From the FDA Drug Label
5.3 Discontinuation of Clopidogrel Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.
The FDA drug label recommends interrupting clopidogrel therapy for five days prior to surgery with a major risk of bleeding, such as mastectomy, and resuming it as soon as hemostasis is achieved 1.
From the Research
Patients can typically resume Plavix (clopidogrel) 5-7 days after a mastectomy, but this timing should be individualized based on bleeding risk and cardiac risk factors. The decision to restart Plavix should be made in consultation with both the surgeon and cardiologist. Before surgery, Plavix is usually discontinued 5-7 days prior to reduce bleeding risk during the procedure. When restarting, ensure the surgical site shows good healing with minimal drainage and no signs of active bleeding. Patients with higher cardiac risk (recent stents, acute coronary syndrome) may need earlier resumption, possibly with bridge therapy using shorter-acting antiplatelet medications. Monitor for any signs of bleeding after restarting, including increased bruising, swelling, or drainage at the surgical site. Plavix works by inhibiting platelet aggregation, which is essential for preventing cardiac events but increases bleeding risk during the healing phase after surgery, necessitating this careful balance between cardiac protection and surgical healing. According to the most recent study 2, patients who received preoperative LMWH bridging therapy or continued clopidogrel therapy had a slightly higher risk of perioperative bleeding, but no significant distinction was found in terms of blood transfusion rates, hospital stay length, bleeding-related reoperation, and 3-month mortality.
Key Considerations
- The timing of resuming Plavix after mastectomy should be individualized based on bleeding risk and cardiac risk factors.
- The decision to restart Plavix should be made in consultation with both the surgeon and cardiologist.
- Patients with higher cardiac risk may need earlier resumption of Plavix, possibly with bridge therapy using shorter-acting antiplatelet medications.
- Monitor for signs of bleeding after restarting Plavix, including increased bruising, swelling, or drainage at the surgical site.
Evidence-Based Recommendations
- The most recent study 2 suggests that patients who received preoperative LMWH bridging therapy or continued clopidogrel therapy had a slightly higher risk of perioperative bleeding.
- However, no significant distinction was found in terms of blood transfusion rates, hospital stay length, bleeding-related reoperation, and 3-month mortality.
- The American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) 3 recommends treatment with an antiplatelet agent, including clopidogrel, for patients with noncardioembolic stroke or transient ischemic attack.
- The guidelines also suggest that the combination of aspirin and extended-release dipyridamole may be used over aspirin, and clopidogrel may be used over aspirin, but the choice of antiplatelet agent should be individualized based on patient factors.