Version May 2024
The effectiveness of clopidogrel results from its antiplatelet activity, which is dependent on its conversion to an active metabolite by the cytochrome P450 (CYP-450) system, principally CYP2C19. Clopidogrel at recommended doses forms less of the active metabolite and has a reduced effect on platelet activity in patients who are homozygous for nonfunctional alleles of the CYP2C19 genes (termed “CYP2C19 poor metabolizers”). Tests are available to identify patients who are CYP2C19 poor metabolizers. Consider use of another platelet P2Y12 inhibitor in patients identified as CYP2C19 poor metabolizers.
Antiplatelet effect: Limited data available: Oral: 0.2 mg/kg/dose once daily. A double-blind, placebo-controlled trial of 906 patients (n=461 neonates; n=445 infants ≤3 months) with cyanotic congenital heart disease surgically treated with a systemic-to-pulmonary artery shunt did not demonstrate a clinical benefit compared to placebo. Concomitant aspirin was used in 88% of patients (Ref). In another trial, 0.2 mg/kg/dose once daily was found to achieve a mean inhibition of platelet aggregation similar to a standard adult dose; Note: This study (PICOLO Trial) included 73 evaluable patients (n=34 neonates [with exclusion of patients with weight <2 kg and GA <35 weeks]; n=39 infants ≤24 months) with a systemic-to-pulmonary artery shunt, intracardiac or intravascular stent, Kawasaki disease, or arterial graft; 79% of patients received concomitant aspirin (Ref).
Antiplatelet effect: Limited data available:
Infants and Children ≤24 months: In the PICOLO trial, a dose of 0.2 mg/kg/dose once daily was found to achieve a mean inhibition of platelet aggregation similar to adults receiving the adult recommended dose; Note: This study included pediatric patients with a systemic-to-pulmonary artery shunt, intracardiac or intravascular stent, Kawasaki disease, or arterial graft; 79% of patients received concomitant aspirin (Ref).
Children >2 years and Adolescents: Initial dose: 1 mg/kg once daily; in general, do not exceed adult dose (Ref).
CYP2C19 poor metabolizers (ie, CYP2C19*2 or *3 carriers): Specific pediatric recommendations are lacking; based on experience in adult patients, routine genetic testing is not recommended in patients treated with clopidogrel undergoing percutaneous coronary intervention; testing may be considered to identify poor metabolizers who would be at risk for poor response while receiving clopidogrel and if identified, these patients may be considered for an alternative P2Y12 inhibitor (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no pediatric-specific dosage adjustments provided in the manufacturer's labeling; use with caution. Based on adult data, no dosage adjustment is required; in adults, GFR stage 5 (ie, end-stage renal disease or an eGFR <15 mL/minute) is associated with higher residual platelet reactivity with maintenance dosing (Ref).
There are no pediatric-specific dosage adjustments provided in the manufacturer's labeling; in adults, no dosage adjustment is necessary.
(For additional information see "Clopidogrel: Drug information")
Dosage guidance:
Clinical considerations: In patients who require concomitant therapeutic anticoagulation, antiplatelet selection and/or duration of therapy may differ in order to balance risks for thrombosis and bleeding (Ref).
Acute coronary syndrome:
Note: Routine platelet-function testing or genetic testing for CYP2C19 polymorphisms is not recommended (Ref).
ST-segment elevation myocardial infarction:
Note: Regardless of the reperfusion strategy, administer clopidogrel in combination with a parenteral anticoagulant and aspirin (Ref).
If using fibrinolytic therapy for reperfusion:
Age ≤75 years: Oral: Initial loading dose: 300 mg once at the time of diagnosis; followed by 75 mg once daily (Ref).
Age >75 years: Oral: 75 mg once daily (Ref).
Patient requires percutaneous coronary intervention following fibrinolytic therapy:
Fibrinolytic administered with a clopidogrel 300 mg loading dose: Oral: Continue 75 mg once daily (do not administer an additional loading dose) (Ref).
Fibrinolytic administered ≤24 hours ago without a loading dose of clopidogrel: Oral: Initial: 300 mg once prior to percutaneous coronary intervention (PCI); followed by 75 mg once daily after PCI (Ref).
Fibrinolytic administered >24 hours ago without a loading dose of clopidogrel: Oral: Initial: 600 mg once prior to PCI; followed by 75 mg once daily after PCI (Ref).
If using percutaneous coronary intervention for reperfusion (alternative agent) (off-label use):
Note: Ticagrelor or prasugrel may be preferred over clopidogrel unless there is high risk for bleeding (Ref).
Oral: Initial: 600 mg once as early as possible before PCI; followed by 75 mg once daily after PCI (Ref).
If no planned reperfusion strategy (alternative agent):
Note: Some experts prefer ticagrelor over clopidogrel (Ref).
Oral: Initial: 300 mg once at the time of diagnosis; followed by 75 mg once daily (Ref).
Duration of therapy:
Preferred approach: Clopidogrel plus aspirin (dual antiplatelet therapy [DAPT]) should be continued for ≥12 months unless major bleeding is a concern. For patients at high risk of bleeding or who experience overt bleeding, DAPT for 6 months may be reasonable. If there have been no major bleeding complications after 12 months, continuation of DAPT may be considered. Reevaluate the need for DAPT at regular intervals based on bleeding and thrombotic risks. When DAPT is complete, discontinue clopidogrel and continue aspirin indefinitely for secondary prevention (Ref).
Alternative approach in select patients to minimize bleeding events: Clopidogrel in combination with aspirin (DAPT) should be continued for 1 to 3 months after PCI, then discontinue aspirin and continue clopidogrel monotherapy. When clopidogrel is discontinued, restart aspirin for secondary prevention (Ref).
Non-ST-segment elevation acute coronary syndromes:
Note: Regardless of the management strategy, administer clopidogrel in combination with a parenteral anticoagulant and aspirin (Ref).
If using an ischemia-guided approach (medical management) (alternative agent):
Note: Some experts prefer ticagrelor over clopidogrel (Ref).
