In an adult patient taking clopidogrel 75 mg daily, how many days before spinal (or epidural) anesthesia should the medication be discontinued?

Discontinuation of Clopidogrel Before Spinal Anesthesia

Central neuraxial anesthesia (spinal or epidural) is contraindicated in patients taking clopidogrel, and the medication must be discontinued for at least 5 days before the procedure. 1

Mandatory Discontinuation Period

• Stop clopidogrel 5 days before spinal or epidural anesthesia to allow adequate platelet function recovery. 1, 2
• This 5-day window allows approximately 50-70% of normal platelet function to return, with roughly 10-14% recovery occurring each day after discontinuation. 3, 4
• The FDA drug label specifically warns to "avoid neuraxial blockade during clopidogrel use because of the risk of spinal hematoma" and recommends discontinuation 5-7 days prior to neuraxial blockade. 5

Evidence Supporting the 5-Day Interval

• Research demonstrates that after 5 days of clopidogrel discontinuation, the majority of patients (10 out of 13 studied) achieve ≤10% platelet inhibition, which is considered safe for neuraxial procedures. 4
• The French Working Group on Perioperative Haemostasis states unequivocally that "central neuraxial anaesthesia is contraindicated in patients on P2Y12 inhibitors (clopidogrel, prasugrel)." 1
• The Association of Anaesthetists of Great Britain & Ireland recommends a 7-day discontinuation period, though acknowledges that 5 days may be adequate based on pharmacokinetic data. 1

Critical Safety Considerations

• Do not perform spinal or epidural anesthesia if clopidogrel has been stopped for less than 5 days, even in urgent situations, due to the risk of vertebral canal hematoma. 1
• The risk of spinal hematoma, while rare (0.85 per 100,000 in patients without coagulopathy), is catastrophic and can result in permanent paralysis. 1
• A documented case exists of epidural hematoma occurring despite stopping clopidogrel 7 days preoperatively when combined with perioperative low molecular weight heparin, highlighting that even adherence to guidelines does not eliminate all risk. 6

Alternative Anesthetic Approaches

• If surgery cannot be delayed 5 days, use general anesthesia or peripheral nerve blocks with low bleeding risk (femoral, axillary, popliteal sciatic blocks) rather than neuraxial techniques. 1
• Superficial peripheral nerve blocks may be performed on clopidogrel with ultrasound guidance by experienced operators, though this carries some risk. 1
• Deep peripheral nerve blocks (infraclavicular, parasacral sciatic, posterior lumbar plexus) remain contraindicated unless clopidogrel has been stopped for 5 days. 1

Postoperative Resumption

• Resume clopidogrel within 24 hours after spinal anesthesia when hemostasis is adequate, particularly in high thrombotic risk patients (recent stents, acute coronary syndrome). 2, 3
• For patients with drug-eluting stents placed within the past 6 months or bare metal stents within 6 weeks, cardiology consultation is mandatory before stopping clopidogrel, as the thrombotic risk may outweigh bleeding concerns. 2, 3

Common Pitfall to Avoid

The most dangerous error is performing neuraxial anesthesia without verifying the exact timing of the last clopidogrel dose. Always document the date and time of the last dose and count forward 5 full days (120 hours minimum) before proceeding with spinal or epidural placement. 1