How long should Plavix (clopidogrel) be withheld prior to a surgical procedure?

From the Guidelines

Plavix (clopidogrel) should be discontinued at least 5 days before elective surgical procedures to minimize bleeding risk, as recommended by the most recent and highest quality study 1. The management of antiplatelet therapy in patients undergoing surgical procedures is crucial to balance the risk of bleeding and thrombotic events.

• The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend discontinuing clopidogrel at least 5 days before elective coronary artery bypass graft (CABG) surgery to reduce the risk of bleeding complications 1.
• However, the most recent study from 2018 suggests that discontinuing clopidogrel 5 days before surgery is optimal, and for intracranial neurosurgery, it is recommended to discontinue clopidogrel 7 days before surgery 1.
• For urgent or emergency surgeries, the decision to discontinue clopidogrel should be made on a case-by-case basis, taking into account the individual patient's risk of bleeding and thrombotic events 1.
• After surgery, clopidogrel can usually be restarted within 24-48 hours when hemostasis is achieved, to minimize the risk of thrombotic events. The timing of clopidogrel discontinuation depends on the specific procedure's bleeding risk and the patient's thrombotic risk, and individualized management is recommended.
• The use of platelet transfusions or antifibrinolytic agents, such as tranexamic acid, may be considered in patients who require urgent surgery while on clopidogrel therapy 1.
• It is essential to weigh the risks and benefits of discontinuing clopidogrel in each patient, considering factors such as the type of surgery, the patient's underlying medical conditions, and the potential consequences of bleeding or thrombotic 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.

Withholding Plavix (clopidogrel) before surgery:

• Clopidogrel should be withheld for 5 days prior to a surgical procedure with a major risk of bleeding, if possible.
• The medication should be restarted as soon as hemostasis is achieved after the surgery 2.

From the Research

Recommendations for Withholding Plavix (Clopidogrel) Before Surgery

The duration for which Plavix (clopidogrel) should be withheld prior to a surgical procedure varies depending on the type of surgery and the patient's condition. Here are some key points to consider:

• For spine surgery, one study suggests stopping clopidogrel more than 7-10 days preoperatively 3.
• For non-emergent cardiac surgery, the American College of Cardiology (ACC) guidelines suggest stopping clopidogrel 5 days before surgery 4.
• However, another study found that stopping clopidogrel 3 days or less before coronary artery bypass grafting (CABG) did not result in a significant difference in hemoglobin drop compared to stopping it 5 days before surgery 4.
• For orthopedic patients, a survey of orthopedic residency programs found that 73% of programs considered waiting 3 days or less for urgent but non-emergent operative interventions on patients on clopidogrel to be acceptable, while 23% felt that no delay at all was necessary 5.
• For peripheral arterial surgery, one study found that discontinuation of preoperative clopidogrel was unnecessary and did not increase the risk of perioperative bleeding complications 6.

Key Considerations

Some key considerations when deciding how long to withhold Plavix (clopidogrel) before surgery include:

• The type of surgery and the associated risk of bleeding
• The patient's underlying medical condition and risk of thrombosis
• The potential benefits and risks of stopping or continuing clopidogrel therapy
• The availability of alternative treatments or strategies to minimize bleeding risk

Variability in Recommendations

It's worth noting that there is variability in the recommendations for withholding Plavix (clopidogrel) before surgery, and the decision should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances 7, 5, 6.