Oral: Initial: 600 mg once at the time of diagnosis; followed by 75 mg once daily (Ref). Some experts prefer an initial dose of 600 mg unless there is high risk for bleeding, in which case, an initial dose of 300 mg is reasonable (Ref).
If using an invasive approach (reperfusion using percutaneous coronary intervention) (alternative agent):
Note: Ticagrelor or prasugrel may be preferred over clopidogrel unless there is high risk for bleeding (Ref).
Oral: Initial: 600 mg once as early as possible before PCI; followed by 75 mg once daily after PCI. If coronary angiography is planned soon after diagnosis, it is reasonable to delay the initial loading dose until after coronary anatomy is known (Ref).
Duration of therapy:
Preferred approach: Clopidogrel plus aspirin (DAPT) should be continued for ≥12 months unless major bleeding is a concern. For patients at high risk of bleeding or who experience overt bleeding, DAPT for 6 months may be reasonable. If there have been no major bleeding complications after 12 months, continuation of DAPT may be considered. Reevaluate the need for DAPT at regular intervals based on bleeding and thrombotic risks. When DAPT is complete, discontinue clopidogrel and continue aspirin indefinitely for secondary prevention (Ref).
Alternative approach in select patients to minimize bleeding events: Clopidogrel in combination with aspirin (DAPT) should be continued for 1 to 3 months after PCI, then discontinue aspirin and continue clopidogrel monotherapy. When clopidogrel is discontinued, restart aspirin for secondary prevention (Ref).
Percutaneous coronary intervention for stable ischemic heart disease (off-label use):
Note: Administer clopidogrel in combination with a parenteral anticoagulant and aspirin for patients who undergo PCI with stenting (Ref).
Oral: Initial: 600 mg once, administered ≥2 hours before PCI, ideally ≥24 hours before PCI; followed by 75 mg once daily (Ref).
Duration of therapy:
• Bare metal stent implantation: Dual antiplatelet therapy (DAPT) for at least 1 month (Ref). Some experts recommend at least 6 months when feasible (Ref). Assess bleeding and ischemic risks to determine if patient should receive a longer duration of DAPT. Upon completion of DAPT, continue aspirin or clopidogrel monotherapy for treatment of stable ischemic heart disease (Ref).
• Drug eluting stent implantation: DAPT for at least 6 months. Assess bleeding and ischemic risks to determine if patient should receive a longer duration of DAPT. Upon completion of DAPT, continue aspirin or clopidogrel monotherapy for treatment of stable ischemic heart disease (Ref).
Alternative approach in select patients to minimize bleeding events: DAPT for 1 to 3 months, then discontinue aspirin and continue clopidogrel monotherapy for up to 12 months or longer. If clopidogrel is discontinued, restart aspirin for treatment of stable ischemic heart disease (Ref).
Carotid artery atherosclerosis, symptomatic (alternative agent) (off-label use):
Note: For patients who are intolerant of aspirin.
Oral: 75 mg once daily (Ref).
Carotid artery stenting (off-label use):
Percutaneous approach:
Initial:
Initiation ≥48 hours before procedure: Oral: 75 mg twice daily in combination with aspirin (Ref).
Initiation <48 hours before procedure: Oral: 450 mg once at least 4 hours before procedure in combination with aspirin (Ref).
Maintenance: Oral: 75 mg once daily in combination with aspirin for at least 4 weeks; then discontinue clopidogrel and continue aspirin indefinitely thereafter. In patients with history of neck irradiation, some experts recommend continuing clopidogrel plus aspirin indefinitely (Ref).
Transcarotid approach:
Initial:
Initiation ≥72 hours before procedure: Oral: 75 mg once daily in combination with aspirin (Ref).
Initiation <72 hours before procedure: Oral: 450 mg once at least 4 hours before procedure in combination with aspirin (Ref).
Maintenance: Oral: 75 mg once daily in combination with aspirin for at least 4 weeks; then discontinue clopidogrel and continue aspirin indefinitely thereafter. In patients with history of neck irradiation, some experts recommend continuing clopidogrel plus aspirin indefinitely (Ref).
Coronary artery bypass graft surgery (off-label use):
Aspirin-allergic or aspirin-intolerant patients: Oral: 75 mg once daily; continue indefinitely (Ref). Some experts recommend a loading dose of 300 mg administered 6 hours after surgery, followed by 75 mg once daily (Ref).
Following off-pump coronary artery bypass graft surgery: Oral: 75 mg once daily in combination with aspirin for 1 year, then discontinue clopidogrel and continue aspirin indefinitely (Ref).
Patients with acute coronary syndrome followed by coronary artery bypass graft surgery: Oral: 75 mg once daily in combination with aspirin for 1 year, then discontinue clopidogrel and continue aspirin indefinitely (Ref).
Isch emic stroke/transient ischemic attack
Note: In patients who receive IV thrombolytic therapy, antiplatelet therapy is generally delayed for at least 24 hours, but administered as soon as possible thereafter (Ref).
Due to intracranial large artery atherosclerosis (50% to 99%), secondary prevention:
Note: Avoid dual antiplatelet therapy (DAPT) in patients with hemorrhagic transformation (Ref).
Oral:
Short-term (90 days) DAPT with concomitant aspirin in patients with recent (≤30 days) stroke or transient ischemic attack (TIA) due to 70% to 99% stenosis of an intracranial large artery: 75 mg once daily for 90 days in combination with aspirin; when clopidogrel is stopped, continue aspirin indefinitely. Some experts recommend a loading dose of 300 to 600 mg once, followed by 75 mg once daily for 90 days (Ref).
