As an elderly patient (≥65 years) on clopidogrel (antiplatelet) who sustained a slip‑and‑fall injury, should I discontinue the medication?

Clopidogrel After Slip-and-Fall in Elderly: Do NOT Stop

In an elderly patient on clopidogrel who sustains a slip-and-fall injury, continue clopidogrel unless there is active major bleeding or an urgent surgical procedure requiring hemostasis. 1, 2

Immediate Assessment Priority

The critical decision hinges on whether the patient has:

• Active pathological bleeding (e.g., expanding intracranial hemorrhage, retroperitoneal bleed, gastrointestinal hemorrhage requiring intervention) – this is the only absolute indication to stop clopidogrel immediately 2
• Need for urgent/emergent surgery in a closed space (intracranial, spinal canal, posterior eye chamber) where even minor bleeding is catastrophic 3
• Occult bleeding risk – elderly patients on clopidogrel who fall require careful assessment for retroperitoneal or other hidden bleeding, even without obvious external injury 4

When to Continue Clopidogrel (Most Scenarios)

For the majority of slip-and-fall injuries without active major bleeding, clopidogrel should be continued. The rationale:

• The FDA label states clopidogrel is contraindicated only in patients with "active pathological bleeding" – a simple fall without hemorrhage does not meet this threshold 2
• Discontinuing clopidogrel increases cardiovascular event risk, particularly in patients with recent acute coronary syndrome or coronary stents (drug-eluting stents require minimum 12 months of therapy) 1, 2
• The thrombotic risk of stopping clopidogrel (stent thrombosis, recurrent MI, stroke) typically exceeds the bleeding risk from continuation in trauma without active hemorrhage 3, 4

When to Stop Clopidogrel

Active Major Bleeding

• Stop immediately if there is active pathological bleeding (intracranial hemorrhage, gastrointestinal bleed requiring transfusion, retroperitoneal hematoma) 2
• Provide supportive care, volume resuscitation, and local hemostatic measures 1
• Consider platelet transfusion (though less effective if given within 2 hours of last maintenance dose or 4 hours of loading dose) 2

Urgent Surgery Required

• For high-risk bleeding procedures (intracranial, spinal canal, posterior chamber eye surgery): stop clopidogrel and delay surgery 5 days if possible 1, 2, 3
• For life-threatening situations where surgery cannot wait (e.g., expanding subdural hematoma): proceed with surgery despite clopidogrel, using strategies to minimize bleeding (platelet transfusion, antifibrinolytics like tranexamic acid) 5, 3
• For most orthopedic trauma (hip fracture repair, long bone fixation): evidence supports proceeding with surgery while continuing clopidogrel, as the thrombotic risk of stopping outweighs bleeding risk 6, 5, 4

Critical Timing Considerations

• If clopidogrel must be stopped, the antiplatelet effect persists for 5–7 days (the platelet lifespan) because clopidogrel irreversibly inhibits platelets 2, 3
• Restart clopidogrel as soon as hemostasis is achieved (typically within 12–24 hours post-procedure) to minimize thrombotic risk 1, 5, 3
• Never delay restarting beyond 24 hours in patients with recent ACS or coronary stents, as this dramatically increases stent thrombosis and MI risk 5

Special Considerations in Elderly Patients

• Age ≥75 years is a relative contraindication for prasugrel (not clopidogrel), so clopidogrel remains appropriate in this population 7, 8
• Body weight <60 kg increases bleeding risk but does not mandate stopping clopidogrel after trauma unless active bleeding is present 7
• Concomitant anticoagulation (warfarin, DOACs) or chronic NSAID use increases bleeding risk and warrants closer monitoring, but is not an absolute reason to stop clopidogrel after a fall 2

Common Pitfalls to Avoid

• Do not reflexively stop clopidogrel in all elderly fall patients – this practice is outdated and increases cardiovascular mortality 5, 3, 4
• Do not assume a 5-day washout is always necessary – for most orthopedic trauma surgery (hip fractures), proceeding with clopidogrel on board is safer than delaying surgery, as delay beyond 4 days increases postoperative mortality 6, 5
• Do not forget to assess for occult bleeding – retroperitoneal hematomas can develop insidiously in elderly patients on antiplatelet therapy after falls 4
• Do not substitute heparin or LMWH for clopidogrel during a perioperative period – this does not protect against stent thrombosis or recurrent ACS 3

Indication-Specific Guidance

Recent Coronary Stent (Drug-Eluting)

• Minimum 12 months of clopidogrel is mandatory – stopping early dramatically increases stent thrombosis risk (often fatal) 1
• If surgery is required within this window, continue clopidogrel unless bleeding risk is prohibitive 1, 5

Recent Acute Coronary Syndrome

• Minimum 12 months of dual antiplatelet therapy (aspirin + clopidogrel) regardless of stent type 1
• Stopping clopidogrel in this population increases recurrent MI and death risk 5, 3

Stroke/MI/Peripheral Artery Disease (Chronic Indication)

• Clopidogrel 75 mg daily indefinitely – stopping increases recurrent vascular events 2
• After a fall, continue unless active bleeding is documented 2, 3

Resumption Protocol After Temporary Interruption

• Restart within 12–24 hours of achieving hemostasis post-procedure 1, 3
• No loading dose needed if patient was on chronic therapy – resume maintenance dose (75 mg daily) 2
• Monitor closely for signs of recurrent bleeding or thrombotic events in the first 48 hours after resumption 5