When to Stop Clopidogrel Before Lumbar Puncture

Clopidogrel (Plavix) should be discontinued at least 7 days before a lumbar puncture to minimize the risk of bleeding complications. 1

Rationale for Discontinuation

P2Y12 inhibitors like clopidogrel inhibit platelet aggregation for the lifetime of the platelet (7-10 days) 2
Clopidogrel increases the risk of bleeding during invasive procedures due to its irreversible antiplatelet effect 2
When possible, the FDA label recommends interrupting clopidogrel therapy for five days prior to surgery with major bleeding risk 2
For procedures with high bleeding risk like LP, where bleeding could occur in closed spaces, longer discontinuation is recommended 1

Clopidogrel should be discontinued for 7 days before an elective lumbar puncture 1
This timeframe allows for adequate dissipation of the antiplatelet effect and generation of new platelets with normal function 2
If LP cannot be delayed and the benefits outweigh the risks, consultation with a hematologist is recommended to consider platelet transfusion 6-8 hours after the last dose of clopidogrel 1

For patients at high thrombotic risk (e.g., recent coronary stent placement), the decision to discontinue clopidogrel requires careful consideration 1
In patients with drug-eluting stents placed within 12 months or bare metal stents within 1 month, cardiology consultation is strongly recommended before stopping clopidogrel 3
For urgent LPs where clopidogrel cannot be discontinued for 7 days, the risk of bleeding must be balanced against the need for immediate diagnosis 1

Aspirin and non-steroidal anti-inflammatory medications alone do not increase the risk of spinal hematoma after LP and do not need to be discontinued 1, 4
For patients on warfarin, LP should not be performed until INR is ≤1.4 1
For patients on prophylactic low molecular weight heparin (LMWH), LP should not be performed until 12 hours after the last dose 1
For patients on therapeutic LMWH, LP should not be performed until 24 hours after the last dose 1

Clopidogrel should be restarted as soon as hemostasis is achieved, typically within 24-48 hours after the procedure 2
For patients at high thrombotic risk, earlier resumption may be considered if there are no signs of bleeding complications 1

Recent research suggests that the risk of spinal hematoma with clopidogrel may be lower than previously thought 5, 4
A 2023 study found no cases of spinal hematoma among 159 patients who underwent LP without discontinuation of ADP receptor antagonists or with shorter than recommended discontinuation periods 5
However, until larger prospective studies confirm these findings, the standard recommendation remains to discontinue clopidogrel for 7 days before LP 1