Short-term (21 days) DAPT with concomitant aspirin in patients with recent (≤30 days) minor stroke or high-risk TIA due to 50% to 69% stenosis of an intracranial large artery: 75 mg once daily for 21 days in combination with aspirin; when clopidogrel is stopped, continue aspirin indefinitely. Some experts recommend a loading dose of 300 to 600 mg once, followed by 75 mg once daily for 21 days (Ref)
D ue to other noncardioembolic causes (eg, small vessel disease), secondary prevention:
Note: For patients with recent (eg, ≤24 hours) minor stroke or high-risk TIA, may consider short-term (21 to 90 days) DAPT with aspirin in combination with clopidogrel followed by long-term single-agent antiplatelet therapy with aspirin, clopidogrel, or aspirin/ER dipyridamole. Avoid DAPT in patients with hemorrhagic transformation (Ref).
Oral: 75 mg once daily indefinitely (Ref). Note: When used as a component of DAPT, give 300 to 600 mg once followed by 75 mg once daily in combination with aspirin for 21 to 90 days, followed with single-agent antiplatelet therapy (Ref). Some experts recommend limiting DAPT to 21 days (Ref).
Peripheral atherosclerotic disease (upper or lower extremity; with or without revascularization) : Oral: 75 mg once daily (Ref).
Transcatheter aortic valve replacement, thromboprophylaxis (off-label use):
Note: Refer to institutional policies and procedures on use of antiplatelet therapy for patients who require therapeutic anticoagulation for a different indication.
Oral: 300 mg once prior to valve implantation in combination with aspirin, followed by 75 mg once daily; may be used in combination with aspirin for 3 to 6 months depending on the type of valve implanted (Ref). To minimize risk of bleeding complications, may give aspirin or clopidogrel alone and reserve dual antiplatelet therapy during the first 3 to 6 months for patients at high risk of a thrombotic event; for either strategy, continue aspirin indefinitely after the initial 3 to 6 months of therapy (Ref).
Transcatheter mitral valve repair with MitraClip device, thromboprophylaxis (off-label use):
Note: Patients are generally treated with antithrombotic therapy (antiplatelet or anticoagulant if there is a concurrent indication) for at least 6 months following the procedure (Ref).
Oral:
Loading dose: 300 mg once immediately following MitraClip insertion or within 24 hours prior to the procedure; may use as monotherapy or in combination with aspirin (Ref).
Maintenance: 75 mg once daily for at least 6 months; may use as monotherapy or in combination with aspirin (Ref).
Transitioning between P2Y12 inhibitors: Note: This provides general guidance on transitioning between P2Y12 inhibitors.
Transitioning from another P2Y12 inhibitor to clopidogrel:
Transitioning from prasugrel:
Patient received prasugrel for ≤5 days: Give a clopidogrel 300 mg loading dose 24 hours after the last dose of prasugrel, followed by 75 mg once daily; some experts do not administer a loading dose (Ref).
Patient received prasugrel for >5 days: Give clopidogrel 75 mg once daily, starting 24 hours after the last dose of prasugrel (Ref).
Transitioning from ticagrelor: Give a clopidogrel 600 mg loading dose 12 to 24 hours after the last dose of ticagrelor, followed by 75 mg once daily (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Note: Patients with chronic kidney disease, especially those with end-stage kidney disease (ESKD), have a higher incidence of high on-treatment platelet reactivity when treated with clopidogrel (Ref). Monitor for thrombotic complications and consider measuring platelet reactivity in patients at high risk for thrombotic events (Ref). Patients with ESKD are also at increased risk for bleeding, with or without antiplatelet therapy (Ref); monitor closely.
Altered kidney function: Mild to severe impairment: No dosage adjustment necessary (Ref).
Hemodialysis, intermittent (thrice weekly): Unlikely to be dialyzed (highly protein bound): No supplemental dose or dosage adjustment necessary (Ref).
Peritoneal dialysis: Unlikely to be dialyzed (highly protein bound): No dosage adjustment necessary (Ref).
CRRT: No dosage adjustment necessary (Ref).
PIRRT (eg, sustained, low-efficiency diafiltration): No dosage adjustment necessary (Ref).
No dosage adjustment necessary.
Clopidogrel may cause minor hemorrhage or major hemorrhage. In the CURE trial, clopidogrel was associated with significantly more major bleeding, defined as disabling bleeding, intraocular bleeding leading to the loss of vision, or bleeding necessitating the need for a transfusion of at least 2 units of blood (Ref). Bleeding should be suspected if patient becomes hypotensive, even if overt signs of bleeding do not exist. It may be possible to restore hemostasis by administering exogenous platelets; however, platelet transfusions within 4 hours of the clopidogrel loading dose or 2 hours of the maintenance dose may be less effective. Other studies suggest that platelet transfusions are ineffective in reversing antiplatelet effects (Ref). May result in temporary or permanent discontinuation (Ref).
Mechanism: Related to the pharmacologic action. Clopidogrel irreversibly binds to the P2Y12 receptor on platelets, which inhibits adenosine diphosphate (ADP)-mediated platelet activation and aggregation (Ref).
Onset: Varied; one study found that clopidogrel was associated with increased risk of major bleeding during all time intervals assessed (0 to 6 months, 7 to 12 months, and 13 to 18 months) (Ref). Other studies suggest that bleeding risk increases after 21 days of therapy (Ref).
Risk factors:
• Age ≥75 years (Ref)
• Concurrent medications that increase the risk of bleeding (eg, aspirin, direct oral anticoagulants, nonsteroidal anti-inflammatory drugs, warfarin) (Ref)
• Higher doses of concurrent aspirin (≥200 mg/day) (Ref)
• Active peptic ulcer disease (Ref)
• Recent trauma or surgery (Ref)
• Recent or recurrent GI bleed (Ref)
• Use >6 months (Ref)
Clopidogrel hypersensitivity may present as immediate (eg, angioedema, urticaria) and delayed reactions. Delayed hypersensitivity reactions range from the more common pruritic maculopapular rash to rare severe cutaneous adverse reactions including drug reaction with eosinophilia and systemic symptoms and acute generalized exanthematous pustulosis (Ref). Drug discontinuation due to a pruritic rash may occur in up to 1.5% of patients (Ref).
