Should clopidogrel be stopped before surgery?

From the Guidelines

Yes, clopidogrel should typically be stopped before surgery, with the general recommendation being to discontinue it at least 5 days prior to elective surgery. The decision to stop clopidogrel before surgery is based on the need to minimize the risk of excessive bleeding during and after surgery, which can be life-threatening. Here are the key points:

• Stop clopidogrel 5 days before planned surgery, as recommended by the most recent guidelines 1.
• Consult with your surgeon and cardiologist to determine the exact timing for your specific case, as individual patient factors may influence the decision.
• Do not stop clopidogrel without medical advice, especially if you have a coronary stent, as this can increase the risk of cardiovascular events.
• After surgery, clopidogrel is usually restarted as soon as it's deemed safe, often within 24-48 hours, to minimize the risk of thrombotic events.

The reason for stopping clopidogrel before surgery is that it's an antiplatelet medication that inhibits blood clotting, increasing the risk of excessive bleeding during and after surgery. By stopping the medication several days in advance, it allows time for new, uninhibited platelets to be produced, restoring normal clotting function. However, for patients with recent coronary stents or at high risk of cardiovascular events, the risks of stopping clopidogrel must be carefully weighed against the bleeding risk, and bridging therapy with shorter-acting antiplatelet drugs may be necessary, as suggested by studies such as 1 and 1.

Some studies, such as 1 and 1, provide guidance on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft (CABG) surgery, and recommend stopping clopidogrel at least 5 days before surgery to minimize the risk of bleeding complications. More recent studies, such as 1, confirm these findings and provide additional guidance on the management of antiplatelet therapy in the perioperative period. Overall, the decision to stop clopidogrel before surgery should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history, as recommended by guidelines such as 1.

From the FDA Drug Label

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. Talk with your doctor about stopping your clopidogrel tablets before you have surgery. Your doctor may tell you to stop taking clopidogrel tablets at least 5 days before you have surgery to avoid excessive bleeding during surgery.

Clopidogrel should be stopped before surgery, if possible, to avoid excessive bleeding.

• The duration of cessation is typically 5 days before surgery.
• The decision to stop clopidogrel should be made in consultation with a doctor, as it may increase the risk of cardiovascular events 2 2.

From the Research

Perioperative Management of Clopidogrel

The decision to stop clopidogrel before surgery depends on various factors, including the type of surgery, patient's cardiovascular risk profile, and the risk of bleeding complications.

• Studies have shown that continuing clopidogrel up to the day of surgery does not increase the risk of bleeding complications in patients undergoing peripheral arterial surgery 3.
• In patients undergoing major lung resection, perioperative clopidogrel use was not associated with increased bleeding complications or transfusion requirements 4.
• However, other studies suggest that discontinuing clopidogrel 5-7 days before high-bleeding-risk surgery may be necessary to minimize the risk of bleeding complications 5, 6, 7.

Bleeding Risk and Cardiovascular Risk

• Patients with a high cardiovascular risk profile may require continued clopidogrel use to prevent cardiovascular events, even if it increases the risk of bleeding complications 3, 4.
• The use of bridging therapy, such as eptifibatide, may be considered in high-risk patients to minimize the risk of cardiovascular events 4.
• The risk of bleeding complications must be balanced against the risk of cardiovascular events, and individualized decisions should be made based on patient-specific factors 5, 7.

Surgical Procedures and Clopidogrel Use

• The type of surgical procedure being performed also plays a role in the decision to stop clopidogrel, with some procedures carrying a higher risk of bleeding complications than others 3, 4, 6.
• Patients undergoing cardiac surgery may require special consideration, with some studies suggesting that clopidogrel should be discontinued 5-7 days before surgery to minimize the risk of bleeding complications 7.