When should Cilostazol (Pletal) be stopped before surgery?

Perioperative Management of Cilostazol Before Surgery

Cilostazol should be stopped 2 days before surgery due to its half-life of 10 hours and reversible antiplatelet effect. 1

Pharmacological Properties of Cilostazol

• Cilostazol is a phosphodiesterase inhibitor with antiplatelet and vasodilator properties 1
• Unlike irreversible antiplatelet agents (such as aspirin, clopidogrel, and prasugrel), cilostazol has a reversible inhibitory effect on platelet function 1
• Cilostazol has a half-life of approximately 10 hours, which means its effects are self-limiting based on its elimination half-life 1
• Due to its reversible mechanism of action, cilostazol does not require the 7-10 days interruption period needed for irreversible antiplatelet agents 1

Timing of Discontinuation

• For reversible antiplatelet agents like cilostazol, discontinuation should be based on the drug's half-life 1
• With a half-life of 10 hours, stopping cilostazol 2 days (48 hours) before surgery allows for approximately 4-5 half-lives to pass, which is sufficient for elimination of most of the drug's antiplatelet effect 1
• This is in contrast to irreversible antiplatelet agents like aspirin and clopidogrel which require 7-10 days interruption to allow for complete platelet pool replenishment 1

Resumption After Surgery

• Antiplatelet drugs should generally be resumed within 24 hours after surgery when adequate hemostasis has been achieved 1
• The American College of Chest Physicians suggests resuming antiplatelet drugs ≤24 hours instead of >24 hours after surgery/procedure 1
• When resuming cilostazol, its antiplatelet effect will return based on its pharmacokinetic properties, much faster than the 5-10 days needed for clopidogrel 1

Special Considerations

• For minor procedures with low bleeding risk (such as dental, dermatologic, or cataract procedures), it may be reasonable to continue cilostazol perioperatively 1
• For high bleeding risk procedures (such as intracranial surgery, spinal surgery, or posterior chamber eye surgery), strict adherence to the 2-day discontinuation period is particularly important 2, 3
• Unlike with irreversible antiplatelet agents, there is no need for platelet transfusions to reverse the effects of cilostazol in emergency situations, as the effect will naturally diminish as the drug is eliminated 1

Bleeding Risk

• Studies have shown that cilostazol does not appear to significantly increase the risk of serious bleeding events, even when used with other antiplatelet agents 4
• However, the combination of cilostazol with other antiplatelet or anticoagulant medications may potentially increase bleeding risk during surgery 5
• If a patient is on multiple antiplatelet or anticoagulant medications, each should be managed according to its specific properties and the bleeding risk of the planned procedure 3

Remember that while these are general recommendations based on the pharmacological properties of cilostazol, the timing of discontinuation should consider the specific surgical procedure's bleeding risk and the patient's thrombotic risk profile.