What are the implications of Clopidogrel (Plavix) on surgical procedures?

From the Guidelines

Plavix (clopidogrel) should be stopped at least 5 days before elective surgery to minimize bleeding risk, as recommended by the most recent guidelines 1. When considering surgery, the management of antiplatelet therapy, including Plavix, is crucial to balance the risks of bleeding and cardiovascular events.

• The decision to stop Plavix should be made in consultation with the patient's cardiologist or surgeon, taking into account the individual's specific medical history and the type of surgery to be performed.
• For patients with coronary stents, the timing of Plavix discontinuation is critical, as stopping the medication too soon after stent placement can increase the risk of stent thrombosis.
• In emergency situations, surgery may need to proceed despite the increased bleeding risk, and measures such as platelet transfusions may be necessary to manage bleeding complications.
• After surgery, Plavix is usually restarted within 24-48 hours, depending on the specific procedure and the patient's individual risk factors. The French working group on perioperative haemostasis (GIHP) and the French study group on thrombosis and haemostasis (GFHT) propose that clopidogrel should be discontinued at least 5 days before an invasive procedure 1, which is consistent with the findings of previous studies 1.
• The proposed discontinuation times for other antiplatelet agents are:

• Aspirin: last intake on D-3 (or D-5 for intracranial neurosurgery)
• Ticagrelor: last intake on D-5 (or D-7 for intracranial neurosurgery)
• Prasugrel: last intake on D-7 (or D-9 for intracranial neurosurgery) It is essential to note that these recommendations are based on the most recent guidelines and may vary depending on the individual patient's circumstances and the specific procedure to be performed.

From the FDA Drug Label

5.3 Discontinuation of Clopidogrel Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.

Surgery and Clopidogrel: When surgery with a major risk of bleeding is planned, it is recommended to interrupt therapy with clopidogrel for five days prior to surgery. After surgery, clopidogrel should be restarted as soon as possible, once hemostasis is achieved. This is to minimize the risk of bleeding during surgery while also reducing the risk of cardiovascular events associated with discontinuing clopidogrel 2.

From the Research

Plavix and Surgery

• The use of Plavix (clopidogrel) in patients undergoing surgery is a topic of interest due to its antiplatelet effects, which can increase the risk of bleeding and transfusion requirements 3, 4, 5, 6, 7.
• Studies have shown that discontinuing clopidogrel before surgery may not be necessary, as it does not significantly reduce the risk of bleeding complications 7.
• Tranexamic acid, an antifibrinolytic agent, has been shown to reduce blood loss and transfusion requirements in patients undergoing coronary artery bypass grafting (CABG) who are taking clopidogrel 3, 4, 6.
• The risk of bleeding and thrombosis must be weighed against each other, and decisions should be made on an individual basis, taking into account the patient's specific medical history and circumstances 5.

Key Findings

• A study published in The Annals of Thoracic Surgery found that tranexamic acid reduced allogeneic erythrocyte transfusion, blood loss, major bleeding, and reoperation in patients undergoing primary and isolated on-pump CABG without clopidogrel and aspirin cessation 3.
• A study published in the Caspian Journal of Internal Medicine found that low-dose tranexamic acid reduced postoperative blood loss in patients treated with clopidogrel and aspirin 4.
• A study published in JAMA Surgery found that tranexamic acid reduced blood loss, major bleeding, and red blood cell transfusion volume and exposure in patients undergoing on-pump CABG who were taking clopidogrel 6.
• A study published in the Journal of Vascular Surgery found that discontinuation of preoperative clopidogrel is unnecessary in peripheral arterial surgery, as it does not increase the risk of bleeding complications 7.