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The World Health Organization considers the antiplatelet drug, clopidogrel (Plavix), to be an essential medication. [1] In 2019, it was the 36th most commonly prescribed drug in the US, with more than 19 million prescriptions among nearly 4.3 million patients. [2,3]

Against that backdrop, it would not be unusual for a patient seeking elective total joint arthroplasty to be taking the drug after stent placement or a previous heart attack or stroke. The dilemma for the orthopaedic surgeon: Should I recommend discontinuing clopidogrel before surgery to prevent bleeding, or should I let the patient continue taking the drug to avoid the risk of adverse cardiovascular events perioperatively?

This is not an easy question to answer, given the lack of evidence-based guidelines on clopidogrel specific to orthopaedic procedures.

A new study from the Florida Orthopaedic Institute, however, offers some insight to help in the decision-making process: The researchers found that holding clopidogrel and continuing clopidogrel are both acceptable options for total joint arthroplasty patients, with no significant difference in mortality, complications, or readmissions.

These findings have been published online ahead of print by The Journal of Arthroplasty.

Study Methodology

For this retrospective study, the researchers identified 158 patients aged 18 and older who were taking clopidogrel and who underwent elective primary and revision total hip and total knee arthroplasty between January 2016 and February 2020. The procedures were performed by 4 fellowship-trained adult reconstruction surgeons.

The patients were stratified into 2 groups:

• Clopidogrel held (n=92), defined as their last preoperative dose taken 5 or more days before surgery
• Clopidogrel not held (n=66), defined as their last preoperative dose taken less than 5 days before surgery

Patients in both groups resumed clopidogrel on POD1.

The researchers collected data on:

• Patient factors, including demographics and comorbidities
• Preoperative factors, including ASA status and preoperative use of aspirin or other anti-platelet medications
• Intraoperative factors, including procedure technique and operative time
• Immediate postoperative factors, including type of postoperative anticoagulant, length of stay, and transfusion status
• Post-discharge factors, including infections, impaired wound healing, and reoperation or readmission within 90 days of surgery

The need for a transfusion during hospitalization and readmission within 90 days of surgery were the primary outcome measures. Secondary outcome measures included complications, infection rate, reoperation rate, and major cardiac and neurologic events within 90 days of surgery.

Study Findings

Overall, 3% of patients received a transfusion postoperatively. This was more likely to occur in the continued to take clopidogrel, with a 9.1% transfusion rate versus 0% for the group that had clopidogrel held. Transfusion status did not significantly affect the postoperative hemoglobin level when measured as a continuous variable.

Per protocol, 95% of patients who continued clopidogrel received general instead of spinal anesthesia. This is related to the risk of spontaneous spinal hematoma in patients whose anticoagulant is not held prior to surgery. However, 3 patients in this group did receive spinal anesthesia in this study, with no adverse events.

Operative time was significantly different between groups, with a shorter operative time in the group in which clopidogrel was not held. The study authors offered 2 possible reasons:

• Only 30% of patients who underwent total knee arthroplasty were in the group that continued clopidogrel, and most of those knees were uncemented.
• Patients who continued clopidogrel may have been viewed as “higher risk” and therefore may have had more aspects of their procedures performed by the attending surgeon rather than slower residents or fellows.

The researchers found no other significant differences between the 2 groups, leading them to conclude that “patients undergoing elective total hip and knee arthroplasty may be safely maintained on clopidogrel without an increased risk of wound complications, infection, length of stay, readmission, reoperation, major medical complications, or mortality.”

However, the researchers cautioned surgeons to keep in mind the potential for an increased risk of postoperative transfusion in these patients.

Source

Maxfield DG, Bernasek TL, Engel CC, Gill MK. Is it safe to continue clopidogrel in elective hip and knee arthroplasty? J Arthroplasty. 2022 Apr 9:S0883-5403(22)00396-5. doi: 10.1016/j.arth.2022.04.005. Online ahead of print.

References

1. World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. Retrieved 2 May 2022.
2. The top 300 of 2019. ClinCalc. Retrieved 2 May 2022.
3. Clopidogrel – drug usage statistics. ClinCalc. 23 December 2019. Retrieved 2 May 2022.