Mechanism: Immediate hypersensitivity reactions: Non–dose-related; immunologic (ie, IgE-mediated) (Ref). Delayed hypersensitivity reactions: Non–dose-related; immunologic (ie, likely involving a T-cell mediated drug-specific immune response) (Ref).
Onset: Rapid to intermediate; mean onset of maculopapular, pruritic rash is 6 ± 2 days after initiation (Ref).
Risk factors:
• Cross-reactivity: Because of structural similarities, cross-reactivity has been reported among the thienopyridines (clopidogrel, prasugrel, ticlopidine) (Ref)
Cases of thrombotic thrombocytopenic purpura (TTP) associated with clopidogrel use have been reported and some have resulted in fatalities (Ref); however, incidence is rare (0.0001%) (Ref). Early signs of TTP are typically skin reactions or neurologic changes (eg, seizure, coma, stroke, headache, blurred vision) (Ref). TTP is typically characterized by thrombocytopenia, hemolytic anemia, kidney failure, and fever (Ref).
Mechanism: Non–dose-related; immunologic or idiosyncratic. The mechanism for TTP is unknown but likely involves microvascular endothelial cell damage (Ref). Decreased ADAMTS-13 activity has been noted; although, some patients have normal ADAMTS13 activity, suggesting that the mechanism may not be immunologic (Ref). Another proposed mechanism is that clopidogrel may act as a hapten in patients with preexisting autoimmune disease (Ref).
Onset: Intermediate; usually occurs within 2 weeks of initiation of therapy (Ref).
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. As with all drugs that may affect hemostasis, bleeding is associated with clopidogrel. Hemorrhage may occur at virtually any site. Risk is dependent on multiple variables, including the concurrent use of multiple agents that alter hemostasis and patient susceptibility.
1% to 10%: Hematologic & oncologic: Major hemorrhage (≤4%; major hemorrhage, life-threatening: ≤2%) (table 1), minor hemorrhage (4% to 5%) (table 2)
|
Drug (Clopidogrel [+ Aspirin]) |
Placebo (+ Aspirin) |
Number of Patients (Clopidogrel [+ Aspirin]) |
Number of Patients (Placebo [+ Aspirin]) |
Comments |
|---|---|---|---|---|
|
4% |
3% |
6,259 |
6,303 |
N/A |
|
2% |
2% |
6,259 |
6,303 |
Life-threatening |
|
0.6% |
0.5% |
22,961 |
22,891 |
N/A |
|
Drug (Clopidogrel [+ Aspirin]) |
Placebo (+ Aspirin) |
Number of Patients (Clopidogrel [+ Aspirin]) |
Number of Patients (Placebo [+ Aspirin]) |
|---|---|---|---|
|
5% |
2% |
6,259 |
6,303 |
|
4% |
3% |
22,961 |
22,891 |
<1%:
Cardiovascular: Hemorrhagic stroke
Nervous system: Intracranial hemorrhage
Postmarketing:
Cardiovascular: Hypotension, vasculitis (Shetty 2013)
Dermatologic: Acute generalized exanthematous pustulosis (Ulman 2014), bullous rash, eczema, erythema multiforme, erythematous rash (Cheema 2011), exfoliative dermatitis, lichen planus, lichenoid eruption (Dogra 2003), maculopapular rash (Cheema 2011), pruritus (Cheema 2011), pustular psoriasis (Meissner 2006), Stevens-Johnson syndrome (Báez-Ferrer 2019), toxic epidermal necrolysis, urticaria (Cheema 2011)
Endocrine & metabolic: Insulin autoimmune syndrome (Rajpal 2017)
Gastrointestinal: Ageusia (Cave 2008), colitis (including ulcerative colitis or lymphocytic colitis), diarrhea, duodenal ulcer (Ebi 2018), gastric ulcer, pancreatitis, stomatitis
Hematologic & oncologic: Acquired blood coagulation disorder (hemophilia A), agranulocytosis, aplastic anemia (Uz 2010), pancytopenia (Matthews 2009), thrombotic thrombocytopenic purpura (Zakarijia 2009)
Hepatic: Acute hepatic failure (Monteiro 2011), hepatitis (noninfectious) (Pisapia 2015)
Hypersensitivity: Angioedema (Cheema 2011), nonimmune anaphylaxis, serum sickness (Phillips 2003)
Immunologic: Drug reaction with eosinophilia and systemic symptoms (Inagaki 2020)
Nervous system: Confusion, hallucination (Osuagwu 2016), headache
Neuromuscular & skeletal: Arthralgia (Coulter 2012), arthritis (Garg 2000), myalgia
Renal: Increased serum creatinine
Respiratory: Bronchospasm, eosinophilic pneumonitis (Inagaki 2020), interstitial pneumonitis (Tomoda 2021)
Miscellaneous: Fever (Cheema 2011)
Hypersensitivity (eg, anaphylaxis) to clopidogrel or any component of the formulation; active pathological bleeding (eg, peptic ulcer, intracranial hemorrhage).
Canadian labeling: Additional contraindications (not in US labeling): Significant liver impairment or cholestatic jaundice; concomitant use of repaglinide.
Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Disease-related concerns:
• Renal impairment: Use with caution in patients with kidney impairment.
Special populations:
• CYP2C19 poor metabolizers: Routine platelet function testing or genetic testing for CYP2C19 polymorphisms is not recommended (ACC/AHA [Levine 2016]; Scott 2013; Sibbing 2019).
• Lower GI bleed patients: An individualized and multidisciplinary approach should be utilized to determine therapy discontinuation and management in patients with acute lower GI bleed (LGIB) who are on antiplatelet medications; risk of ongoing bleeding should be weighed with risk of thromboembolic events. If antiplatelet agents are discontinued, they should generally be resumed as soon as possible and at least within 7 days, taking into account control of bleeding and cardiovascular risk. Aspirin should generally not be discontinued. Dual antiplatelet therapy (DAPT) should generally not be discontinued in the 90 days post-acute coronary syndrome or 30 days post-coronary stenting (Strate 2016).
