Post-polypectomy Bleeding in Patients on Clopidogrel
Post-polypectomy Bleeding in Patients on Clopidogrel
Background Current guidelines recommend the cessation of clopidogrel therapy 5 days and 7–10 days prior to colonoscopic polypectomy. Recent studies have advocated for continued clopidogrel as post-polypectomy bleeding (PPB) rates have been similar to those in the general population not on antithrombotic therapy.
Aim To assess colonoscopic post-polypectomy bleeding in patients on continued clopidogrel therapy.
Methods A literature search was conducted for studies that investigated PPB in patients on continued clopidogrel therapy. The primary outcome of interest was the pooled relative risk ratio (RR) of colonoscopic PPB in patients on continued clopidogrel therapy vs. controls. Secondary outcomes were a comparison of immediate and delayed colonoscopy PPB in patients on continued clopidogrel therapy vs. controls.
Results Five observational studies included 574 subjects on continued clopidogrel therapy and 6169 control subjects. The pooled RR for PPB on continued clopidogrel therapy was 2.54 (95% CI 1.68–3.84, P < 0.00001). For immediate PPB there was a nonsignificant pooled RR of 1.76 (95% CI 0.90–3.46, P = 0.10), and delayed PPB there was a significant pooled RR of 4.66 (95% CI 2.37–9.17, P < 0.00001).
Conclusions The results of this meta-analysis suggest that continued clopidogrel increases the risk of delayed but not immediate post-polypectomy bleeding. Clopidogrel interruption in individuals with coronary artery disease predisposes to serious acute ischaemic events. In high-risk patients, endoscopists should be cognisant of these risks and consider deferring elective colonoscopy and polypectomy until it is considered safe to interrupt clopidogrel therapy.
With the successful implementation of population-based screening programs for colorectal cancer in many jurisdictions, rates of colonoscopy and subsequent polypectomy rates are rising. Bleeding is the most common complication of colonoscopic polypectomy with rates ranging from 0.3% to 6%. Immediate post-polypectomy bleeding (PPB) is observed at the time of the procedure, and delayed PPB can occur from hours to 30 days post procedure. Contributing risk factors for PPB include patient-related factors such as advanced age, hypertension, coronary artery disease, diabetes mellitus, chronic renal failure and chronic obstructive pulmonary disease. Procedure-related factors include size of the polyp removed, number of polyps removed, location and mode of removal.
Although colorectal cancer is a leading cause of malignancy-related mortality it is overshadowed by the growing burden of cardiovascular disease. Clopidogrel or thienopyridine therapy is a cornerstone for treatment of myocardial ischaemia, and secondary prevention of cardiovascular and cerebrovascular events. The most frequent indication for clopidogrel prescription is prevention of coronary artery stent thrombosis following percutaneous coronary intervention (PCI). A meta-analysis by Eisenberg et al. demonstrated discontinuation of antithrombotic therapy is the dominant risk factor for coronary artery stent thrombosis in patients with drug-eluting stents, with events occurring as early as 5–10 days after cessation of clopidogrel therapy.
Current guidelines recommend the cessation of clopidogrel therapy 5 days and 7–10 days prior to colonoscopic polypectomy to reduce the risk of procedure-related bleeding. This recommendation is based upon consensus expert opinion due to the lack of randomised control trials. Despite these recommendations, a survey of gastroenterologists in the United States showed that only 48% of respondents discontinued clopidogrel accordingly prior to colonoscopic polypectomy. Recent studies by Feagins and Singh et al. have advocated the continued use of clopidogrel therapy for colonoscopic polypectomy as their studies have shown PPB rates similar to those reported in the general population. We performed a meta-analysis of studies assessing the risk of clinically significant immediate and delayed PPB in patients receiving continued clopidogrel therapy.
Abstract and Introduction
Abstract
Background Current guidelines recommend the cessation of clopidogrel therapy 5 days and 7–10 days prior to colonoscopic polypectomy. Recent studies have advocated for continued clopidogrel as post-polypectomy bleeding (PPB) rates have been similar to those in the general population not on antithrombotic therapy.
Aim To assess colonoscopic post-polypectomy bleeding in patients on continued clopidogrel therapy.
Methods A literature search was conducted for studies that investigated PPB in patients on continued clopidogrel therapy. The primary outcome of interest was the pooled relative risk ratio (RR) of colonoscopic PPB in patients on continued clopidogrel therapy vs. controls. Secondary outcomes were a comparison of immediate and delayed colonoscopy PPB in patients on continued clopidogrel therapy vs. controls.
Results Five observational studies included 574 subjects on continued clopidogrel therapy and 6169 control subjects. The pooled RR for PPB on continued clopidogrel therapy was 2.54 (95% CI 1.68–3.84, P < 0.00001). For immediate PPB there was a nonsignificant pooled RR of 1.76 (95% CI 0.90–3.46, P = 0.10), and delayed PPB there was a significant pooled RR of 4.66 (95% CI 2.37–9.17, P < 0.00001).
Conclusions The results of this meta-analysis suggest that continued clopidogrel increases the risk of delayed but not immediate post-polypectomy bleeding. Clopidogrel interruption in individuals with coronary artery disease predisposes to serious acute ischaemic events. In high-risk patients, endoscopists should be cognisant of these risks and consider deferring elective colonoscopy and polypectomy until it is considered safe to interrupt clopidogrel therapy.
Introduction
With the successful implementation of population-based screening programs for colorectal cancer in many jurisdictions, rates of colonoscopy and subsequent polypectomy rates are rising. Bleeding is the most common complication of colonoscopic polypectomy with rates ranging from 0.3% to 6%. Immediate post-polypectomy bleeding (PPB) is observed at the time of the procedure, and delayed PPB can occur from hours to 30 days post procedure. Contributing risk factors for PPB include patient-related factors such as advanced age, hypertension, coronary artery disease, diabetes mellitus, chronic renal failure and chronic obstructive pulmonary disease. Procedure-related factors include size of the polyp removed, number of polyps removed, location and mode of removal.
Although colorectal cancer is a leading cause of malignancy-related mortality it is overshadowed by the growing burden of cardiovascular disease. Clopidogrel or thienopyridine therapy is a cornerstone for treatment of myocardial ischaemia, and secondary prevention of cardiovascular and cerebrovascular events. The most frequent indication for clopidogrel prescription is prevention of coronary artery stent thrombosis following percutaneous coronary intervention (PCI). A meta-analysis by Eisenberg et al. demonstrated discontinuation of antithrombotic therapy is the dominant risk factor for coronary artery stent thrombosis in patients with drug-eluting stents, with events occurring as early as 5–10 days after cessation of clopidogrel therapy.
Current guidelines recommend the cessation of clopidogrel therapy 5 days and 7–10 days prior to colonoscopic polypectomy to reduce the risk of procedure-related bleeding. This recommendation is based upon consensus expert opinion due to the lack of randomised control trials. Despite these recommendations, a survey of gastroenterologists in the United States showed that only 48% of respondents discontinued clopidogrel accordingly prior to colonoscopic polypectomy. Recent studies by Feagins and Singh et al. have advocated the continued use of clopidogrel therapy for colonoscopic polypectomy as their studies have shown PPB rates similar to those reported in the general population. We performed a meta-analysis of studies assessing the risk of clinically significant immediate and delayed PPB in patients receiving continued clopidogrel therapy.
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