When to hold medications before colonoscopy?
Overview
Patients will ask pharmacist which medications need to be held before colonoscopy. Most medications can be taken with a sip of water about 3 hours before the procedure including low-dose aspirin or NSAIDs. For others, work with prescribers and consider some rules of thumb...
Holding medications before colonoscopy
Anticoagulants
In general, suggest holding warfarin 5 days before the procedure or direct oral anticoagulants (DOACs), such as Pradaxa (dabigatran), one to 2 days before in patients with normal renal function. Most warfarin patients don't need to be "bridged" with low-molecular-weight heparin (enoxaparin, etc) unless their clot risk is high.
Antiplatelets
Expect most patients to hold Plavix (clopidogrel) or Effient (prasugrel) at least 5 to 7 days before or Brilique (ticagrelor) 3 to 5 days before. Platelets recover more quickly after stopping Brilique (ticagrelor).
- Explain that anticoagulants OR antiplatelets can usually be restarted right away if polyps are NOT removed.
- If polyps are removed, suggest resuming warfarin about 12 hrs after the procedure, antiplatelets 24 hrs after and DOACs 48 to 72 hrs after.
Diabetes medications
Consider glucose control, dietary intake, and whether the patient has type 1 or type 2 diabetes. Keep in mind, patients will be on a clear liquid diet the day before the procedure. On the day prior to the colonoscopy, suggest holding sulfonylureas. Expect premixed insulin doses to be halved the day prior. And suggest giving usual basal insulin doses or halving the PM dose. If patients count carbohydrates, advise giving mealtime insulin as usual the day before. Otherwise, suggest giving half the normal dose.
- All other diabetes medications can be continued as usual the day prior.
- On the morning of the procedure, generally suggest holding diabetes medications. But suggest continuing some basal insulin especially in patients with type 1 diabetes.
References
- ASGE Standards of Practice Committee, Acosta RD, Abraham NS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3-16.
- Feagins LA. Management of Anticoagulants and Antiplatelet Agents During Colonoscopy. Am J Med. 2017;130(7):786-795.
- Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S-e350S.
