Is Clopidogrel Cessation Before Colonoscopy Unnecessary?
Is Clopidogrel Cessation Before Colonoscopy Unnecessary?
Hello, I'm Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. I wanted to talk with you briefly about another issue with Plavix. No, this is not another proton pump inhibitor and Plavix issue, but it's one that relates to how we do our gastrointestinal procedures.
A recent study from the authors at the Syracuse Veteran's Administration in New York suggests that holding Plavix/clopidogrel is perhaps not necessary in patients undergoing colonoscopy and even polypectomy. The basis of their article comes from a retrospective analysis of 142 patients who were taking clopidogrel/Plavix, and in comparison, nearly 1200 patients who were controls. All of these patients had polypectomies, and the authors showed that in the patients who had continued use of the clopidogrel/Plavix, there was no significant difference as it relates to acute bleeding between patients who were taking Plavix and those who were off their Plavix. There was, however, a significant difference, albeit somewhat nominal, in the delayed hemorrhage risk -- 3% vs 1%, and the P value was .02. There was a difference as it relates to hospitalization and complications during hospitalization -- a relatively nominal difference -- but statistically significant, again in favor of the patients who didn't receive Plavix, suggesting that this may relate to a more complex type of bleed. As far it relates to post-polypectomy bleeds, these were primarily late bleeds within the next 2 weeks after a polypectomy.
So, the authors concluded, based on this study, that for these procedures perhaps, Plavix need not be routinely held. Now, they looked at a number of risks as far as stratification biases, and there was no difference between the patients who were on Plavix and those who weren't as it relates to the type of polypectomy that they had (cold biopsy, hot biopsy, snare, cold snare, hot snare) - that didn't seem to influence things. They looked at the number of polypectomies performed and there seemed to be an inference that those people with more polypectomies were more likely to have a post-polypectomy bleed. In patients who were taking Plavix plus an antiplatelet agent, this was also a factor mitigating toward a higher risk for postpolypectomy bleed. Interestingly, Plavix by itself in a logistic regression analysis was not an independent risk for identifying patients with a bleed as opposed to polypectomy syndrome.
Now, what does this mean? Does it mean you should stop Plavix or you should start Plavix and have patients keep taking Plavix? One thing that is very important to point out in this study is that the majority of the patients -- nearly 70% -- had been taking clopidogrel for longer than 1 year. What does that mean? Well, they probably could have very safely stopped their clopidogrel for an elective procedure. I'm going to give you several take-home messages about this and suggest several things that you must read if you're doing colonoscopies and you're interfacing with patients who are taking clopidogrel.
Number 1: Understand that for elective procedures, a white paper consensus by the American College of Gastroenterology and the American College of Cardiology both said that patients who receive bare metal stents can stop their Plavix safely after 30 days, and patients who are taking Plavix (and typically aspirin) can stop their Plavix safely after 6 months if undergoing elective GI procedures. You must read this because this is really the standard and should be the standard of care. It's been endorsed by both the American College of Gastroenterology and the ACC (American College of Cardiology Board of Trustees), and published in the December issue of the American Journal of Gastroenterology. I'll annotate this for you to go back and check this reference. You should have this and must read it if you're doing these procedures.
Number 2: These patients should never stop taking aspirin. If you are stopping their aspirin, you are going against society guidelines. Please don't stop the aspirin! If you stop the clopidogrel, that's fine, but never mess with the aspirin.
Number 3: I never stop these drugs myself. I will advise the patient to stop the clopidogrel at the advice of their cardiologist or their neurologist or vascular surgeon. I don't want to be the one who stops these medications. I'll recommend to them that we believe their medication should be stopped and can be safely stopped, but the final order comes from the person who prescribed these medications. It's very important as a colonoscopist. I don't care if you're a general surgeon or a colorectal surgeon or a gastroenterologist performing these procedures. You don't want to be the one stopping the therapy that you weren't really managing in the patient's disease state. It's very important -- please go back and check the pre-procedural instructions from your office to make sure that these drugs are not routinely being held.
Number 4: These patients can stop their medications in anticipation of elective procedures. Why not? In the VA study, these patients had been taking Plavix for over a year. So, why wouldn't they have stopped their medications going into an elective procedure? The ASGE [American Society for Gastrointestinal Endoscopy] guidelines that were just recently published -- and I'll annotate these for you as a reference as well -- suggest that if you are undergoing an elective procedure, in anticipation of polypectomy, which is viewed as a high-risk gastrointestinal procedure, that your antiplatelet therapy should be held for 7-10 days. Again, you shouldn't stop these medications in the face of messing with the other disease states -- a cardiologist or a neurologist should be involved -- and the aspirin should also be continued. Please make sure that this is being done, but for an elective procedure (as was the case in these patients undergoing colonoscopy), I think you'd be below the standard of care if you routinely go ahead and say Plavix is alright based on this retrospective study, and it really is in defiance of the most recent published guidelines. Also, it doesn't make sense as it relates to the American College of Gastroenterology and Cardiology white paper consensus that was just published.
