What is the recommended time to discontinue Clopidogrel (Plavix) before surgery?

From the Guidelines

Clopidogrel should be stopped 5 days before elective surgery to reduce bleeding risk, as recommended by the most recent guidelines 1. When considering the management of patients on clopidogrel who require surgery, it's essential to balance the risk of bleeding against the risk of thrombotic events.

• For elective surgeries, stopping clopidogrel 5 days before the procedure is generally recommended to minimize bleeding complications, as stated in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline 1.
• In cases of urgent surgery, the decision to stop clopidogrel should be made on a case-by-case basis, considering the individual patient's risk factors and the potential benefits and risks of proceeding with or without stopping the medication.
• The timing of clopidogrel cessation may need to be adjusted based on the type of surgery, the patient's overall health status, and the presence of any comorbid conditions that may affect bleeding or thrombotic risk.
• It's crucial to consult with both the surgeon and cardiologist before making a decision about stopping clopidogrel, as they can provide valuable insights into the patient's specific situation and help determine the best course of action.
• The 2025 guideline also recommends resuming oral P2Y12 inhibitors, including clopidogrel, after surgery when the bleeding risk is not excessive, typically within 24-72 hours 1.
• The evidence from the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline 1 supersedes previous recommendations, providing the most up-to-date guidance on the management of patients on clopidogrel who require surgery.

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.

The recommended time to stop Clopidogrel before surgery is 5 days prior to the surgery, when possible, to minimize the risk of bleeding while also considering the risk of cardiovascular events 2. Key points:

• Discontinuation of clopidogrel increases the risk of cardiovascular events
• Restart clopidogrel as soon as possible after surgery
• Resume clopidogrel as soon as hemostasis is achieved
• Interrupt therapy with clopidogrel for 5 days prior to surgery, when possible.

From the Research

Time to Stop Clopidogrel Before Surgery

• The optimal time to stop clopidogrel before surgery is a topic of debate, with various studies suggesting different durations 3, 4, 5, 6, 7.
• A study published in 2009 found that stopping clopidogrel 7 days before surgery was not enough to negate the difference in reoperations for bleeding compared to non-clopidogrel patients 3.
• Another study published in 2019 found that there was no significant difference in hemoglobin drop between patients who stopped clopidogrel 3 days or less before coronary artery bypass grafting (CABG) and those who stopped it 5 days before CABG 4.
• A 2011 study found that the timing of clopidogrel cessation within 7 days did not affect postoperative bleeding risk, but high-risk patients undergoing elective operations may not require preoperative clopidogrel cessation 5.
• A multicenter randomized trial published in 2013 found that tranexamic acid reduced bleeding and transfusion requirements in patients receiving coronary artery bypass grafting (CABG) who were exposed to clopidogrel 6.
• A propensity score analysis published in 2011 found that clopidogrel discontinuation within 5 days of surgery was independently associated with transfusion requirement, and suggested that clopidogrel should be discontinued more than 5 days before surgery 7.

Key Findings

• Stopping clopidogrel 7 days before surgery may not be enough to prevent bleeding complications 3.
• The timing of clopidogrel cessation within 7 days may not affect postoperative bleeding risk 5.
• Tranexamic acid may reduce bleeding and transfusion requirements in patients receiving CABG who are exposed to clopidogrel 6.
• Clopidogrel discontinuation within 5 days of surgery is associated with increased transfusion requirements 7.

Study Results

• A study of 170 patients taking clopidogrel in the perioperative period found that patients taking clopidogrel experienced a significantly higher rate of return trips to the operating room (6.5%) compared to non-clopidogrel patients (0.015%) 3.
• A retrospective single-center study of 90 patients found that there was no significant difference in hemoglobin drop between patients who stopped clopidogrel 3 days or less before CABG and those who stopped it 5 days before CABG 4.
• A review of 104 patients receiving clopidogrel who underwent abdominal operations found that the timing of clopidogrel cessation within 7 days did not affect postoperative bleeding risk 5.
• A multicenter randomized trial of 552 patients found that tranexamic acid reduced bleeding and transfusion requirements in patients receiving CABG who were exposed to clopidogrel 6.
• A propensity score analysis of 1,947 consecutive patients undergoing coronary surgery found that clopidogrel discontinuation within 5 days of surgery was independently associated with transfusion requirement 7.