Elsevier

Injury

Volume 44, Issue 6, June 2013, Pages 743-746
Injury

Clopidogrel has no effect on mortality from hip fracture

https://doi.org/10.1016/j.injury.2012.11.028Get rights and content

Abstract

Over 76,000 patients in the UK sustain a proximal femoral fracture. Clopidogrel is currently the world's second best selling drug. There has been much recent controversy surrounding the optimal time for surgical intervention in this medically challenging group of patients.

This consecutive series of 1225 patients from our unit over six years included thirty patients concurrently taking clopidogrel whilst sustaining a hip fracture.

Our study demonstrated no significant difference in ASA grade, intra-operative blood loss or subsequent transfusion, post-operative wound complication, or mortality to one year in those taking clopidogrel.

The authors therefore advocate timely surgical intervention as rapidly as circumstances allow.

Introduction

The UK National Hip Fracture Database Report 2010 recorded over 76,000 proximal femoral fractures.1 This group of patients frequently present a significant medical and surgical challenge to all involved in their care, presenting with numerous co-morbidities including stroke and ischaemic heart disease.2 Their polypharmacy often includes anticoagulants such as warfarin, aspirin, and clopidogrel.

Clopidogrel (Plavix®, Bristol-Myers Squibb/Sanofi Pharmaceuticals partnership) is an oral antithrombotic agent indicated for treatment and secondary prevention of acute coronary syndrome and stroke. This includes patients who have undergone percutaneous coronary intervention and coronary artery bypass grafting.3 It is currently the world's second best selling drug, with worldwide sales of over $7 billion.4 Current guidelines suggest that treatment is indicated for up to one year depending on disease severity.5

Clopidogrel acts by irreversibly modifying the platelet adenosine diphosphate (ADP) receptor, meaning those platelets exposed to the drug are affected for the remainder of their lifespan.6 An in vivo study of healthy volunteers showed complete recovery of platelet function seven days after the last clopidogrel dose.7 The British National Formulary therefore suggests stopping Clopidogrel seven days prior to elective surgery if the antiplatelet effect is not desirable.8 No current agreed guidelines exist for trauma patients admitted as an emergency.

Recent studies regarding surgeon's attitudes towards the optimal time for operative intervention in patients sustaining a hip fracture whilst on clopidogrel, and the potential consequences of surgical delay in medically co-morbid patients have shown a marked division of opinion.9

The aims of this study are therefore to establish whether early surgical intervention can safely be considered and if it significantly affects intra-operative blood loss, subsequent need for transfusion, and mortality within the year after surgery.

Section snippets

Patients and methods

The study design is a consecutive series of patients admitted to xxx under the care of the senior author [xxx]. All data were prospectively collected on admission using a standard proforma used for both in patient stay and subsequent follow up. All surviving patients were followed up either at clinic or by telephone up to one year after injury, however the last 360 patients recruited to the series had limited follow-up to 120 days. To provide a comparable group of patients only those with an

Results

2310 patients were admitted with a hip fracture between June 2005 and June 2011. Twenty six patients who were treated conservatively and sixty pathological fractures from bone secondaries were excluded from the series, none of these excluded patients were taking clopidogrel. 30 patients taking Clopidogrel were identified and all were graded 3 or greater according to American Society of Anaesthesiologist grading. All patients with an ASA grade 1 or 2 were excluded from the study (999 patients),

Discussion

Our study of twelve hundred and twenty five consecutive patients showed no significant increase in intra-operative blood loss, subsequent transfusion need, or increase in mortality up to one year after the surgical event. We therefore conclude that patients taking clopidogrel should be operated on as soon as circumstances allow ensuring the most favourable surgical outcome.

The consequence of pre-operative delay after hip fracture was comprehensively addressed by Moran et al.10 This prospective

Conclusion

This study demonstrates there were no adverse effects of early surgery for patients taking clopidogrel at the time of admission with a hip fracture. These findings have been supported now by a number of previous studies and all these studies indicate that these patients can be managed by normal protocols for these patients with early surgery.

Conflict of interest

None declared.

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