When to stop Plavix (clopidogrel) therapy?

From the Guidelines

Plavix (clopidogrel) therapy should be stopped 5 to 7 days before elective coronary artery bypass grafting (CABG) to minimize the risk of bleeding, as recommended by the 2011 ACCF/AHA guidelines 1. When considering stopping Plavix, it's essential to weigh the risks and benefits, taking into account the patient's individual risk factors and medical history.

• For patients with unstable angina or non-ST-elevation myocardial infarction (UA/NSTEMI), Plavix is typically continued for at least 1 month and ideally up to 1 year, unless CABG is planned 1.
• In patients undergoing percutaneous coronary intervention (PCI), Plavix is usually continued for at least 12 months, especially if a drug-eluting stent is used.
• For patients with a history of stroke or peripheral artery disease, Plavix may be continued indefinitely, depending on their specific condition and risk factors. Before stopping Plavix, it's crucial to consult with the prescribing cardiologist or neurologist, especially if planning surgery.
• Elective surgeries should ideally be delayed until completing the minimum recommended duration of Plavix therapy.
• For urgent surgeries, Plavix should be discontinued 5-7 days before the procedure to reduce bleeding risk, as recommended by the guidelines 1. Never stop Plavix suddenly without medical guidance, as this can increase the risk of thrombotic events, particularly in patients with recent stent placement.
• After stopping Plavix, some patients may need to transition to aspirin therapy for continued cardiovascular protection. It's also important to note that Plavix works by irreversibly inhibiting platelet aggregation, and it takes about 5-7 days for the body to produce enough new platelets to restore normal clotting function.
• Therefore, stopping Plavix requires careful planning and monitoring to minimize the risk of adverse 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.

When to stop Plavix (clopidogrel) therapy:

• Discontinuation of clopidogrel should be avoided as it increases the risk of cardiovascular events.
• If discontinuation is necessary (e.g., to treat bleeding or for surgery with a major risk of bleeding), it is recommended to:
  • Interrupt therapy with clopidogrel for five days prior to surgery.
  • Restart clopidogrel as soon as possible after the surgery.
  • Resume clopidogrel as soon as hemostasis is achieved. 2

From the Research

Stopping Plavix (Clopidogrel) Therapy

The decision to stop Plavix (clopidogrel) therapy depends on various factors, including the patient's risk of bleeding and ischemic events.

• The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend aspirin plus a P2Y12 inhibitor (such as clopidogrel) for at least 12 months for patients with acute coronary syndrome (ACS) 3.
• However, the optimal duration of dual antiplatelet therapy (DAPT) beyond 1 year is not well established, and recommendations vary according to the risk of bleeding 3.
• If the bleeding risk is low, prolonged DAPT may be considered, while a shorter duration (3-6 months) of DAPT may be reasonable if the bleeding risk is high 3.
• A high risk of bleeding is traditionally defined as a 1-year risk of serious bleeding of at least 4% or a risk of intracranial hemorrhage of at least 1% 3.
• Patients at higher risk of bleeding include those who are 65 years old or older, have low body weight, diabetes, or prior bleeding, or take oral anticoagulants 3.

Factors Influencing the Decision to Stop Clopidogrel

Several factors influence the decision to stop clopidogrel, including:

• The risk of ischemic events: patients with a high risk of ischemic events may benefit from prolonged DAPT 4.
• The risk of bleeding: patients with a high risk of bleeding may require a shorter duration of DAPT or alternative antiplatelet strategies 4.
• The type of stent used: patients who receive newer-generation drug-eluting stents may be able to stop DAPT earlier than those who receive older-generation stents 5.
• The patient's clinical characteristics: patients with certain clinical characteristics, such as diabetes or prior bleeding, may require individualized antiplatelet strategies 6.

Alternative Antiplatelet Strategies

Alternative antiplatelet strategies, such as clopidogrel monotherapy or aspirin monotherapy, may be considered after completion of DAPT:

• Clopidogrel monotherapy has been shown to reduce bleeding events compared with aspirin plus clopidogrel in patients with high bleeding and ischemic risk 6.
• Aspirin monotherapy is commonly used after completion of DAPT, but clopidogrel monotherapy may be associated with reductions in major adverse cardiac events and stroke compared with aspirin monotherapy 7.