How many days should Plavix (clopidogrel) be held prior to orthopedic surgery?

From the Guidelines

Plavix (clopidogrel) should be held for 5 days prior to orthopedic surgery to reduce bleeding risk, as recommended by the most recent guidelines 1. The exact timing depends on the specific surgical procedure and the patient's individual risk factors for both bleeding and thrombosis.

• For high-risk orthopedic procedures like joint replacements, a longer waiting period may be considered, but the general recommendation is 5 days for clopidogrel and ticagrelor, and 7 days for prasugrel 1.
• This waiting period allows platelet function to return to normal, as Plavix irreversibly inhibits platelet aggregation by blocking the P2Y12 receptor.
• The medication's effects on platelets last for the lifetime of the affected platelets (7-10 days), but since only a portion of circulating platelets are affected at any time, hemostasis begins to normalize after 5 days.
• For patients with recent coronary stents or at high risk for cardiovascular events, the decision to discontinue Plavix requires careful consideration and may benefit from a cardiology consultation to determine the optimal approach, which might include bridging therapy with shorter-acting antiplatelet agents in some cases, as suggested by earlier guidelines 1.
• However, the most recent guidelines from 2018 1 provide a clear recommendation for the management of antiplatelet therapy in patients undergoing elective invasive procedures, including orthopedic 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 duration to hold Plavix (clopidogrel) prior to orthopedic surgery is 5 days 2.

From the Research

Holding Plavix Prior to Orthopedic Surgery

• The decision to hold Plavix (clopidogrel) prior to orthopedic surgery depends on various factors, including the type of surgery, patient's medical history, and risk of bleeding or thrombosis 3.
• There is no clear consensus on the exact number of days to hold Plavix before orthopedic surgery, but studies suggest that the risk of bleeding is higher if the medication is continued perioperatively 4, 3.
• One study found that patients who underwent nonelective orthopaedic surgery while taking Plavix had similar transfusion rates and complications compared to those not taking Plavix, even with a surgical delay of less than 5 days 5.
• Another study recommended that efforts should be made to continue clopidogrel therapy through the perioperative period, taking precautions to minimize bleeding, and that antiplatelet therapy should be reinstated as soon as considered reasonable after surgery 3.
• The American College of Cardiology and American Heart Association guidelines suggest that patients undergoing orthopedic surgery should have their antiplatelet therapy managed on an individual basis, taking into account the risk of bleeding and thrombosis 4.

Risks and Considerations

• The risk of bleeding is a significant concern when continuing Plavix perioperatively, especially in patients undergoing major orthopedic surgery 6, 7.
• The risk of thrombosis is also a concern when discontinuing Plavix, particularly in patients with a history of cardiovascular or cerebrovascular events 4, 3.
• Patients with drug-eluting stents are at higher risk of stent thrombosis if clopidogrel is discontinued, and therefore, the decision to hold Plavix should be made on an individual basis 3.

Recommendations

• Orthopedic surgeons should take a team approach to assess the individual risks for all patients and consider continuation of clopidogrel therapy perioperatively where possible 3.
• The decision to hold Plavix should be based on the patient's medical history, type of surgery, and risk of bleeding or thrombosis, and should be made in consultation with the patient's cardiologist or primary care physician 4, 3.