Colonoscopic post‑polypectomy bleeding in patients on uninterruptedclopidogrel therapy: A systematic review and meta‑analysis

Abstract

Current guidelines recommend temporary cessation of clopidogrel for 7-10 days for patients on clopidogrel undergoing colonoscopy with polypectomy. However, recent prospective randomized controlled trials have advocated for uninterrupted clopidogrel, due to similar post-polypectomy bleeding (PPB) rates with and without continued clopidogrel therapy. Thus, a meta-analysis was conducted to assess the risk of PPB rate in patients on continued clopidogrel therapy. Systemically identified publications were used to compare the rate of PPB in patients on continued clopidogrel therapy with those who had interrupted clopidogrel therapy. The primary outcome was the incidence of PPB. The secondary outcomes were immediate PPB, delayed PPB and serious cardio-thrombotic events. This study has been registered in PROSPERO (no. CRD42018118325). A total of five studies were identified, which included 655 patients in the continued clopidogrel group and 6620 patients in the control group. There was an increased risk of PPB with continued clopidogrel [P=0.0003; risk ratio (RR), 1.96; 95% confidence interval (CI), 1.36-2.83). The rate of immediate PPB was slightly higher in the continued clopidogrel group (5.77% vs. 1.77%, respectively), but was not statistically significant (P=0.06; RR, 1.57; 95%CI, 0.98-2.51). The rate of delayed PPB was increased in the continued clopidogrel group (P=0.0008; RR, 3.10; 95%CI, 1.60-5.98). However, no significant difference in serious cardio-thrombotic events was observed within 30 days (P=0.74; RR, 0.78; 95%CI, 0.18-3.40). Although continued clopidogrel therapy decreased the incidence of serious cardio-thrombotic events, the risk of delayed PPB was increased. Therefore, endoscopists should make all preparations to prevent bleeding in the perioperative period for patients at high thrombotic risk and on continued clopidogrel therapy, if polypectomy cannot be reasonably postponed.

Risk of colonoscopic post-polypectomy bleeding in patients on single antiplatelet therapy: systematic review with meta-analysis

“…Few meta-analyses evaluated the colonoscopic postpolypectomy bleeding in patients on antiplatelet therapy [31][32][33][34]. However, none of these assessed the risk of PPB in single APAs.…”

“…ASGE guidelines recommend discontinuation of thienopyridines at least 5 to 7 days before high-risk endoscopic procedure or switching to aspirin monotherapy which may be continued safely in the peri-endoscopic period [ 4 ]. Two well-conducted meta-analyses assessed the pooled relative risk ratio of colonoscopic PPB in patients who continued clopidogrel therapy; however, they both included patients on an uninterrupted single APAs therapy or DAPT [ 32 , 34 ].…”

Establishment of a model for predicting delayed post-polypectomy bleeding: A real-world retrospective study

“…Furthermore, we also evaluated the effects of anticoagulant and antiplatelet drugs on DPPB. Previous studies have shown that patients who take these drugs are more likely to suffer significant bleeding events (12,(17)(18)(19). This study showed no significant difference in antithrombotic users, probably because patients taking these drugs in our center had been asked to have a cessation for more than 5-7 days according to the guideline (20).…”

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update

“…The groups were well matched but numbers were relatively small to examine differences in an infrequent event, and the rate of PPB in the placebo group was higher than expected when compared with other studies of patients undergoing polypectomy not previously on antiplatelet agents. A meta-analysis 76 assessing the risks of immediate and PPB associated with continued clopidogrel use at time of polypectomy included the above trial. A total of five studies were identified which included 655 patients in the 'continuing clopidogrel' group and 6620 controls with interrupted clopidogrel therapy.…”