Is it necessary to stop clopidogrel (Plavix) due to basal cell carcinoma (basalioma) surgery?

Management of Clopidogrel for Basalioma Surgery

For patients undergoing basalioma (basal cell carcinoma) surgery, clopidogrel can be safely continued perioperatively and does not need to be discontinued. 1

Risk Assessment and Recommendations

• Minor dermatologic procedures, including skin cancer surgeries like basalioma removal, have a very low risk (<1%) of major bleeding with continuation of antiplatelet therapy 1
• The American College of Chest Physicians specifically recommends continuing antiplatelet therapy for minor dermatologic procedures rather than stopping it 7-10 days before the procedure 1
• While minor bleeding may increase with antiplatelet continuation compared to patients not on therapy, the incidence rates vary (2-51%) and typically only require adequate attention to postprocedure hemostasis 1

Balancing Thrombotic vs. Bleeding Risk

• The risk of coronary thrombosis after antiplatelet drug withdrawal is significantly higher than the risk of surgical bleeding if therapy is continued, especially for minor procedures 2, 3
• For patients with coronary stents, clopidogrel discontinuation increases the risk of stent thrombosis, which carries significant morbidity and mortality 1
• If a patient has a drug-eluting stent placed within the past 6-12 months, the thrombotic risk is particularly high, making continuation of antiplatelet therapy even more important 1

Specific Guidance for Basalioma Surgery

• For minor skin procedures like basalioma excision, several prospective cohort studies including 200 patients showed only a very low risk (<1%) of major bleeding with continuation of antiplatelet therapy 1
• The FDA label for clopidogrel notes that discontinuation increases cardiovascular event risk and recommends restarting as soon as possible when temporarily discontinued 4
• If temporary discontinuation is absolutely necessary (which is not the case for basalioma surgery), the FDA recommends interrupting therapy for five days prior to surgery with major bleeding risk 4

Special Considerations

• For patients on dual antiplatelet therapy (clopidogrel plus aspirin), both medications can typically be continued for minor dermatologic procedures 1, 2
• Prospective studies in general surgery patients have shown no significant increase in bleeding complications when continuing clopidogrel perioperatively 5
• Adequate hemostasis techniques during and after the procedure are important to minimize minor bleeding, which may be slightly increased 1

Important Caveats

• The surgeon should be informed about the patient's antiplatelet therapy to ensure appropriate hemostatic measures are taken during and after the procedure 1
• If the basalioma is located in a highly vascular area or if the planned procedure is extensive, individual risk assessment may be warranted, but in most cases, clopidogrel can still be safely continued 2
• Patients should be monitored for minor bleeding after the procedure, though this is typically manageable with local measures 1

In conclusion, based on current guidelines and evidence, clopidogrel should be continued for basalioma surgery as the cardiovascular risks of discontinuation outweigh the minimal bleeding risks associated with this minor dermatologic procedure.