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• W3147388960 abstract "We read with great interest the study by Chan et al1Chan F.K.L. et al.Gastroenterology. 2019; 156: 918-925Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar on the risk of postpolypectomy bleeding with uninterrupted clopidogrel therapy in patients with cardiovascular disease. According to the authors’ conclusions, the study does not support the existing guidelines, which recommend withholding clopidogrel 7 days before polypectomy to decrease bleeding risk because, among clopidogrel users undergoing colonoscopy polypectomy, the rates of immediate and delayed bleeding were not statistically significantly higher in patients who continued clopidogrel before the procedure. We congratulate the authors on this important trial and their efforts to provide, through a high-quality randomized design, stronger evidences to guideline recommendations, which are mostly based on retrospective observational data. Nevertheless, the authors’ conclusions deserve comments. First, only 35 of 419 resected polyps (7.7%) were ≥10 mm in size. By restricting the analysis to these polyps, 6 bleeding events (28.5%; 3 immediate and 3 delayed) occurred in the clopidogrel arm and 1 event (7.1%) in the placebo arm. Although this difference is not statistically significant, we must take into account that the study is strongly underpowered for this subgroup analysis. We believe that this 4-fold higher incidence of bleeding events in the clopidogrel group raises concerns on the safety of polypectomy on clopidogrel for polyps ≥10 mm and inevitably limits the generalizability of the authors’ conclusions. Conversely, as far as subcentimetric polyps are concerned, the comparable incidence rate of bleeding events between the clopidogrel and placebo arm (3.3% vs 4.4%, respectively) gives strengths to the older version of European Society of Gastrointestinal Endoscopy guidelines,2Boustière C. et al.Endoscopy. 2011; 43: 445-461Crossref PubMed Scopus (205) Google Scholar which recommended withholding thienopyridines only for polyps >10 mm and considered the possibility of resection of small polyps followed by endoscopic clip placement. Second, the authors enrolled into the study about 80% of patients who were on dual antiplatelet therapy, likely owing to coronary revascularization and/or acute coronary syndrome. Given that the interruption of antiplatelet therapy represents the main risk factor for stent-related thrombotic complications, which are associated to high morbidity and mortality, we do believe that the authors’ conclusions on the safety of continuing clopidogrel for polypectomies may be paradoxically misleading and even harmful. Indeed, for patients with recently placed intracoronary stents, any effort should be made to minimize the risk of bleeding that could require temporary interruption of antithrombotic therapy with potential catastrophic cardiovascular consequences. Thus, at present, deferring elective endoscopic procedures until patient has received the P2Y12 receptor antagonists for the minimum recommended duration should remain the best practice recommendation for patients on dual antiplatelet therapy, as indicated in the American College of Cardiology Foundation and American College of Gastroenterology consensus statement.3Becker R.C. et al.Am J Gastroenterol. 2009; 104: 2903-2917Crossref PubMed Scopus (31) Google Scholar Risk of Postpolypectomy Bleeding With Uninterrupted Clopidogrel Therapy in an Industry-Independent, Double-Blind, Randomized TrialGastroenterologyVol. 156Issue 4PreviewGuidelines recommend withholding clopidogrel 7 days before polypectomy to decrease bleeding risk, but these were written based on limited evidence. We investigated whether uninterrupted clopidogrel therapy increases the risk of delayed postpolypectomy bleeding in patients undergoing colonoscopy. Full-Text PDF ReplyGastroenterologyVol. 157Issue 2PreviewWe thank Milam Sonneveld et al, Laura Lomonaca et al, and Franco Radaelli et al for their interest in our study and appreciate their point of view. Sonneveld et al argued that postpolypectomy bleeding is rarely life threatening, whereas the outcome of a thrombotic event during clopidogrel interruption can be devastating. Their belief, however, lacks data support and contradicts current practice guidelines that clopidogrel should be withheld before polypectomy. We therefore believe that vigorously designed studies to evaluate the true risk of postpolypectomy bleeding will inform clinical practice. Full-Text PDF" @default.
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• W3147388960 date "2019-08-01" @default.
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• W3147388960 title "RE: Risk of Postpolypectomy Bleeding With Uninterrupted Clopidogrel Therapy in an Industry-Independent, Double-Blind, Randomized, Trial" @default.
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