• Surgical patients: In patients undergoing cardiac surgery (eg, coronary artery bypass graft surgery), discontinue clopidogrel at least 24 hours and up to 5 days before surgery in consultation with a cardiologist, interventional cardiologist, and cardiac surgeon (ACC/AHA [Grines 2007]; ACC/AHA [Lawton 2022]). In patients undergoing noncardiac surgery, the risks and benefits of clopidogrel should be evaluated between the surgeon and the cardiology team. Elective noncardiac surgery should not be performed in patients in whom DAPT will need to be discontinued perioperatively within 30 days following bare metal stent placement or within 3 months of drug-eluting stent placement. In patients undergoing urgent noncardiac surgery during the first 4 to 6 weeks after BMS or DES placement, DAPT may be continued. In patients undergoing noncardiac surgery that requires discontinuation of clopidogrel, hold for 5 days preoperatively, continue aspirin and re-start clopidogrel as soon as possible (eg, ≤24 hours) after surgery based on bleeding and thrombotic risks (ACC/AHA [Fleisher 2014]; ACC/AHA [Lawton 2022]; ACC/AHA [Levine 2016]; ACCP [Douketis 2022]).
Other warnings/precautions:
• Discontinuation of therapy: For patients who undergo percutaneous coronary intervention with stenting, premature interruption of therapy may result in increased risk of myocardial infarction, stent thrombosis, stroke, or death. If therapy must be held temporarily (eg, bleeding, surgery), restart as soon as possible. Duration of therapy is determined by the type of stent placed (bare metal or drug eluting), whether an acute coronary syndrome event was ongoing at the time of placement, as well as risks for bleeding and thrombosis (ACC/AHA [Lawton 2022]).
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral:
Plavix: 75 mg
Generic: 75 mg, 300 mg
Yes
Tablets (Clopidogrel Bisulfate Oral)
75 mg (per each): $6.57 - $6.96
300 mg (per each): $15.94 - $27.84
Tablets (Plavix Oral)
75 mg (per each): $9.86
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Tablet, Oral:
Plavix: 75 mg, 300 mg [DSC]
Generic: 75 mg, 300 mg
5 mg/mL Oral Suspension
A 5 mg/mL oral suspension may be made using tablets. Crush four 75 mg tablets and reduce to a fine powder. Add a small amount of a 1:1 mixture of Ora-Sweet and Ora-Plus and mix to a uniform paste; mix while adding the vehicle in geometric proportions to almost 60 mL; transfer to a calibrated bottle, rinse mortar with vehicle, and add quantity of vehicle sufficient to make 60 mL. Label "shake well". Stable 60 days at room temperature or under refrigeration.
Oral: May be administered without regard to food.
NG tube: Consider use of extemporaneously compounded oral suspension (Ref); alternatively, based on experience in adult patients, may crush tablet(s), mix with 10 mL of water, draw dose volume into a syringe for NG administration, and administer; after administration flush syringe and NG tube with an additional 20 mL of water (Ref).
Oral: Administer without regard to meals. May administer through an NG tube by crushing tablet(s), mixing with 10 mL of water, drawing into a syringe then flushing down the NG tube; flush syringe and NG tube with an additional 20 mL of water (Ref). Compounding an extemporaneously prepared oral suspension has also been described (Ref). Additionally, tablets may be crushed and mixed with sterile water or with Ora-Sweet and Ora-Plus for use in desensitization protocols (Ref).
Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).
An FDA-approved patient medication guide, which is available with the product information and at https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/020839s072lbl.pdf#page=24, must be dispensed with this medication.
Reduction of atherothrombotic events (myocardial infarction [MI], stroke, and vascular deaths) in patients with recent MI, stroke, or established peripheral arterial disease (FDA approved in adults); reduction of atherothrombotic events in patients with non-ST-segment elevation acute coronary syndrome (unstable angina and non-ST-elevation MI) managed medically and with coronary revascularization (FDA approved in adults); reduction of death rate and atherothrombotic events in patients with acute ST-elevation MI (STEMI) managed medically (FDA approved in adults).
Plavix may be confused with Elavil, Paxil, Pradax (Canada), Pradaxa
Substrate of CYP2C19 (major), CYP3A4 (minor); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential; Inhibits BCRP/ABCG2, CYP2B6 (weak), CYP2C8 (moderate)
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Abrocitinib: Agents with Antiplatelet Properties may enhance the antiplatelet effect of Abrocitinib. Management: Do not use antiplatelet drugs with abrocitinib during the first 3 months of abrocitinib therapy. The abrocitinib prescribing information lists this combination as contraindicated. This does not apply to low dose aspirin (81 mg/day or less). Risk X: Avoid combination
Acalabrutinib: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Agents with Antiplatelet Properties (e.g., P2Y12 inhibitors, NSAIDs, SSRIs, etc.): May enhance the antiplatelet effect of other Agents with Antiplatelet Properties. Risk C: Monitor therapy
Alpelisib: BCRP/ABCG2 Inhibitors may increase the serum concentration of Alpelisib. Management: Avoid coadministration of BCRP/ABCG2 inhibitors and alpelisib due to the potential for increased alpelisib concentrations and toxicities. If coadministration cannot be avoided, closely monitor for increased alpelisib adverse reactions. Risk D: Consider therapy modification
Amodiaquine: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Amodiaquine. Risk X: Avoid combination
Anagrelide: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Anticoagulants: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Anticoagulants. Risk C: Monitor therapy
Apixaban: Antiplatelet Agents (P2Y12 Inhibitors) may enhance the adverse/toxic effect of Apixaban. Specifically, the risk for bleeding may be increased. Management: Carefully consider risks and benefits of this combination and monitor closely; Canadian labeling recommends avoiding prasugrel or ticagrelor. Risk D: Consider therapy modification
Atazanavir: May diminish the antiplatelet effect of Clopidogrel. Atazanavir may decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Coadministration of clopidogrel and atazanavir is not recommended and alternative should be sought if possible. If combined, monitor closely for evidence of diminished antiplatelet response to clopidogrel. Risk D: Consider therapy modification
