Patients on both aspirin and a second antiplatelet agent (dual antiplatelet therapy or DAPT) are usually instructed in the U.S. and Europe to stop thienopyridine therapy for 5 to 7 days before colonoscopy, while continuing aspirin. Patients often resume the second agent one or more days after colonoscopy, depending on procedures performed.
In a single-center, single-endoscopist, randomized controlled trial from Korea, 42 patients on DAPT (75.9% clopridogel; 21% ticagrelor; and 2.9% prasugrel) with 104 eligible polyps continued DAPT throughout colonoscopy and polypectomy, and 48 patients stopped their second agent one week prior to colonoscopy and resumed it one day after the procedure.
The DAPT group had an average of 2.5 polyps per patient resected versus 2.2 in the aspirin-only group. About one third of lesions were 6 to 10 mm in size, and 88% were adenomas.
Intraprocedural bleeding was not different between the groups (4.8% DAPT vs 2.2% aspirin), but the rate of “nonsignificant” hematochezia was 19% with DAPT versus 8.9% with aspirin, (P=0.170), and one patient in the DAPT group required repeat endoscopy and treatment with hemoclips two days after polypectomy. A composite bleeding outcome was significantly more common with DAPT, with polyp size 6 to 10 mm predicting bleeding in a multivariable analysis.
The authors concluded that cold snare polypectomy of lesions ≤10 mm in patients on DAPT is safe. I’m not so sure. A 20% rate of “nonsignificant” hematochezia could generate a substantial number of postprocedural phone calls, and a management paradigm resulting in the need for reintervention in 2.4% of patients undergoing polyp resection of lesions ≤10 mm in size would not be ideal. It’s an important issue, and we need larger trials.
Won D, Kim JS, Ji JS, Kim BW, Choi H. Cold snare polypectomy in patients taking dual antiplatelet therapy: a randomized trial of discontinuation of thienopyridines. Clin Transl Gastroenterol
2019 Oct 10. (Epub ahead of print) (https://doi.org/10.14309/ctg.0000000000000091