Why would a patient on Plavix (clopidogrel) and Eliquis (apixaban) be prescribed both medications?

From the Guidelines

A patient on Plavix and Eliquis would be in a high-risk scenario requiring close monitoring due to increased bleeding risk, and the combination should be used for the shortest duration necessary, ideally not exceeding 1-6 months, as supported by the most recent evidence 1. The combination of Plavix (clopidogrel) and Eliquis (apixaban) is typically prescribed for patients with both atrial fibrillation requiring anticoagulation and recent coronary stent placement requiring antiplatelet therapy.

• The duration of this combination therapy is limited, depending on bleeding risk, stent type, and reason for stenting.
• This approach balances the need to prevent stroke from atrial fibrillation (Eliquis) while also preventing stent thrombosis (Plavix).
• However, this combination significantly increases bleeding risk, so patients require close monitoring for bleeding complications, including bruising, blood in urine or stool, or unusual bleeding from gums.
• According to the 2022 study published in Circulation: Arrhythmia and Electrophysiology 1, the addition of aspirin to warfarin during the initial 3 months after valve implantation was shown to decrease the incidence of thrombotic events, but at the expense of increased bleeding.
• The study also suggests that for patients with AF or an indication for anticoagulation, acute coronary syndrome (ACS) is the most common scenario when dual antiplatelet therapy must be initiated on top of anticoagulation, and that triple therapy should only be reserved for patients at the highest risk for thrombotic complications, and ideally not exceed 30 days.
• The 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1 also provides recommendations for antithrombotic therapy, including the use of oral anticoagulants and antiplatelet therapy, but the most recent evidence from 2022 1 takes precedence in guiding clinical decision-making.
• The patient should be informed about bleeding risks and the importance of regular follow-up appointments to reassess the need for continued dual therapy, and a proton pump inhibitor should be initiated prophylactically to reduce GI bleeding risk, as recommended by the 2022 study 1.

From the Research

Patient Medication Regimen

• A patient on Plavix (clopidogrel) and Eliquis (apixaban) is likely being treated for a condition that requires both antiplatelet and anticoagulation therapies, such as atrial fibrillation and coronary artery disease 2, 3.
• The use of dual therapy, consisting of an antiplatelet agent and an anticoagulant, is a common approach in patients with atrial fibrillation undergoing coronary artery stenting, as it is associated with a lower risk of bleeding compared to triple therapy 3, 4.

Benefits and Risks of Dual Therapy

• Dual therapy with clopidogrel and apixaban has been shown to be effective in reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, while also minimizing the risk of bleeding 5.
• However, the risk of bleeding is still a concern, particularly in patients with renal dysfunction, and close monitoring is necessary to adjust doses and minimize this risk 6.

Specific Medications

• Plavix (clopidogrel) is an antiplatelet agent that works by inhibiting platelet activation and aggregation, while Eliquis (apixaban) is a direct oral anticoagulant that works by inhibiting factor Xa 2, 5.
• The combination of these two medications is often used in patients with atrial fibrillation and coronary artery disease, as it provides a balanced approach to reducing the risk of thrombosis and bleeding 3, 4.