Can a spinal tap be performed on a patient taking Plavix (clopidogrel)?

From the Guidelines

Performing a spinal tap (lumbar puncture) while on Plavix (clopidogrel) is generally not recommended without careful consideration of risks, and ideally, Plavix should be discontinued 5-7 days before an elective spinal tap due to the increased risk of bleeding complications. Plavix is an antiplatelet medication that inhibits blood clotting by preventing platelets from sticking together, which is beneficial for preventing heart attacks and strokes but creates a higher risk of bleeding during invasive procedures.

Key Considerations

• The risk of bleeding complications, such as subdural hematoma, is increased when performing a spinal tap on patients taking Plavix 1.
• If the spinal tap is urgently needed and cannot be delayed, the doctor will need to weigh the risks of bleeding against the necessity of the procedure.
• In emergency situations, platelet transfusions may be considered to temporarily reverse the antiplatelet effects, as suggested by studies on patients with thrombocytopenia 1.

Clinical Guidelines

• The British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy guidelines recommend discontinuing P2Y12 receptor antagonists, such as clopidogrel, five days before high-risk endoscopic procedures in patients at low thrombotic risk 1.
• The UK Joint Specialist Societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults suggests that clopidogrel inhibits platelet aggregation for the whole lifespan of the platelet, which is between 7 and 10 days, and that a platelet transfusion can be given 6-8 hours after the last dose of clopidogrel prior to LP, in consultation with a haematologist 1.

Patient Management

• Always inform your healthcare provider about all medications you're taking, including Plavix, before any procedure.
• The final decision should be made by your physician based on your specific medical situation, weighing the urgency of the diagnostic information needed against the bleeding risk.
• The patient's platelet count, the trend and cause of thrombocytopenia, and the presence of other coagulopathies should be taken into consideration when deciding whether to perform a spinal tap 1.

From the FDA Drug Label

Avoid neuraxial blockade during clopidogrel use because of the risk of spinal hematoma When possible, discontinue clopidogrel 5 to 7 days prior to labor, delivery, or neuraxial blockade.

Spinal tap (neuraxial blockade) is not recommended while on Plavix (clopidogrel) due to the risk of spinal hematoma. It is advised to discontinue Plavix 5 to 7 days prior to the procedure if possible 2.

From the Research

Spinal Tap on Plavix

• The risk of hematoma from aspirin or clopidogrel (Plavix) owing to lumbar puncture has been evaluated in several studies 3, 4, 5, 6.
• A study published in the Mayo Clinic proceedings found that antiplatelet medication use within 1 week of lumbar puncture was associated with a 3% incidence of bloody tap and 4% incidence of traumatic tap that cleared 3.
• Another study published in Arquivos de neuro-psiquiatria recommended that lumbar puncture in patients using anticoagulants and antiplatelet agents should be done with caution, considering the opposing risks of bleeding and thrombotic complications 4.
• A case report published in the Journal of the neurological sciences described a patient who developed a spontaneous spinal epidural hematoma after adding clopidogrel to aspirin therapy, highlighting the risk of bleeding complications with dual antiplatelet treatment 5.
• A study published in The spine journal reported a case of late epidural hematoma in a patient on clopidogrel therapy postoperatively, emphasizing the need for vigilance in observing patients for late postoperative complications 6.

Risks and Considerations

• The use of antiplatelet agents, such as clopidogrel, increases the risk of bleeding complications, including hematoma and epidural hematoma 3, 5, 6.
• The risk of bleeding complications may be higher when clopidogrel is used in combination with other antiplatelet agents, such as aspirin 5.
• Patients on antiplatelet therapy should be closely monitored for signs of bleeding complications after lumbar puncture or spinal surgery 4, 6.

Clinical Implications

• Clinicians should carefully weigh the risks and benefits of performing a lumbar puncture in patients on antiplatelet therapy, considering the potential risks of bleeding complications 3, 4.
• Patients on clopidogrel therapy should be informed of the potential risks of bleeding complications and closely monitored for signs of complications after lumbar puncture or spinal surgery 5, 6.