Bemiparin: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Bemiparin. Management: Avoid concomitant use of bemiparin with antiplatelet agents. If concomitant use is unavoidable, monitor closely for signs and symptoms of bleeding. Risk D: Consider therapy modification
Berotralstat: BCRP/ABCG2 Inhibitors may increase the serum concentration of Berotralstat. Management: Decrease the berotralstat dose to 110 mg daily when combined with BCRP inhibitors. Risk D: Consider therapy modification
BuPROPion: CYP2B6 Inhibitors (Weak) may increase the serum concentration of BuPROPion. Risk C: Monitor therapy
Calcium Channel Blockers: May diminish the therapeutic effect of Clopidogrel. Risk C: Monitor therapy
Cangrelor: May diminish the antiplatelet effect of Clopidogrel. More specifically, while the use of Cangrelor is expected to increase total platelet inhibition in patients who have previously received Clopidogrel, Cangrelor is expected to decrease binding of Clopidogrel metabolites to P2Y12 receptors and thus reduce the extent of irreversible platelet inhibition. Management: Avoid administration of clopidogrel until cangrelor infusion is discontinued. Risk D: Consider therapy modification
Caplacizumab: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Caplacizumab. Specifically, the risk of bleeding may be increased. Management: Avoid coadministration of caplacizumab with antiplatelets if possible. If coadministration is required, monitor closely for signs and symptoms of bleeding. Interrupt use of caplacizumab if clinically significant bleeding occurs. Risk D: Consider therapy modification
Cephalothin: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Cephalothin. Specifically, the risk for bleeding may be increased. Risk C: Monitor therapy
Cladribine: BCRP/ABCG2 Inhibitors may increase the serum concentration of Cladribine. Management: Avoid concomitant use of BCRP inhibitors during the 4 to 5 day oral cladribine treatment cycles whenever possible. If combined, consider dose reduction of the BCRP inhibitor and separation in the timing of administration. Risk D: Consider therapy modification
Cobicistat: May decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Consider alternatives to this combination when possible, as HIV treatment guidelines recommend that this combination not be coadministered. If coadministered, monitor closely for evidence of diminished antiplatelet response to clopidogrel. Risk D: Consider therapy modification
Collagenase (Systemic): Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Collagenase (Systemic). Specifically, the risk of injection site bruising and or bleeding may be increased. Risk C: Monitor therapy
CYP2C19 Inducers (Strong): May increase serum concentrations of the active metabolite(s) of Clopidogrel. Management: Consider alternatives to this combination when possible. If combined, monitor for increased clopidogrel effects and toxicities (eg, bleeding) if clopidogrel is combined with a strong CYP2C19 inducer. Risk D: Consider therapy modification
CYP2C19 Inhibitors (Moderate): May decrease serum concentrations of the active metabolite(s) of Clopidogrel. Risk C: Monitor therapy
CYP2C19 Inhibitors (Strong): May decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Consider alternatives to this combination whenever possible. If such a combination must be used, monitor patients closely for evidence of a diminished response to clopidogrel. Risk D: Consider therapy modification
Dabigatran Etexilate: Antiplatelet Agents (P2Y12 Inhibitors) may enhance the adverse/toxic effect of Dabigatran Etexilate. Specifically, the risk of bleeding may be increased. Antiplatelet Agents (P2Y12 Inhibitors) may increase the serum concentration of Dabigatran Etexilate. Specifically, clopidogrel may increase dabigatran serum concentrations. Management: Carefully consider risks and benefits of this combination and monitor closely; Canadian labeling recommends avoiding prasugrel or ticagrelor. Risk D: Consider therapy modification
Dabrafenib: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Dabrafenib. Risk C: Monitor therapy
Danshen: May decrease serum concentrations of the active metabolite(s) of Clopidogrel. Danshen may decrease the serum concentration of Clopidogrel. Risk C: Monitor therapy
Daprodustat: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Daprodustat. Management: Reduce the daprodustat starting dose by half if combined with moderate CYP2C8 inhibitors, unless the dose is 1 mg, then no dose adjustment is required. Monitor hemoglobin and adjust daprodustat dose when starting or stopping moderate CYP2C8 inhibitors. Risk D: Consider therapy modification
Dasabuvir: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Dasabuvir. Risk C: Monitor therapy
Dasatinib: May enhance the anticoagulant effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Deoxycholic Acid: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Deoxycholic Acid. Specifically, the risk for bleeding or bruising in the treatment area may be increased. Risk C: Monitor therapy
Desloratadine: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Desloratadine. Risk C: Monitor therapy
Diamorphine: May diminish the antiplatelet effect of Antiplatelet Agents (P2Y12 Inhibitors). Diamorphine may decrease the serum concentration of Antiplatelet Agents (P2Y12 Inhibitors). Risk C: Monitor therapy
Edoxaban: Antiplatelet Agents (P2Y12 Inhibitors) may enhance the adverse/toxic effect of Edoxaban. Specifically, the risk of bleeding may be increased. Management: Carefully consider the anticipated risks and benefits of this combination. If combined, increased monitoring for bleeding is recommended. Risk D: Consider therapy modification
Enoxaparin: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Enoxaparin. Management: Discontinue antiplatelet agents prior to initiating enoxaparin whenever possible. If concomitant administration is unavoidable, monitor closely for signs and symptoms of bleeding. Risk D: Consider therapy modification
Enzalutamide: CYP2C8 Inhibitors (Moderate) may increase serum concentrations of the active metabolite(s) of Enzalutamide. CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Enzalutamide. Risk C: Monitor therapy
Erythromycin (Systemic): May diminish the antiplatelet effect of Clopidogrel. Risk C: Monitor therapy
