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 patient should stop taking clopidogrel 5 days before lithotripsy, as it is a surgery with a major risk of bleeding, and then resume it as soon as hemostasis is achieved 1.
From the Research
Clopidogrel should be stopped at least 5 days before lithotripsy procedures to minimize the risk of bleeding complications. The decision to stop clopidogrel before lithotripsy should be individualized based on the patient's specific thrombotic risk, as noted in studies such as 2. Patients with recent coronary stents, particularly drug-eluting stents placed within the past 6-12 months, may require consultation with their cardiologist before stopping clopidogrel due to the risk of stent thrombosis.
Key Considerations
- The optimal timing of clopidogrel cessation before surgery is controversial, but stopping it at least 5 days before the procedure is commonly recommended to reduce bleeding risk, as seen in 3.
- The risk of bleeding complications is higher when clopidogrel is stopped within 5 days of surgery, as demonstrated in 3.
- However, the risk of bleeding does not seem to vary significantly by the timing of cessation within 7 days of an operation, as noted in 2.
- After lithotripsy, clopidogrel can typically be resumed 24-48 hours following the procedure if there are no bleeding complications.
Evidence Summary
Studies such as 4, 3, and 2 provide insights into the management of clopidogrel before surgical procedures, including lithotripsy. While the exact duration for stopping clopidogrel may vary based on individual patient risk factors, the consensus leans towards stopping it at least 5 days before the procedure to balance the risk of bleeding against the risk of thrombotic events. It's also important to consider the findings from 5 and 6, which discuss the overall efficacy and safety of clopidogrel in preventing thrombotic events, although they do not directly address the timing of cessation before lithotripsy.
Clinical Decision Making
The management of clopidogrel before lithotripsy should be tailored to the individual patient's risk profile, considering both the risk of bleeding and the risk of thrombotic events. Consultation with both the urologist and the cardiologist (if applicable) is crucial to determine the safest approach for each patient. The decision should be based on the most recent and highest quality evidence available, such as the studies referenced here 4, 3, 2.