Clopidogrel, ticagrelor or prasugrel use before and after endoscopic procedures

If antiplatelet therapy has been prescribed for a specific period (eg dual antiplatelet therapy for 12 months following an acute coronary syndrome or implantation of a drug-eluting stent), delay elective procedures until after this period whenever possible. Early interruption of antiplatelet therapy increases the risk of ischaemic events and thrombosisKeeling, 2016.

For all patients scheduled for a procedure with a low risk of bleeding, P2Y₁₂ inhibitor therapy (eg clopidogrel, ticagrelor, prasugrel) may be continuedASGE Standards of Practice Committee, 2016Chan, 2018Veitch, 2016.

For patients with a low risk of a thromboembolic event scheduled for a procedure with a high risk of bleeding, clopidogrel and ticagrelor should be stopped 5 days before the procedure, and prasugrel 7 days before the procedureChan, 2018. Aspirin (which presents less of a procedural bleeding risk) may be substituted until P2Y₁₂ inhibitor therapy can be safely restarted, but this should be considered on a case-by-case basisASGE Standards of Practice Committee, 2016Chan, 2018Veitch, 2016.

For patients with a high risk of a thromboembolic event scheduled for a procedure with a high risk of bleeding, if the procedure cannot be deferred, seek expert advice. Stopping P2Y₁₂ inhibitor therapy (eg clopidogrel, ticagrelor, prasugrel) may be required. If temporary interruption of P2Y₁₂ inhibitor therapy is required, stop clopidogrel and ticagrelor 5 days before the procedure, and prasugrel 7 days before the procedureASGE Standards of Practice Committee, 2016. If P2Y₁₂ inhibitor therapy is stopped, aspirin should be substituted, or (in the case of dual antiplatelet therapy) continued. Restart antiplatelet therapy as soon as possible after the procedure, ideally within 48 hoursKristensen, 2014.