Esomeprazole: May diminish the antiplatelet effect of Clopidogrel. Esomeprazole may decrease serum concentrations of the active metabolite(s) of Clopidogrel. Risk X: Avoid combination
Etravirine: May decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Consider alternatives to clopidogrel in patients treated with etravirine. If combined, monitor for reduced clopidogrel effectiveness. Risk D: Consider therapy modification
FentaNYL: May diminish the antiplatelet effect of Antiplatelet Agents (P2Y12 Inhibitors). FentaNYL may decrease the serum concentration of Antiplatelet Agents (P2Y12 Inhibitors). Risk C: Monitor therapy
Grapefruit Juice: May decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Advise patients receiving clopidogrel to minimize consumption of grapefruit and grapefruit juice. Consumption of three 200 mL glasses of grapefruit juice a day may substantially reduce clopidogrel antiplatelet effects. Risk D: Consider therapy modification
Heparin: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Heparin. Management: Decrease the dose of heparin or agents with antiplatelet properties if coadministration is required. Risk D: Consider therapy modification
Herbal Products with Anticoagulant/Antiplatelet Effects (eg, Alfalfa, Anise, Bilberry): May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Bleeding may occur. Risk C: Monitor therapy
Ibritumomab Tiuxetan: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Ibritumomab Tiuxetan. Both agents may contribute to impaired platelet function and an increased risk of bleeding. Risk C: Monitor therapy
Ibrutinib: May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Icosapent Ethyl: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Inotersen: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Lansoprazole: May decrease serum concentrations of the active metabolite(s) of Clopidogrel. Risk C: Monitor therapy
Lecanemab: May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Specifically, the risk of hemorrhage may be increased. Risk C: Monitor therapy
Limaprost: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Lipid Emulsion (Fish Oil Based): May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Morphine (Systemic): May diminish the antiplatelet effect of Antiplatelet Agents (P2Y12 Inhibitors). Morphine (Systemic) may decrease the serum concentration of Antiplatelet Agents (P2Y12 Inhibitors). Management: Consider alternative anti-ischemic/analgesic therapies (eg, beta-blockers, nitroglycerin) in patients with acute coronary syndromes treated with a P2Y12 inhibitor when possible. The risks associated with other opioids are unknown. Risk D: Consider therapy modification
Multivitamins/Fluoride (with ADE): May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Multivitamins/Minerals (with ADEK, Folate, Iron): May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Multivitamins/Minerals (with AE, No Iron): May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Nirmatrelvir and Ritonavir: May diminish the antiplatelet effect of Clopidogrel. Nirmatrelvir and Ritonavir may decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Avoid coadministration of clopidogrel and nirmatrelvir/ritonavir when possible. Consider using alternative COVID-19 therapy or an alternative antiplatelet such as prasugrel if clinically appropriate. Risk D: Consider therapy modification
Obinutuzumab: Agents with Antiplatelet Properties may enhance the adverse/toxic effect of Obinutuzumab. Specifically, the risk of serious bleeding-related events may be increased. Risk C: Monitor therapy
Ombitasvir, Paritaprevir, Ritonavir, and Dasabuvir: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Ombitasvir, Paritaprevir, Ritonavir, and Dasabuvir. Specifically, the concentrations of the dasabuvir component may be increased. Risk C: Monitor therapy
Omega-3 Fatty Acids: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Omeprazole: May diminish the antiplatelet effect of Clopidogrel. Omeprazole may decrease serum concentrations of the active metabolite(s) of Clopidogrel. Risk X: Avoid combination
Ozanimod: CYP2C8 Inhibitors (Moderate) may increase serum concentrations of the active metabolite(s) of Ozanimod. Risk C: Monitor therapy
PACLitaxel (Conventional): CYP2C8 Inhibitors (Moderate) may increase the serum concentration of PACLitaxel (Conventional). Risk C: Monitor therapy
PACLitaxel (Protein Bound): CYP2C8 Inhibitors (Moderate) may increase the serum concentration of PACLitaxel (Protein Bound). Risk C: Monitor therapy
Pantoprazole: May decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Due to the possible risk for impaired clopidogrel effectiveness, clinicians should carefully consider the need for proton pump inhibitor therapy in patients receiving clopidogrel. Other acid-lowering therapies do not appear to share this interaction. Risk C: Monitor therapy
PAZOPanib: BCRP/ABCG2 Inhibitors may increase the serum concentration of PAZOPanib. Risk X: Avoid combination
Pentosan Polysulfate Sodium: May enhance the adverse/toxic effect of Agents with Antiplatelet Properties. Specifically, the risk of bleeding may be increased by concurrent use of these agents. Risk C: Monitor therapy
Pentoxifylline: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Pioglitazone: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Pioglitazone. Risk C: Monitor therapy
Pirtobrutinib: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Prostacyclin Analogues: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Repaglinide: Clopidogrel may increase the serum concentration of Repaglinide. Management: Avoid use of clopidogrel and repaglinide if possible; if the combination must be used, limit total repaglinide daily dose to no more than 4 mg. This is contraindicated in some non-US labeling. Risk D: Consider therapy modification
Ritonavir: May diminish the antiplatelet effect of Clopidogrel. Ritonavir may decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Avoid coadministration of clopidogrel and ritonavir-boosted protease inhibitors. If coadministration cannot be avoided, monitor closely for evidence of diminished antiplatelet response to clopidogrel with use of this combination. Risk D: Consider therapy modification
Rivaroxaban: Antiplatelet Agents (P2Y12 Inhibitors) may enhance the adverse/toxic effect of Rivaroxaban. Specifically, the risk of bleeding may be increased. Management: Carefully consider risks and benefits of this combination and monitor closely; Canadian labeling recommends avoiding prasugrel or ticagrelor. Risk D: Consider therapy modification
