THERAPEUTICS

Brands

• Plavix, clopidogrel bisulfate

Generic?

• Yes

Class

• Antiplatelet agent

Commonly Prescribed for

(FDA approved in bold)

• Acute coronary syndrome/non-ST-segment elevation myocardial infarction (ACS/ NSTEMI): decrease the rate of a combined endpoint of cardiovascular death, myocardial infarction (MI), or stroke

• ST-segment elevation myocardial infarction (STEMI): reduce the rate of death from any cause and the rate of a combined endpoint of death, reinfarction, or stroke. The benefit for patients who undergo primary percutaneous intervention is unknown

• Recent MI, recent stroke, or established peripheral arterial disease: reduce the combined endpoint of new ischemic stroke, new MI, and other vascular death

• Pain in peripheral artery disease

• Prevention of clots following angioplasty with stenting

How the Drug Works

• Inhibitor of platelet aggregation. Clopidogrel, once metabolized by CYP2C19, irreversibly binds to the platelet P2Y12 class of adenosine diphosphate (ADP) receptor and inhibits the activation of the GPIIb/IIIa complex

How Long Until It Works

• Inhibition of platelet aggregation begins as soon as 2 hours after a single oral dose of clopidogrel. Platelets are affected for their lifespan (7–10 days)

If It Works

• Continue to use for MI or stroke prevention

If It Doesn't Work

• Check CYP2C19 dysfunctional genotype (2% White, 4% Black, 14% Chinese). Avoid concomitant use of proton pump inhibitor (e.g., omeprazole). Warfarin is superior for atrial fibrillation embolic stroke. Control all stroke risk factors such as smoking, hyperlipidemia, and hypertension. For acute events, admit patients for treatment and diagnostic testing

Best Augmenting Combos for Partial Response or Treatment-Resistance

• Based on CHANCE study, combination of clopidogrel and aspirin is superior to aspirin alone in reducing the risk of a secondary stroke in the first 90 days and does not increase the risk of hemorrhage

Tests

• None required

ADVERSE EFFECTS (AEs)

How the Drug Causes AEs

• Antiplatelet effect increases bleeding risk

Notable AEs

• Bleeding, thrombotic thrombocytopenic purpura

Life-Threatening or Dangerous AEs

• GI hemorrhage (2%), intracranial hemorrhage (0.1–0.4%), or intraocular bleeding leading to vision loss