Should platelet transfusion be given perioperatively or only as a backup in case of bleeding in patients who stopped taking clopidogrel (Plavix) and aspirin 2 days prior to surgery?

From the Guidelines

Prophylactic platelet transfusion is not recommended for patients who stopped clopidogrel and aspirin just 2 days prior to surgery; instead, platelets should be reserved as a backup in case of excessive bleeding. Two days is insufficient time for complete recovery of platelet function after discontinuation of these medications, particularly for clopidogrel which typically requires 5-7 days for full platelet function recovery, as suggested by the 2011 ACCF/AHA guideline for coronary artery bypass graft surgery 1. Aspirin's effects may persist for 7-10 days. Unnecessary prophylactic transfusion carries risks including transfusion reactions, infection transmission, and alloimmunization. The better approach is to monitor the patient closely during surgery for signs of abnormal bleeding and have platelets immediately available if needed. If significant bleeding occurs that appears related to platelet dysfunction, transfusion of 1-2 units of platelets can help restore hemostasis. This approach balances the risks of bleeding against the risks of unnecessary transfusion. For elective procedures with high bleeding risk, ideally these medications should be discontinued earlier (5-7 days for clopidogrel, 7-10 days for aspirin) when possible, in consultation with the patient's cardiologist to assess thrombotic risk, as also recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1.

Some studies suggest that the duration of discontinuation of P2Y12 inhibitors before surgery could be tailored based on the type of inhibitor and the patient's individual response, with a 72-to-120-hour discontinuation potentially being sufficient for most patients taking ticagrelor, as proposed by the French working group on perioperative haemostasis and the French study group on thrombosis and haemostasis 1. However, the most recent and highest quality evidence still supports the general recommendation of discontinuing clopidogrel and aspirin for at least 5 days before elective surgery to minimize bleeding risks.

Key considerations in managing patients on antiplatelet therapy who require surgery include:

• The type and dose of antiplatelet medication
• The timing of medication discontinuation
• The patient's individual risk of bleeding and thrombosis
• The type of surgery and its associated bleeding risk
• The availability of platelets and other blood products for potential transfusion, as discussed in the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery 1.

Ultimately, the decision to transfuse platelets should be made on a case-by-case basis, taking into account the patient's specific clinical situation and the potential benefits and risks of transfusion.

From the FDA Drug Label

Thienopyridines, including clopidogrel bisulfate, increase the risk of bleeding. If a patient is to undergo surgery and an antiplatelet effect is not desired, discontinue clopidogrel bisulfate five days prior to surgery. Because the half-life of clopidogrel’s active metabolite is short, it may be possible to restore hemostasis by administering exogenous platelets; however, platelet transfusions within 4 hours of the loading dose or 2 hours of the maintenance dose may be less effective.

The patient stopped taking clopidogrel and aspirin 2 days prior to surgery, which is less than the recommended 5 days. Platelet transfusion should be considered as a backup in case of bleeding, rather than given perioperatively, as the risk of bleeding is still present due to the recent discontinuation of clopidogrel and aspirin 2.

From the Research

Perioperative Platelet Transfusion in Patients Stopped Taking Clopidogrel and Aspirin

• The decision to give platelet transfusion perioperatively or only as a backup in case of bleeding in patients who stopped taking clopidogrel and aspirin 2 days prior to surgery depends on various factors, including the type of surgery, the patient's risk of thrombosis, and the risk of bleeding 3, 4, 5.
• Studies suggest that aspirin can be continued perioperatively in most cases, except when bleeding may occur in closed spaces or where excessive blood loss is expected 3, 6.
• Clopidogrel, on the other hand, should not be discontinued before non-cardiac procedures, especially in patients with acute coronary syndrome or during stent re-endothelialization 3, 5.
• In patients who have stopped taking clopidogrel 2 days prior to surgery, the risk of bleeding may be increased, and platelet transfusion may be necessary to restore normal hemostasis 7.
• However, prophylactic platelet transfusion is not recommended, and platelets should only be transfused in patients with abnormal bleeding thought to be related to the persisting effect of antiplatelet therapy 4.

Risks Associated with Premature Withdrawal of Antiplatelet Agents

• Premature withdrawal of antiplatelet agents is associated with a 10% risk of all vascular events, including stent thrombosis and potentially fatal consequences 5.
• The risk of thrombosis outweighs the risk of bleeding in most cases, and antiplatelet agents should not be withdrawn unless the risk of bleeding exceeds the thrombotic risk 3, 6.

Management of Antiplatelet Agents in the Perioperative Period

• Aspirin use should not be stopped in the perioperative period unless the risk of bleeding exceeds the thrombotic risk from withholding the drug 5.
• Clopidogrel use should be stopped at least 5 days prior to most elective surgery, except in cases where the risk of thrombosis is high 5.
• Glycoprotein IIb/IIIa inhibitors must be discontinued preoperatively for more than 12 hours to allow normal hemostasis 5.