Rosuvastatin: BCRP/ABCG2 Inhibitors may increase the serum concentration of Rosuvastatin. Risk C: Monitor therapy
Selective Serotonin Reuptake Inhibitors: May enhance the antiplatelet effect of Antiplatelet Agents (P2Y12 Inhibitors). Risk C: Monitor therapy
Selexipag: CYP2C8 Inhibitors (Moderate) may increase serum concentrations of the active metabolite(s) of Selexipag. Management: Reduce the selexipag dose to once daily when combined with moderate CYP2C8 inhibitors. Revert back to twice daily selexipag dosing upon stopping the moderate CYP2C8 inhibitor. Risk D: Consider therapy modification
Selumetinib: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Serotonin/Norepinephrine Reuptake Inhibitors: May enhance the antiplatelet effect of Antiplatelet Agents (P2Y12 Inhibitors). Risk C: Monitor therapy
Sibutramine: CYP2B6 Inhibitors (Weak) may increase serum concentrations of the active metabolite(s) of Sibutramine. CYP2B6 Inhibitors (Weak) may increase the serum concentration of Sibutramine. Risk C: Monitor therapy
Sodium Zirconium Cyclosilicate: May decrease serum concentrations of the active metabolite(s) of Clopidogrel. Management: Separate the administration of sodium zirconium cyclosilicate and clopidogrel by at least 2 hours. Risk D: Consider therapy modification
Talazoparib: BCRP/ABCG2 Inhibitors may increase the serum concentration of Talazoparib. Risk C: Monitor therapy
Thrombolytic Agents: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Thrombolytic Agents. Risk C: Monitor therapy
Tipranavir: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Topotecan: BCRP/ABCG2 Inhibitors may increase the serum concentration of Topotecan. Risk X: Avoid combination
Treprostinil: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Treprostinil. Risk C: Monitor therapy
Tucatinib: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Tucatinib. Risk C: Monitor therapy
Ubrogepant: BCRP/ABCG2 Inhibitors may increase the serum concentration of Ubrogepant. Management: Use an initial ubrogepant dose of 50 mg and second dose (at least 2 hours later if needed) of 50 mg when used with a BCRP inhibitor. Risk D: Consider therapy modification
Urokinase: Agents with Antiplatelet Properties may enhance the anticoagulant effect of Urokinase. Risk X: Avoid combination
Vitamin E (Systemic): May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Vonoprazan: May diminish the therapeutic effect of Clopidogrel. Risk C: Monitor therapy
Warfarin: Clopidogrel may enhance the anticoagulant effect of Warfarin. Risk C: Monitor therapy
Zanubrutinib: May enhance the antiplatelet effect of Agents with Antiplatelet Properties. Risk C: Monitor therapy
Consumption of three 200 mL glasses of grapefruit juice a day may substantially reduce clopidogrel antiplatelet effects. Management: Avoid or minimize the consumption of grapefruit or grapefruit juice (Holmberg 2013).
Avoid or minimize the consumption of grapefruit juice (Holmberg 2013).
Information related to use during pregnancy is limited (Bauer 2012; De Santis 2011; Myers 2011). Based on available data, an increased risk of major birth defects, miscarriage, or adverse fetal outcomes has not been associated with maternal use of clopidogrel. According to the manufacturer, use should not be withheld if needed for emergent treatment of stroke or myocardial infarction during pregnancy. Discontinue use 5 to 7 days prior to labor, delivery, or neuraxial blockade if possible due to increased risk of maternal bleeding and hemorrhage.
Available guidelines recommend using clopidogrel only when strictly needed and for the shortest duration possible until additional fetal safety data are available (ESC [Regitz-Zagrosek 2018]).
Signs of bleeding; hemoglobin and hematocrit periodically. Monitor mean inhibition of platelet aggregation: Goal of 30% to 50% inhibition (similar to adults receiving 75 mg/day). For unstable angina/non-ST-elevation myocardial infarction in adults, platelet function testing has been used to determine platelet inhibitory response if results of testing may alter management (Wright 2011).
Clopidogrel requires in vivo biotransformation to an active thiol metabolite. The active metabolite irreversibly blocks the P2Y12 component of ADP receptors on the platelet surface, which prevents activation of the GPIIb/IIIa receptor complex, thereby reducing platelet aggregation. Platelets blocked by clopidogrel are affected for the remainder of their lifespan (~7 to 10 days).
Onset of action: Inhibition of platelet aggregation (IPA): Dose-dependent:
300 to 600 mg loading dose: Detected within 2 hours
50 to 100 mg/day: Detected by the second day of treatment
Peak effect: Time to maximal IPA: Dose-dependent: Note: Degree of IPA based on adenosine diphosphate (ADP) concentration used during light aggregometry:
300 to 600 mg loading dose:
ADP 5 micromole/L: 20% to 30% IPA at 6 hours post administration (Montelescot 2006)
ADP 20 micromole/L: 30% to 37% IPA at 6 hours post administration (Montelescot 2006)
50 to 100 mg/day: ADP 5 micromole/L: 50% to 60% IPA at 5 to 7 days (Herbert 1993)
Duration of action: Platelet aggregation and bleeding time gradually return to baseline after ~5 days after discontinuation.
Absorption: Rapid, well absorbed
Protein binding: Parent drug: 98%; Inactive metabolite (carboxylic acid derivative): 94%
Metabolism: Extensively hepatic via esterase-mediated hydrolysis to a carboxylic acid derivative (inactive) and via CYP450-mediated (CYP2C19 primarily) oxidation to a thiol metabolite (active)
Half-life elimination: Parent drug: ~6 hours; Thiol derivative (active metabolite): ~30 minutes; carboxylic acid derivative (inactive; main circulating metabolite): ~8 hours; Note: A clopidogrel radiolabeled study has shown that covalent binding to platelets accounts for 2% of radiolabel and has a half-life of 11 days.
Time to peak, serum: ~0.75 hours
Excretion: Following administration of a single 14C-labeled clopidogrel oral dose; radioactivity measured over 5 days: Urine (50%); feces (46%)
Altered kidney function: After repeated doses of clopidogrel 75 mg/day, patients with severe (CrCl 5 to 15 mL/minute) and moderate (CrCl 30 to 60 mL/minute) renal impairment showed low (25%) inhibition of ADP-induced platelet aggregation.
Sex: Less inhibition of ADP-induced platelet aggregation was observed in women.
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