So, go back and look at your records and make sure that you're not giving routine instructions for stopping antiplatelet agents. Don't stop aspirin -- keep aspirin. Don't be the one to stop it yourself. Even stopping aspirin has its own risks. We've seen this in the most recent paper from Hong Kong from the Annals that we reviewed previously that stopping aspirin by itself, even for short periods of time, has factors that are associated with significant morbidity and even mortality.
So, putting this in perspective, this paper from the group at the VA in Syracuse, I think we need to put this into perspective and say it's nice but really doesn't necessarily answer the question about stopping medications routinely. We really should stop these medications for elective procedures. If you're forced to do a procedure that's not elective, you always can go ahead and perform these diagnostic procedures on clopidogrel and those type of agents.
Think about clipping. Think about doing some type of hemostatic delivery if you've found that this patient is at least at risk for a large polyp and you stumble in or pull out and come back at a time where you can stop the agents and readdress. The other point here is that the cold snare is more likely to be helpful for you in the patients taking clopidogrel. There was no difference as far as cold snare between clopidogrel patients or non-clopidogrel patients. You really do make a difference as it relates to the late polypectomy bleeds, which are all thermal-related. The acute bleed, if you see it's bleeding, you can certainly intervene at the point before you leave, but again cold snare I find very, very helpful, in particular for diminutive polyps.
So, go back and look what you're doing. Don't take this article too much as a cavalier approach to Plavix, and don't stop anything. I think we really need to put things into perspective, but also try to stratify the risks. Include the element of the prescription being held by the prescribing physician, and not you as a colonoscopist. Again, I think you'll find that this really will serve you well. Be in concert with the National Society guidelines. I think it's really important. Please review the most recent ASG guidelines and also the white paper consensus from the ACC and ACG. I look forward to chatting with you again. I hope this provides you some meaningful input and makes a meaningful difference to your patients. Thanks for listening.
Hello, I'm Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. I wanted to talk with you briefly about another issue with Plavix. No, this is not another proton pump inhibitor and Plavix issue, but it's one that relates to how we do our gastrointestinal procedures.
A recent study from the authors at the Syracuse Veteran's Administration in New York suggests that holding Plavix/clopidogrel is perhaps not necessary in patients undergoing colonoscopy and even polypectomy. The basis of their article comes from a retrospective analysis of 142 patients who were taking clopidogrel/Plavix, and in comparison, nearly 1200 patients who were controls. All of these patients had polypectomies, and the authors showed that in the patients who had continued use of the clopidogrel/Plavix, there was no significant difference as it relates to acute bleeding between patients who were taking Plavix and those who were off their Plavix. There was, however, a significant difference, albeit somewhat nominal, in the delayed hemorrhage risk -- 3% vs 1%, and the P value was .02. There was a difference as it relates to hospitalization and complications during hospitalization -- a relatively nominal difference -- but statistically significant, again in favor of the patients who didn't receive Plavix, suggesting that this may relate to a more complex type of bleed. As far it relates to post-polypectomy bleeds, these were primarily late bleeds within the next 2 weeks after a polypectomy.
So, the authors concluded, based on this study, that for these procedures perhaps, Plavix need not be routinely held. Now, they looked at a number of risks as far as stratification biases, and there was no difference between the patients who were on Plavix and those who weren't as it relates to the type of polypectomy that they had (cold biopsy, hot biopsy, snare, cold snare, hot snare) - that didn't seem to influence things. They looked at the number of polypectomies performed and there seemed to be an inference that those people with more polypectomies were more likely to have a post-polypectomy bleed. In patients who were taking Plavix plus an antiplatelet agent, this was also a factor mitigating toward a higher risk for postpolypectomy bleed. Interestingly, Plavix by itself in a logistic regression analysis was not an independent risk for identifying patients with a bleed as opposed to polypectomy syndrome.
Now, what does this mean? Does it mean you should stop Plavix or you should start Plavix and have patients keep taking Plavix? One thing that is very important to point out in this study is that the majority of the patients -- nearly 70% -- had been taking clopidogrel for longer than 1 year. What does that mean? Well, they probably could have very safely stopped their clopidogrel for an elective procedure. I'm going to give you several take-home messages about this and suggest several things that you must read if you're doing colonoscopies and you're interfacing with patients who are taking clopidogrel.
