Pharm

Clopidogrel

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Clopidogrel, Plavix

  • See Also
  1. Platelet ADP Receptor Antagonist
  2. Antiplatelet Therapy for Vascular Disease
  3. Ticagrelor
  4. Prasugrel
  • Indications
  • Prevention of Thrombotic Events
  1. See Platelet ADP Receptor Antagonist
  2. See Antiplatelet Therapy for Vascular Disease
  3. Cerebrovascular Accident Prevention
  4. Coronary Artery Disease Prevention (especially if Aspirin Allergy)
  5. Post-ST Elevation MI (with or without reperfusion)
  • Contraindications
  1. Active Bleeding
  • Mechanism
  1. See Platelet ADP Receptor Antagonist
  • Background
  1. Clopidogrel is generic as of May 2012
  • Dosing
  • Clopidogrel (Plavix)
  1. Standard dosing
    1. Plavix 75 mg orally daily
  2. Acute Myocardial Infarction
    1. Loading dose: Plavix 300 mg (if age <75 years)
    2. Then initiate standard 75 mg daily Plavix dose with Aspirin 81 mg
  3. Impending Percutaneous Coronary Intervention (PCI)
    1. Plavix 600 mg orally once
    2. Then initiate standard 75 mg daily Plavix dose after PCI
  • Pharmacokinetics
  1. Metabolized to active form by CYP2C19
    1. Clopidogrel may have poor efficacy in poor CYP2C19 metabolizers
  • Adverse Effects
  1. Gastrointestinal Bleeding
    1. Clopidogrel is associated with less GI Bleeding than Aspirin or Prasugrel
    2. Consider as alternative if GI Bleeding occurs with Aspirin
    3. However, switching to Clopidogrel does not prevent recurrent GI Bleed
      1. GI Bleed occurs in 8% of those switched to Clopidogrel
      2. Consider adding Proton Pump Inhibitor (PPI) to Aspirin instead of Clopidogrel
  • Safety
  1. Unknown safety in pregnancy
  2. Unknown safety in Lactation
  • Drug Interactions
  • General
  1. Agents that reduce Clopidogrel activity
    1. Opioids
    2. Strong CYP2C19 Inhibitors
      1. See Proton Pump Inhibitors related Drug Interactions as below
      2. Fluconazole, Ketaconazole or Voriconazole
      3. Fluoxetine, Fluvoxamine
  2. Agents whose levels are significantly increased by Clopidogrel
    1. Repaglinide
  3. Agents that increase bleeding risk when combined with Clopidogrel
    1. Aspirin
    2. Selective Serotonin Reuptake Inhibitor (SSRI)
    3. Serotonin Norepinephrine Reuptake Inhibitor (SNRI)
  1. Agents that reduce conversion of Plavix to active metabolite (unclear clinical impact)
    1. Omeprazole
    2. Esomeprazole
  2. Safe agents that do not appear to interact with Plavix
    1. Lansoprazole
    2. Dexlansoprazole
    3. Pantoprazole
    4. Famotidine (high dose)
  3. Limit Proton Pump Inhibitors to high risk patients
    1. Prior GI Bleed
    2. Advanced age
    3. Concurrent Aspirin, NSAIDs, Corticosteroids, or Warfarin
  4. Application
    1. Avoid Proton Pump Inhibitors unless clear indication
    2. If a Proton Pump Inhibitor is needed
      1. Choose one that that does not interfere with Cloipidogrel (e.g. Lansoprazole)
      2. Consider agent that does not interact with PPIs such as Ticagrelor (Brilanta) in place of Clopidogrel
    3. Best data suggests no increased risk of cardiovascular events with PPI and Clopidogrel
  5. References
    1. (2013) Presc Lett 20(6): 36
    2. Mehta (2011) Clin Cardiol 34(9): 528-31 [PubMed]
  • Management
  • Reversal
  1. See Platelet ADP Receptor Antagonist
  2. Stop 5 days before elective surgery
  • Resources
  1. Clopidogrel (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=86ee71f2-850e-4c8e-87f3-c7a618d59d95
  • References
  1. Filler and Lovecchio (2017) Crit Dec Emerg Med 31(7): 24
  2. Switaj (2017) Am Fam Physician 95(4): 232-40 [PubMed]