Can a patient with a history of stent placement safely discontinue Effient (prasugrel) for 6 days before a procedure, or is the standard duration 5 days?

Discontinuation of Effient (Prasugrel) Before Procedures in Stented Patients

For patients with a history of coronary stent placement requiring a procedure, prasugrel (Effient) must be discontinued for at least 7 days before surgery, not 5 or 6 days. 1, 2, 3

Standard Discontinuation Timeline

• The FDA-approved prescribing information explicitly states: "When possible, discontinue prasugrel at least 7 days prior to any surgery" 3
• The American College of Cardiology guidelines consistently recommend a minimum 7-day discontinuation period for prasugrel before elective procedures 1, 2
• This 7-day window is longer than the 5-day requirement for clopidogrel because prasugrel causes irreversible platelet inhibition that lasts the entire platelet lifespan (7-10 days) 2

Why 7 Days (Not 5 or 6)

• Prasugrel requires a longer washout period than clopidogrel due to its more potent and irreversible antiplatelet effects 1
• The American College of Chest Physicians specifically distinguishes prasugrel from clopidogrel, recommending stopping prasugrel 5 days before CABG surgery while continuing aspirin 1
• For intracranial or spinal surgery specifically, guidelines recommend adding 2 additional days (total 9 days) to the discontinuation period 2

Critical Safety Considerations

• Do not start prasugrel in patients likely to undergo urgent surgery 3
• The risk of significant bleeding is substantial if CABG or other surgery is required within 7 days of prasugrel administration 3
• Patients weighing <60 kg have increased bleeding risk and may require dose reduction to 5 mg maintenance (though this doesn't change the 7-day discontinuation requirement) 1, 3

Balancing Thrombotic vs. Bleeding Risk

• If surgery must occur within 6 weeks of bare-metal stent placement or 6 months of drug-eluting stent placement, continuing dual antiplatelet therapy through surgery may be considered despite bleeding risk 1
• However, this decision applies primarily to truly urgent/emergent procedures where delaying surgery poses greater risk than bleeding 1
• For elective procedures, surgery should be deferred until the appropriate antiplatelet therapy duration is completed 1

Common Pitfall to Avoid

Do not confuse prasugrel's 7-day discontinuation requirement with clopidogrel's 5-day requirement - this is a critical distinction that directly impacts bleeding risk 1, 2, 3