Should I stop Plavix for orthopedic surgery?

A 60 year old woman with a stroke five years ago, who has been on Plavix ever since, gets hospitalized with a broken arm after a fall (it’s been icy this winter!). The orthopedics resident asks you if it’s okay to hold the Plavix, since they’re worried about her bleeding risk in the OR. “For ambulatory surgery,” he says, “We tell them to stop Plavix for 5 days before the procedure.”

Although there are some pretty solid recommendations on aspirin and warfarin in the perioperative setting, there aren’t clear guidelines for Plavix and DOACS….especially when you consider that orthopedic procedures have different bleeding risks than neurosurgical procedures than ophthalmologic procedures. One study of 40 patients undergoing hip fracture surgery reported no difference in bleeding between patients on Plavix versus those who were not. This systematic review of nine studies concludes that delaying hip fracture surgery for Plavix washout did not decrease bleeding and led to more post-op complications.

The American Academy of Neurology sought to provide clarity in this 2013 statement. They stated that while aspirin seems to increase bleeding risk for orthopedic surgeries (but not other kinds of procedures!) there was “insufficient evidence” to make a confident statement about Plavix. However they did point out that when bleeding did occur, most of the time it was mild–but when clotting occurred (like a stroke or PE), it was more morbid.

NB: however, Plavix is known to increase the risk of potential serious complications in spinal anesthesia. You probably want to avoid that. That being said, nothing is impossible, and there are cases of using platelet transfusions during spinal anesthesia to get people on Plavix through the case. It has been generally concluded that aspirin and spinal anesthesia are fine.

Conclusion: there is no one correct answer. For the woman above, if she just had drug-eluting stents put in last week, you should not stop the Plavix (and probably should not do surgery without talking with her cardiologist). If she’s been on Plavix for 5 years, and the surgery is going to be long and complicated, then it might be okay to hold it for a few days? Maybe? I probably wouldn’t because my personal opinion is, bleeding eventually stops, but a clot causes permanent damage. The orthopedics resident is right that holding Plavix for 5 days is general practice (although not clear where the evidence for this comes from). However, that’s in non-hospitalized patients who are functional enough to get to their scheduled surgery and go home after.