Plavix Use in Endoscopy - New Policy
As a practice, we have been reviewing the latest recommendations on the safe use of antiplatelet drugs in patients who need to undergo colonoscopy or similar procedures. These tests carry a small risk of hemorrhage with tissue removal, cautery, or dilations, which needs to be balanced against the importance of maintaining full anticoagulation for certain conditions.
There is a growing concern among cardiologists that the risk of clot formation is much higher than previously thought when Plavix is held for even a few days, with potential serious clinical consequences. A consensus guideline (from the American College of Cardiology and the American Heart Association plus others) in September 2007 concluded “that premature discontinuation of dual antiplatelet therapy markedly increases the risk of catastrophic stent thrombosis and death or myocardial infarction.”
In appreciation of this concern, we have revised our policy. We are currently recommending that patients continue on their usual Plavix dosing before and after a colonoscopy or upper endoscopy. When a treating cardiologist, neurologist or primary physician knows the patient well, they certainly can independently determine whether discontinuing Plavix for 5 days would be safe for their patient – and override our general policy – since they know the specific circumstances for the antiplatelet drug use.
Hemorrhage Risk
Older studies suggest about a 1% risk of bleeding with removal of a significant-sized polyp, although these studies were done before the Plavix era. There is little good information in large colonoscopy series to guide decisions on risks vs. benefits of holding these agents before and/or after polypectomy.
Disadvantages of Continuing Plavix
- Potential need to repeat a colonoscopy off of Plavix IF a larger polyp were found, due to the fear of increased risk of serious hemorrhage. We believe this would happen rarely, but repeating the colonoscopy would require another bowel prep.
- Potential need to repeat an upper endoscopy off Plavix IF dilation of an esophageal stricture was required.
- In addition to the inconvenience of a duplicate procedure, repeating either test could result in additional expense.
Special Case: Drug-Eluting Stents
In a study of 2,229 patients, stent thrombosis occurred in 0.7% of patients more than 30 days after placement of a DES, with case fatality rate of 45%. Thrombosis occurred in 29% of patients who prematurely stopped dual therapy. Other studies show a mortality rate of 20-45% if thrombosis occurs.
A study of 8,146 patients showed late stent thrombosis in 0.5% up to 3 years out.
No good data is available for colonoscopies in DES anticoagulation studies. One patient was described who underwent colonoscopy with polypectomy 343 or more days after DES placement while off antiplatelet therapy, and had a heart attack.
Thank you for taking the time to look over this information. Please call 612-871-1145 with any questions regarding this change in practice.
References:
Brilakis ES, Banerjee S, Berger P. The risk of drug-eluting stent thrombosis with noncardiac surgery. Current Cardiology Reports 2007; 9:406-411.
Brilakis ES, Banerjee S, Berger P. Perioperative management of patients with coronary stents. Journal of the American College of Cardiology 2007; 49: 2145-50.
Fleisher LA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. Circulation 2007; 116(17): 1971-96.
Fleisher LA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. Circulation 2007; 116(17): e418-e499.
Howard-Alpe GM, de Bono J, Hudsmith L, Orr WP, Foex P, Sear JW. Coronary artery stents and non-cardiac surgery. British Journal of Anesthesia 2007; 98: 560-74.