Clopidogrel

Clopidogrel - In addition to standard therapy (aspirin, LMWH, -blocker and nitrate), clopidogrel reduces the risk of MI, stroke and cardiovascular death in patients with unstable angina and non-ST-elevation MI (The CURE investigators. N Engl J Med 2001;345: 494–502).NICE and the European Society of Cardiology both endorse the use of clopidogrel in combination with aspirin in non-ST-elevation acute coronary syndrome patients. Clopidogrel is also used with aspirin in STEMI and after angioplasty for up to 12 months.

Uses:
Acute coronary syndrome

Contraindications:
Warfarin
Severe liver impairment
Active bleeding
Breast feeding

Administration:
Unstable angina and non-ST-elevation MI: single 300 mg loading dose,
followed by 75 mg daily (with aspirin 75 mg/day) for up to 12 months
(or 600 mg if primary PCI)
Monitor: FBC
         Clotting screen
Discontinue 7 days prior to surgery

How not to use clopidogrel:
Omit clopidogrel if patient likely to go for CABG within 5 days Not recommended under 18 years of age Pregnancy

Adverse effects:
Bleeding (can protect with ranitidine)
Abnormal LFTs and raised serum creatinine
Haematological disorders including pancytopenia

Cautions:
Avoid for 7 days after ischaemic stroke
Increase risk of bleeding with the concurrent use of:
  aspirin (although recommended for up to 12 months in CURE study)
  NSAIDs
  heparin
  thrombolytics
  glycoprotein IIb/IIIa inhibitors
Avoid concomitant use of PPIs, fluoxetine, fluconazole, ciprofloxacin and carbamazepine (clopidogrel may be less effective).

Organ failure:
Hepatic: avoid in severe liver impairment