Should ticagrelor (Brilinta) be held before a colonoscopy that may involve biopsy or polypectomy, and if so, how many days prior should it be stopped?

Management of Ticagrelor (Brilinta) Before Colonoscopy

For colonoscopy with potential polypectomy, stop ticagrelor 3-5 days before the procedure, but for diagnostic colonoscopy without polypectomy, continue ticagrelor without interruption. 1

Risk Stratification by Procedure Type

Diagnostic colonoscopy with biopsies only:

• Continue ticagrelor without interruption—this is a low-bleeding-risk procedure 2
• No medication adjustment is required 2

Colonoscopy with polypectomy:

• This is classified as a high-bleeding-risk procedure requiring medication management 2
• The decision to hold ticagrelor depends on your patient's thrombotic risk profile 2

Management Algorithm Based on Thrombotic Risk

Low Thrombotic Risk Patients

Definition: Remote MI (>1 year ago), stable ischemic heart disease without stent, or peripheral vascular disease 2

• Stop ticagrelor 3-5 days before colonoscopy 1
• If on dual antiplatelet therapy (ticagrelor + aspirin), continue aspirin throughout the perioperative period 2
• Resume ticagrelor within 24 hours after the procedure if hemostasis is adequate 1

High Thrombotic Risk Patients

Definition: Drug-eluting stent placed ≤12 months ago, bare-metal stent placed ≤1 month ago, or acute coronary syndrome within 6 weeks 2

This requires mandatory cardiology consultation before any decision to stop ticagrelor 2. The following options should be discussed:

1. Defer elective colonoscopy until >6 weeks post-stent or post-ACS event 2
2. For small polyps (<1 cm): Proceed with cold snare polypectomy while continuing ticagrelor 2
3. Continue aspirin throughout if dual antiplatelet therapy must be modified 2

Evidence on Timing: Why 3-5 Days?

The 2022 American College of Chest Physicians guideline specifically recommends stopping ticagrelor 3-5 days (rather than 7-10 days) before elective non-cardiac surgery based on its pharmacokinetic profile 1. Ticagrelor has a relatively short plasma half-life of 12 hours and reversible platelet binding, allowing faster recovery of platelet function compared to clopidogrel 1. However, research shows significant interindividual variability in platelet function recovery, with some patients requiring up to 72 hours for adequate platelet aggregation 3.

The 3-5 day window balances bleeding risk against unnecessary prolonged interruption of antiplatelet therapy 1.

Bleeding Risk Data

• Meta-analysis data demonstrates that continuing P2Y12 inhibitors (including ticagrelor) during colonoscopy with polypectomy increases post-polypectomy bleeding risk approximately 2-fold (risk ratio 1.96,95% CI 1.36-2.83) 2
• Aspirin alone does not significantly increase post-polypectomy bleeding risk and should be continued 2, 4

Post-Procedure Management

• Resume ticagrelor within 24 hours after the procedure if no bleeding complications occur 1
• Counsel patients about increased bleeding risk compared to those not on antiplatelet therapy 2
• Monitor for delayed bleeding, which can occur up to 2 weeks post-polypectomy 2

Critical Pitfalls to Avoid

Never stop ticagrelor without consulting the prescribing cardiologist in patients with recent coronary stents—abrupt cessation can precipitate stent thrombosis and increase cardiovascular events 2. This is the most dangerous error in perioperative antiplatelet management.

Do not bridge with heparin when stopping ticagrelor—bridging is not recommended and increases bleeding risk without proven benefit 2, 5.

Do not stop aspirin if the patient is on dual antiplatelet therapy—aspirin must be continued throughout the perioperative period when ticagrelor is held 2.

Recognize that dual antiplatelet therapy (ticagrelor + aspirin) markedly worsens bleeding during high-risk procedures, but stopping both agents simultaneously dramatically increases thrombotic risk 2.