Polypectomy bleed risk low in patients on antiplatelet agents

Maintaining antiplatelet therapy during colonoscopy with polypectomy carries a low risk of delayed bleeding.

Moreover, routinely using endoscopic clips in these patients increases safety while remaining cost effective, according to two studies published in the October issue of Clinical Gastroenterology and Hepatology.

The first study, by Dr. Linda A. Feagins of the North Texas VA Health Care System, Dallas, and her colleagues, looked at 219 patients taking thienopyridines, including clopidogrel and prasugrel, who underwent colonoscopy with polypectomy (Clin. Gastroenterol. Hepatol. 2013 [doi:10.1016/j.cgh.2013.02.003]).

Source: American Gastroenterological Institute

The majority of patients had a history of stent placement; the remainder had coronary artery disease with or without bypass, a history of cerebral accident, or aspirin allergy.

Data on immediate postpolypectomy bleeding requiring further endoscopic treatment, as well as delayed bleeds occurring within 30 days of the procedure, were collected, with "clinically important" delayed bleeding defined as bleeds requiring repeat colonoscopy, hospitalization, a drop in hemoglobin of at least 2 g/dL, or blood transfusion.

The investigators found that immediate bleeding occurred in 16 patients (7.3%) on uninterrupted antiplatelet therapy, compared with 14 (4.7%) of 297 controls (P = .25).

Looking at delayed bleeding among the 210 antiplatelet therapy users for whom 30-day follow-up was complete, 11% experienced "unimportant" delayed bleeding and 2.4% experienced clinically important events.

That compared with "unimportant" delayed events among 5.9% of controls and zero cases of clinically important delayed bleeds among these patients (P = .013).

Despite the significant difference, Dr. Feagins called the rate of bleeding in the antiplatelet therapy group "probably acceptable in comparison with the potentially catastrophic consequences of stent thrombosis."

"For patients who are at high risk for thromboembolic events with thienopyridine cessation and for whom colonoscopy cannot be delayed reasonably, our data support the decision to continue thienopyridines during colonoscopy," she noted.

The second study, by Dr. Neehar Parikh of Northwestern University in Chicago, concerned whether the use of routine clip placement after colon polypectomy would be cost effective both for patients taking antiplatelet agents and those not (Clin. Gastroenterol. Hepatol. 2013 [doi:10.1016/j.cgh.2012.12.044]).

Using a software-generated decision analysis model and published bleeding rates from the literature, Dr. Parikh and his colleagues created a reference case of a 50-year-old patient who had a single 1.0- to 1.5-cm polyp removed during colonoscopy.

They found that prophylactic clip placement was not cost effective until the risk of postpolypectomy bleeding increased to 2.01%; it was not cost saving until the probability reached 2.07%.

Indeed, while "placing one prophylactic clip in patients on antiplatelet/anticoagulation therapy appears cost effective ... the use of two clips is equivocal and not favorable in those patients on anticoagulation and antiplatelet therapy, respectively, on the basis of mean bleeding rates reported," the investigators wrote.

The cost calculation also varies according to clip price, they added, although they clarified that, "on the basis of listed current clip costs, prophylactic clip placement is favorable for those patients on antiplatelet and anticoagulation therapy."

Dr. Feagins and her fellow investigators reported no conflicts of interest. She disclosed funding from the Department of Veterans Affairs. Dr. Parikh and his colleagues also reported no financial conflicts. They disclosed funding from the National Institute of Diabetes and Digestive and Kidney Diseases, as well as the Agency for Healthcare Research and Quality.

Maintaining antiplatelet therapy during colonoscopy with polypectomy carries a low risk of delayed bleeding.

Moreover, routinely using endoscopic clips in these patients increases safety while remaining cost effective, according to two studies published in the October issue of Clinical Gastroenterology and Hepatology.

The first study, by Dr. Linda A. Feagins of the North Texas VA Health Care System, Dallas, and her colleagues, looked at 219 patients taking thienopyridines, including clopidogrel and prasugrel, who underwent colonoscopy with polypectomy (Clin. Gastroenterol. Hepatol. 2013 [doi:10.1016/j.cgh.2013.02.003]).

Source: American Gastroenterological Institute

The majority of patients had a history of stent placement; the remainder had coronary artery disease with or without bypass, a history of cerebral accident, or aspirin allergy.

Data on immediate postpolypectomy bleeding requiring further endoscopic treatment, as well as delayed bleeds occurring within 30 days of the procedure, were collected, with "clinically important" delayed bleeding defined as bleeds requiring repeat colonoscopy, hospitalization, a drop in hemoglobin of at least 2 g/dL, or blood transfusion.

The investigators found that immediate bleeding occurred in 16 patients (7.3%) on uninterrupted antiplatelet therapy, compared with 14 (4.7%) of 297 controls (P = .25).

Looking at delayed bleeding among the 210 antiplatelet therapy users for whom 30-day follow-up was complete, 11% experienced "unimportant" delayed bleeding and 2.4% experienced clinically important events.

That compared with "unimportant" delayed events among 5.9% of controls and zero cases of clinically important delayed bleeds among these patients (P = .013).

