How to manage Dual Antiplatelet Therapy (DAPT) with aspirin and Plavix (clopidogrel) in a patient undergoing mandibulectomy?

From the Guidelines

Management of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel (Plavix) in a patient undergoing mandibulectomy requires careful balancing of bleeding and thrombotic risks, with the most recent guidelines suggesting continuation of aspirin throughout the perioperative period and temporary discontinuation of clopidogrel 5 days before surgery, as recommended by the 2024 ESC guidelines 1.

Key Considerations

• The patient's risk of bleeding and thrombosis should be carefully assessed, taking into account the type of surgery, the patient's medical history, and the presence of any comorbidities.
• Aspirin should be continued throughout the perioperative period, as it provides some protection against stent thrombosis while posing less bleeding risk than full DAPT.
• Clopidogrel should be temporarily discontinued 5 days before surgery, as it significantly increases surgical bleeding risk.
• The decision to restart clopidogrel postoperatively should be made on a case-by-case basis, taking into account the patient's individual risk factors and the surgical team's assessment of the risk of bleeding.

Perioperative Management

• For patients with recent stent placement (less than 3 months for bare metal stents or less than 6-12 months for drug-eluting stents), consider delaying elective surgery or consulting cardiology about alternative antiplatelet management.
• In emergency situations, proceed with surgery while maintaining aspirin and using strategies to minimize bleeding, including meticulous surgical technique, topical hemostatic agents, and tranexamic acid.
• Postoperatively, close monitoring for both bleeding and thrombotic complications is essential, with prompt intervention if either develops.

Evidence-Based Recommendations

• The 2024 ESC guidelines recommend continuation of aspirin throughout the perioperative period and temporary discontinuation of clopidogrel 5 days before surgery 1.
• The 2018 French working group on perioperative haemostasis and the French study group on thrombosis and haemostasis recommend a multidisciplinary approach to managing antiplatelet therapy in patients undergoing elective invasive procedures, including consideration of the patient's risk of bleeding and thrombosis 1.
• The 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease recommends continuation of aspirin peri-operatively if the bleeding risk allows, and resumption of the recommended antiplatelet therapy as soon as possible post-operatively 1.

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.

Management of Dual Antiplatelet Therapy (DAPT) with aspirin and Plavix (clopidogrel) in a patient undergoing mandibulectomy:

• The patient should interrupt therapy with clopidogrel for five days prior to mandibulectomy, if possible.
• Aspirin should be managed according to the surgeon's or anesthesiologist's recommendations, as the label does not provide specific guidance on aspirin management in this context.
• Clopidogrel should be restarted as soon as hemostasis is achieved after surgery.
• It is essential to weigh the risk of bleeding against the risk of cardiovascular events when deciding to interrupt or restart DAPT therapy 2.

From the Research

Management of Dual Antiplatelet Therapy in Mandibulectomy

• The management of Dual Antiplatelet Therapy (DAPT) with aspirin and Plavix (clopidogrel) in a patient undergoing mandibulectomy is crucial to balance the risk of bleeding and thrombotic events.
• According to a study published in the British journal of anaesthesia 3, the maintenance of DAPT until the day of coronary artery bypass graft surgery increased postoperative bleeding at 24 hours, consistent with increased blood transfusion.
• However, a study published in Medicina oral, patologia oral y cirugia bucal 4 found that dental extraction in patients receiving dual antiplatelet therapy can be safe when using sutures and gauze impregnated with tranexamic acid.
• Another study published in Folia medica 5 found that single and multiple dental extractions in patients receiving acetylsalicylic acid or clopidogrel can be safely performed without discontinuation of the therapy with provided appropriate local haemostasis.

Recommendations for Oral and Maxillofacial Surgeons

• A study published in Oral and maxillofacial surgery clinics of North America 6 recommends that for most outpatient surgical procedures, maintenance and continuation of antiplatelet therapy are recommended.
• Consultation with the patient's cardiologist, physician, and/or vascular surgeon is always recommended before interrupting or withholding this treatment modality 6.
• The decision to continue or discontinue DAPT should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.

Considerations for Mandibulectomy

• The risk of bleeding and thrombotic events should be carefully evaluated in patients undergoing mandibulectomy who are receiving DAPT 3, 7.
• The use of tranexamic acid and local haemostasis measures may help to minimize the risk of bleeding in these patients 4, 5.
• Close collaboration with the patient's medical team is essential to ensure optimal management of DAPT during the perioperative period 6.