How many days before cataract surgery should a patient stop taking Plavix (clopidogrel)?

Management of Clopidogrel (Plavix) Before Cataract Surgery

For patients undergoing cataract surgery, clopidogrel (Plavix) should be continued throughout the perioperative period without interruption. 1

Rationale for Continuing Clopidogrel During Cataract Surgery

Cataract surgery is considered a low bleeding risk procedure, and the evidence strongly supports continuing antiplatelet therapy during this type of surgery:

• The American College of Chest Physicians (ACCP) specifically recommends continuing antiplatelet therapy throughout the perioperative period for cataract surgery 2, 1
• The minimal bleeding risk associated with cataract surgery is outweighed by the potential thromboembolic risks of discontinuation 1
• The risks of medical and ophthalmic events surrounding cataract surgery are extremely low, making the absolute differences in risk associated with changes in antiplatelet use minimal 3

Bleeding Risk vs. Thrombotic Risk

Bleeding Risk

• Cataract surgery carries a very low risk of significant bleeding complications, even when antiplatelet therapy is continued
• Local hemostasis techniques used during cataract surgery are typically sufficient to manage any minor bleeding 2
• Topical or intracameral anesthesia (rather than injectable anesthesia) is preferred for patients on antiplatelet therapy to further minimize bleeding risk 1, 4

Thrombotic Risk

• Discontinuing clopidogrel increases the risk of thromboembolic events, which can have serious consequences 1
• For each day after interruption of clopidogrel, only 10% to 14% of normal platelet function is restored; it takes 7 to 10 days for complete platelet function recovery 2
• This prolonged interruption period creates an unnecessary window of thrombotic risk for a procedure with minimal bleeding risk

Special Considerations

For Patients with Recent Coronary Stents

• Patients with recent coronary stent placement are at particularly high risk if antiplatelet therapy is discontinued 1
• For patients on dual antiplatelet therapy (aspirin plus clopidogrel) with stents placed within the last 6-12 weeks, both antiplatelet agents should be continued during cataract surgery 2, 1

Resumption of Therapy

• If clopidogrel is interrupted for any reason, it should be resumed within 24 hours after surgery 2
• When resuming clopidogrel at the standard maintenance dose (75 mg/day), it takes 5-10 days to attain maximal platelet function inhibition 2
• A loading dose (300-600 mg) can achieve maximal inhibition within 12-15 hours if rapid effect is needed 2

Important Caveats

• For patients with extremely high bleeding risk factors or surgeon preference, if clopidogrel must be interrupted, the 2022 ACCP guidelines suggest stopping it 5 days before surgery (not the traditional 7-10 days) 2
• Laboratory monitoring of antiplatelet therapy (platelet function testing) is not routinely recommended before cataract surgery 2
• The discontinuation of antiplatelet therapy before cataract surgery may increase the risk of thromboembolism without significantly reducing bleeding complications 4

In conclusion, the evidence-based approach for cataract surgery strongly favors continuing clopidogrel throughout the perioperative period, as the minimal bleeding risk is far outweighed by the potential thromboembolic risks of discontinuation.