Number 1: Understand that for elective procedures, a white paper consensus by the American College of Gastroenterology and the American College of Cardiology both said that patients who receive bare metal stents can stop their Plavix safely after 30 days, and patients who are taking Plavix (and typically aspirin) can stop their Plavix safely after 6 months if undergoing elective GI procedures. You must read this because this is really the standard and should be the standard of care. It's been endorsed by both the American College of Gastroenterology and the ACC (American College of Cardiology Board of Trustees), and published in the December issue of the American Journal of Gastroenterology. I'll annotate this for you to go back and check this reference. You should have this and must read it if you're doing these procedures.
Number 2: These patients should never stop taking aspirin. If you are stopping their aspirin, you are going against society guidelines. Please don't stop the aspirin! If you stop the clopidogrel, that's fine, but never mess with the aspirin.
Number 3: I never stop these drugs myself. I will advise the patient to stop the clopidogrel at the advice of their cardiologist or their neurologist or vascular surgeon. I don't want to be the one who stops these medications. I'll recommend to them that we believe their medication should be stopped and can be safely stopped, but the final order comes from the person who prescribed these medications. It's very important as a colonoscopist. I don't care if you're a general surgeon or a colorectal surgeon or a gastroenterologist performing these procedures. You don't want to be the one stopping the therapy that you weren't really managing in the patient's disease state. It's very important -- please go back and check the pre-procedural instructions from your office to make sure that these drugs are not routinely being held.
Number 4: These patients can stop their medications in anticipation of elective procedures. Why not? In the VA study, these patients had been taking Plavix for over a year. So, why wouldn't they have stopped their medications going into an elective procedure? The ASGE [American Society for Gastrointestinal Endoscopy] guidelines that were just recently published -- and I'll annotate these for you as a reference as well -- suggest that if you are undergoing an elective procedure, in anticipation of polypectomy, which is viewed as a high-risk gastrointestinal procedure, that your antiplatelet therapy should be held for 7-10 days. Again, you shouldn't stop these medications in the face of messing with the other disease states -- a cardiologist or a neurologist should be involved -- and the aspirin should also be continued. Please make sure that this is being done, but for an elective procedure (as was the case in these patients undergoing colonoscopy), I think you'd be below the standard of care if you routinely go ahead and say Plavix is alright based on this retrospective study, and it really is in defiance of the most recent published guidelines. Also, it doesn't make sense as it relates to the American College of Gastroenterology and Cardiology white paper consensus that was just published.
So, go back and look at your records and make sure that you're not giving routine instructions for stopping antiplatelet agents. Don't stop aspirin -- keep aspirin. Don't be the one to stop it yourself. Even stopping aspirin has its own risks. We've seen this in the most recent paper from Hong Kong from the Annals that we reviewed previously that stopping aspirin by itself, even for short periods of time, has factors that are associated with significant morbidity and even mortality.
So, putting this in perspective, this paper from the group at the VA in Syracuse, I think we need to put this into perspective and say it's nice but really doesn't necessarily answer the question about stopping medications routinely. We really should stop these medications for elective procedures. If you're forced to do a procedure that's not elective, you always can go ahead and perform these diagnostic procedures on clopidogrel and those type of agents.
Think about clipping. Think about doing some type of hemostatic delivery if you've found that this patient is at least at risk for a large polyp and you stumble in or pull out and come back at a time where you can stop the agents and readdress. The other point here is that the cold snare is more likely to be helpful for you in the patients taking clopidogrel. There was no difference as far as cold snare between clopidogrel patients or non-clopidogrel patients. You really do make a difference as it relates to the late polypectomy bleeds, which are all thermal-related. The acute bleed, if you see it's bleeding, you can certainly intervene at the point before you leave, but again cold snare I find very, very helpful, in particular for diminutive polyps.
So, go back and look what you're doing. Don't take this article too much as a cavalier approach to Plavix, and don't stop anything. I think we really need to put things into perspective, but also try to stratify the risks. Include the element of the prescription being held by the prescribing physician, and not you as a colonoscopist. Again, I think you'll find that this really will serve you well. Be in concert with the National Society guidelines. I think it's really important. Please review the most recent ASG guidelines and also the white paper consensus from the ACC and ACG. I look forward to chatting with you again. I hope this provides you some meaningful input and makes a meaningful difference to your patients. Thanks for listening.
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