theoretical bleeding concerns 1

Clopidogrel monotherapy: 3

• Expected to increase bleeding risk similar to or greater than aspirin based on platelet inhibition potency

Critical Pitfalls to Avoid

Never stop clopidogrel without cardiology input in high-risk patients: 1, 2

• Abrupt cessation in patients with recent coronary stents can precipitate catastrophic stent thrombosis
• This risk outweighs bleeding concerns in very high-risk patients

Do not use the outdated 5-day discontinuation period: 1, 2

• Current evidence-based standard is 7 days based on 2021 BSG/ESGE guidelines
• The 5-day window from 2016 guidelines has been superseded

Never stop aspirin when holding clopidogrel: 1

• Aspirin must be continued throughout to maintain baseline antiplatelet coverage
• Stopping both agents dramatically increases thrombotic risk

Avoid heparin bridging: 1

• Bridging anticoagulation is not recommended for antiplatelet therapy discontinuation
• This applies only to warfarin in high thromboembolic risk scenarios, not to P2Y12 inhibitors

Special Considerations

For patients with coagulopathy or liver disease: 2

• Obtain complete blood count and INR/PT prior to sphincterotomy
• Attempt to correct coagulopathy before performing sphincterotomy
• Consider alternative approaches like biliary stenting without sphincterotomy if coagulopathy cannot be corrected

Asian-Pacific guidelines concordance: 1

• APAGE/APSDE guidelines align with BSG/ESGE recommendations: continue aspirin, withhold P2Y12 inhibitors 5 days before in moderate-to-low thrombotic risk patients
• Resume P2Y12 inhibitors after adequate hemostasis is achieved