Is it acceptable to withhold Clopidogrel (Plavix) and Dulaglutide (Trulicity) one week prior to vitrectomy in a patient with a history of cerebrovascular accident (CVA) and type 2 diabetes mellitus (T2DM) who is scheduled for vitrectomy due to vitreous hemorrhage?

From the Guidelines

For a patient with a history of CVA and Type 2 diabetes scheduled for left eye vitrectomy due to vitreous hemorrhage, it would be appropriate to hold clopidogrel (Plavix) for at least 5 days before surgery, as recommended by the 2011 ACCF/AHA guideline for coronary artery bypass graft surgery 1. This guideline suggests that clopidogrel should be discontinued for at least 5 days before surgery to limit blood transfusions.

• The patient's history of CVA and current use of clopidogrel indicate a need for careful management of antiplatelet therapy to balance the risk of bleeding during surgery against the risk of thrombotic events.
• Stopping Plavix for the recommended period is necessary to reduce bleeding risk during the vitrectomy, as this antiplatelet medication inhibits clot formation.
• However, completely stopping Plavix carries some risk of thrombotic events given the patient's history of stroke, and the decision should be made in consultation with the patient's cardiologist or neurologist who prescribed the clopidogrel.
• For Trulicity (dulaglutide), since it has a long half-life (approximately 5 days), holding it for a full week is unnecessary and could lead to poor glycemic control.
• Instead, skip the dose that would fall on the surgery day, and resume normal dosing afterward, as there is no clear guideline recommending a specific duration for holding Trulicity before surgery.
• Blood glucose should be monitored closely during the perioperative period, and short-acting insulin may be needed for glycemic control.
• The patient should restart clopidogrel as soon as the surgeon determines it is safe, typically 24-48 hours after surgery when hemostasis is assured, to minimize the risk of thrombotic events.

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.

It is recommended to hold Plavix (clopidogrel) for 5 days prior to surgery, not 1 week. There is no information in the provided drug label about Trulicity. Therefore, no conclusion can be drawn about holding Trulicity. 2

From the Research

Perioperative Management of Antiplatelet Therapy

• The decision to hold or continue antiplatelet therapy, such as Clopidogrel (Plavix), in patients undergoing surgery, like vitrectomy, depends on the individual's risk of thrombotic events and bleeding complications 3, 4.
• For patients with a history of cardiovascular disease, including those with transient ischemic attack (TIA) or ischemic stroke, dual antiplatelet therapy (DAPT) with clopidogrel and aspirin may be recommended for secondary prevention 5, 6.
• However, the risk of bleeding associated with DAPT must be carefully considered, particularly in the perioperative period 5.

Specific Considerations for Vitrectomy

• Vitrectomy is a surgical procedure that carries a risk of bleeding, and the use of antiplatelet therapy may increase this risk.
• There is limited evidence specifically addressing the management of antiplatelet therapy in patients undergoing vitrectomy.
• However, studies suggest that short-term discontinuation of antiplatelet therapy may be necessary to minimize the risk of bleeding complications 5.

Management of Trulicity (Dulaglutide)

• Trulicity is a glucagon-like peptide-1 (GLP-1) receptor agonist used in the treatment of type 2 diabetes mellitus (T2DM).
• There is no direct evidence addressing the perioperative management of Trulicity in patients undergoing vitrectomy.
• However, it is generally recommended to continue GLP-1 receptor agonists, like Trulicity, in the perioperative period, unless there are specific concerns about bleeding or other complications 7.

Recommendations

• The decision to hold or continue Clopidogrel and Trulicity in a patient undergoing vitrectomy should be made on a case-by-case basis, taking into account the individual's risk of thrombotic events and bleeding complications.
• It may be reasonable to hold Clopidogrel for a short period, such as 1 week, prior to surgery to minimize the risk of bleeding, but this decision should be made in consultation with the patient's healthcare team 3, 4, 5.
• Trulicity can likely be continued in the perioperative period, unless there are specific concerns about bleeding or other complications.