What is the recommended anticoagulation strategy for a patient on Plavix (clopidogrel) with acute pulmonary embolism, considering the risk of bleeding?

From the Guidelines

For a patient on Plavix (clopidogrel) with acute pulmonary embolism, the recommended anticoagulation strategy is to initiate anticoagulation therapy as soon as possible, preferably with a direct oral anticoagulant (DOAC) such as apixaban, over low molecular weight heparin (LMWH) and vitamin K antagonist (VKA) regimen, unless there are contraindications to DOACs, as stated in the 2019 ESC guidelines 1. When considering the use of Eliquis (apixaban) as a loading dose in this context, it's crucial to note that the guidelines do not specifically address loading doses for patients already on antiplatelet therapy like clopidogrel. However, given the preference for DOACs over LMWH-VKA for anticoagulation in acute pulmonary embolism, apixaban can be considered at a standard dose of 10 mg twice daily for the first 7 days, followed by 5 mg twice daily, without a specific loading dose recommendation for patients on clopidogrel. Key considerations include:

• The risk of bleeding, which is increased by the concurrent use of clopidogrel and anticoagulation therapy.
• The necessity of clopidogrel, which should be evaluated and potentially discontinued if safe to do so.
• Close monitoring for signs of bleeding and regular assessment of renal function and complete blood count. The decision to extend anticoagulation is based on the balance between the risk of recurrent venous thromboembolism and the risk of anticoagulant-related bleeding, as well as patient preference, with a standard duration of 3-6 months for provoked PE and potentially longer for unprovoked PE, as suggested by the guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Anticoagulation Strategy for Acute Pulmonary Embolism

The recommended anticoagulation strategy for a patient on Plavix (clopidogrel) with acute pulmonary embolism (PE) involves the use of direct oral anticoagulants (DOACs) such as apixaban, edoxaban, rivaroxaban, or dabigatran as first-line therapy 2.

Eliquis (Apixaban) Loading

• Eliquis (apixaban) is an oral factor Xa inhibitor with a rapid onset of action and predictable pharmacokinetics, allowing for a fixed-dose regimen 3.
• Apixaban has been shown to be effective in treating venous thromboembolism (VTE), including PE, with a reduced risk of major bleeding compared to conventional treatment regimens 3, 4.
• However, there is no specific guidance on the use of Eliquis loading in patients on Plavix with acute PE.

Considerations for Patients on Plavix

• Patients on Plavix (clopidogrel) may have an increased risk of bleeding when initiating anticoagulation therapy 5.
• The use of DOACs such as apixaban, edoxaban, rivaroxaban, or dabigatran may be preferred over vitamin K antagonists due to their more predictable pharmacokinetics and lower risk of bleeding 2, 5.
• Validated bleeding risk assessments, such as HAS-BLED, should be performed to identify patients at high risk of bleeding and to address modifiable factors 5.

Recommendations

• For patients with acute PE and a systolic blood pressure of 90 mm Hg or higher, DOACs such as apixaban, edoxaban, rivaroxaban, or dabigatran are recommended as first-line therapy 2.
• The use of Eliquis (apixaban) may be considered in patients with acute PE, but the decision to use a loading dose should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.