Despite the significant difference, Dr. Feagins called the rate of bleeding in the antiplatelet therapy group "probably acceptable in comparison with the potentially catastrophic consequences of stent thrombosis."

"For patients who are at high risk for thromboembolic events with thienopyridine cessation and for whom colonoscopy cannot be delayed reasonably, our data support the decision to continue thienopyridines during colonoscopy," she noted.

The second study, by Dr. Neehar Parikh of Northwestern University in Chicago, concerned whether the use of routine clip placement after colon polypectomy would be cost effective both for patients taking antiplatelet agents and those not (Clin. Gastroenterol. Hepatol. 2013 [doi:10.1016/j.cgh.2012.12.044]).

Using a software-generated decision analysis model and published bleeding rates from the literature, Dr. Parikh and his colleagues created a reference case of a 50-year-old patient who had a single 1.0- to 1.5-cm polyp removed during colonoscopy.

They found that prophylactic clip placement was not cost effective until the risk of postpolypectomy bleeding increased to 2.01%; it was not cost saving until the probability reached 2.07%.

Indeed, while "placing one prophylactic clip in patients on antiplatelet/anticoagulation therapy appears cost effective ... the use of two clips is equivocal and not favorable in those patients on anticoagulation and antiplatelet therapy, respectively, on the basis of mean bleeding rates reported," the investigators wrote.

The cost calculation also varies according to clip price, they added, although they clarified that, "on the basis of listed current clip costs, prophylactic clip placement is favorable for those patients on antiplatelet and anticoagulation therapy."

Dr. Feagins and her fellow investigators reported no conflicts of interest. She disclosed funding from the Department of Veterans Affairs. Dr. Parikh and his colleagues also reported no financial conflicts. They disclosed funding from the National Institute of Diabetes and Digestive and Kidney Diseases, as well as the Agency for Healthcare Research and Quality.

Maintaining antiplatelet therapy during colonoscopy with polypectomy carries a low risk of delayed bleeding.

Moreover, routinely using endoscopic clips in these patients increases safety while remaining cost effective, according to two studies published in the October issue of Clinical Gastroenterology and Hepatology.

The first study, by Dr. Linda A. Feagins of the North Texas VA Health Care System, Dallas, and her colleagues, looked at 219 patients taking thienopyridines, including clopidogrel and prasugrel, who underwent colonoscopy with polypectomy (Clin. Gastroenterol. Hepatol. 2013 [doi:10.1016/j.cgh.2013.02.003]).

Source: American Gastroenterological Institute

The majority of patients had a history of stent placement; the remainder had coronary artery disease with or without bypass, a history of cerebral accident, or aspirin allergy.

Data on immediate postpolypectomy bleeding requiring further endoscopic treatment, as well as delayed bleeds occurring within 30 days of the procedure, were collected, with "clinically important" delayed bleeding defined as bleeds requiring repeat colonoscopy, hospitalization, a drop in hemoglobin of at least 2 g/dL, or blood transfusion.

The investigators found that immediate bleeding occurred in 16 patients (7.3%) on uninterrupted antiplatelet therapy, compared with 14 (4.7%) of 297 controls (P = .25).

Looking at delayed bleeding among the 210 antiplatelet therapy users for whom 30-day follow-up was complete, 11% experienced "unimportant" delayed bleeding and 2.4% experienced clinically important events.

That compared with "unimportant" delayed events among 5.9% of controls and zero cases of clinically important delayed bleeds among these patients (P = .013).

Despite the significant difference, Dr. Feagins called the rate of bleeding in the antiplatelet therapy group "probably acceptable in comparison with the potentially catastrophic consequences of stent thrombosis."

"For patients who are at high risk for thromboembolic events with thienopyridine cessation and for whom colonoscopy cannot be delayed reasonably, our data support the decision to continue thienopyridines during colonoscopy," she noted.

The second study, by Dr. Neehar Parikh of Northwestern University in Chicago, concerned whether the use of routine clip placement after colon polypectomy would be cost effective both for patients taking antiplatelet agents and those not (Clin. Gastroenterol. Hepatol. 2013 [doi:10.1016/j.cgh.2012.12.044]).

Using a software-generated decision analysis model and published bleeding rates from the literature, Dr. Parikh and his colleagues created a reference case of a 50-year-old patient who had a single 1.0- to 1.5-cm polyp removed during colonoscopy.

They found that prophylactic clip placement was not cost effective until the risk of postpolypectomy bleeding increased to 2.01%; it was not cost saving until the probability reached 2.07%.

Indeed, while "placing one prophylactic clip in patients on antiplatelet/anticoagulation therapy appears cost effective ... the use of two clips is equivocal and not favorable in those patients on anticoagulation and antiplatelet therapy, respectively, on the basis of mean bleeding rates reported," the investigators wrote.

The cost calculation also varies according to clip price, they added, although they clarified that, "on the basis of listed current clip costs, prophylactic clip placement is favorable for those patients on antiplatelet and anticoagulation therapy."

Dr. Feagins and her fellow investigators reported no conflicts of interest. She disclosed funding from the Department of Veterans Affairs. Dr. Parikh and his colleagues also reported no financial conflicts. They disclosed funding from the National Institute of Diabetes and Digestive and Kidney Diseases, as well as the Agency for Healthcare Research and Quality.