What is the recommended duration to stop common anticoagulant and antiplatelet medications, including aspirin, before major foot surgery?

Perioperative Management of Antiplatelet and Anticoagulant Medications for Major Foot Surgery

For major foot surgery, aspirin should be discontinued ≤7 days before surgery, while other antiplatelet and anticoagulant medications require different discontinuation timeframes based on their specific pharmacological properties. 1

Antiplatelet Medications

Aspirin

• Discontinue ≤7 days before major foot surgery 1
• Consider continuing aspirin in patients with drug-eluting coronary stents if the bleeding risk is intermediate 1
• Resume aspirin 12-24 hours after surgery when adequate hemostasis has been achieved 1

P2Y12 Inhibitors

• Clopidogrel: Discontinue 5 days before surgery 1
• Prasugrel: Discontinue 7 days before surgery 1
• Ticagrelor: Discontinue 3-5 days before surgery 1

NSAIDs with Antiplatelet Effects

• Naproxen: Discontinue 3-5 days before surgery due to antiplatelet effects 2
• Other NSAIDs: Discontinue 3-5 days before surgery 2

Other Antiplatelet Agents

• Pentoxifylline: Discontinue 2-3 days before surgery 3

Anticoagulant Medications

Direct Oral Anticoagulants (DOACs)

• Apixaban: Discontinue at least 48 hours prior to surgery with moderate or high bleeding risk 4
• Apixaban: Discontinue at least 24 hours prior to surgery with low bleeding risk 4
• Other DOACs: Similar timeframes (2-5 days) depending on renal function 3

Warfarin

• Discontinue 5 days before surgery 3
• Consider bridging therapy only for high-risk patients 5

Special Considerations

Patients with Coronary Stents

• For patients with drug-eluting stents (DES) at high risk of thrombosis:
  • If possible, postpone surgery until 6 months to 1 year after stent placement 1
  • For intermediate bleeding risk procedures, maintain aspirin but stop clopidogrel 5 days before surgery 1
  • For high bleeding risk procedures, consider stopping both aspirin and clopidogrel 5 days before surgery 1

Resumption of Therapy

• Resume antiplatelet therapy as soon as adequate hemostasis is achieved, typically within 24 hours after surgery 1
• For patients with drug-eluting stents, some experts recommend a loading dose of 300 mg clopidogrel when resuming therapy 1

Important Caveats and Pitfalls

• The irreversible effect of aspirin on platelets lasts for the entire platelet lifespan (7-10 days), but clinical studies show normalization of bleeding times within 96 hours after discontinuation 6
• Patients may not report over-the-counter use of NSAIDs with antiplatelet effects, so thorough medication reconciliation is essential 2
• Bleeding risk is significantly increased when multiple antiplatelet or anticoagulant medications are combined 2
• For patients with recent acute coronary events, surgery should be postponed at least 6 weeks if possible 1
• Bridging anticoagulation during the 24-48 hours after stopping apixaban and prior to surgery is not generally required 4

Evidence Quality Considerations

The recommendations provided are based primarily on guidelines from the American College of Chest Physicians (2022) and other specialty societies. However, it's important to note that many of these recommendations are conditional with very low certainty of evidence 1, highlighting the need for clinical judgment when applying these guidelines to individual patients.