What care is needed for an 86-year-old diabetic male on Plavix (clopidogrel) with a fractured right second toe due to a nail injury?

From the Guidelines

Care for an 86-year-old diabetic male on Plavix with a fractured second toe requires careful management of both the fracture and his underlying conditions, prioritizing immobilization, pain management, and close monitoring for infection signs, as outlined in the 2024 iwgdf/idsa guidelines on the diagnosis and treatment of diabetes-related foot infections 1. The toe should be buddy-taped to the adjacent toe using cotton padding between the toes and medical tape to immobilize the fracture, allowing it to heal properly over 4-6 weeks. Pain can be managed with acetaminophen (Tylenol) up to 3000mg daily, avoiding NSAIDs like ibuprofen as they can interact with Plavix and increase bleeding risk. The patient should wear wide, supportive shoes with a rigid sole to protect the toe and limit movement. Due to diabetes, daily wound inspection is crucial to monitor for infection signs like redness, warmth, swelling, or drainage, as infections in diabetic patients can be severe and require prompt treatment, according to the 2012 infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1. Blood glucose levels should be closely monitored as pain and reduced mobility may affect diabetes control. Plavix should not be discontinued without consulting his cardiologist, as it prevents blood clots but increases bleeding risk. If significant swelling occurs, elevating the foot above heart level and applying ice for 15-20 minutes several times daily (with a cloth barrier to protect diabetic skin) can help. The patient should follow up with his primary care physician within a week and seek immediate medical attention if he experiences increased pain, numbness, skin color changes, or signs of infection. Key considerations include:

• Monitoring for signs of infection, such as purulent secretions, erythema, warmth, tenderness, pain, or induration, as recommended by the 2012 guideline 1
• Assessing the affected limb and foot for arterial ischemia, venous insufficiency, and other factors, as suggested by the 2012 guideline 1
• Evaluating the foot for deformities, such as Charcot arthropathy, claw or hammer toes, bunions, or callosities, which can predispose to foot wounds and impair wound healing, as noted in the 2012 guideline 1
• Determining the ratio of systolic blood pressure in the ankle to the systolic blood pressure in the brachial artery (ABI) to assess for peripheral arterial disease (PAD), as recommended by the 2012 guideline 1.

From the FDA Drug Label

Of the total number of subjects in the CAPRIE and CURE controlled clinical studies, approximately 50% of patients treated with clopidogrel were 65 years of age and older, and 15% were 75 years and older. No dosage adjustment is necessary in elderly patients.

The patient is an 86-year-old diabetic male on Plavix (clopidogrel) with a fractured right second toe. Key considerations for his care include:

• Monitoring for signs of bleeding due to the antiplatelet effect of clopidogrel
• Managing his diabetes to prevent infection and promote healing
• Providing appropriate pain management
• Immobilizing the toe to allow for proper healing of the fracture
• Considering the risk of bleeding when administering any additional medications, especially NSAIDs, opioids, warfarin, SSRIs, and SNRIs 2 No specific dosage adjustment of clopidogrel is necessary for this elderly patient 2.

From the Research

Considerations for Care

• The patient's age (86 years) and history of diabetes may affect wound healing, and careful monitoring is necessary 3.
• The use of Plavix (clopidogrel) may increase the risk of bleeding, and this should be considered when managing the wound 3.
• The fracture of the right second toe requires proper management to prevent infection and promote healing 4.

Wound Management

• A standard examination should be performed to ensure that there is no damage to underlying structures (e.g., nerves, tendons, and vasculature) 3.
• Foreign bodies should be meticulously looked for and removed if found 3.
• The wound should be cleaned and dressed properly, and the patient should be educated on how to care for the wound at home 5.
• The patient should be instructed on warning signs of infection and advised to return for a wound check within 48 hours 3.

Infection Prevention

• Antibiotic prophylaxis may be considered to reduce the risk of wound infection, especially in patients with a high risk of infection (e.g., those with diabetes) 4.
• The patient should be educated on how to prevent infection, including keeping the wound clean and dry, and avoiding contamination 6.
• The patient's concerns about wound care and infection should be addressed, and they should be provided with clear instructions on what to do in case of an emergency 5.

Medication Management

• The patient's medication regimen, including Plavix, should be carefully managed to minimize the risk of bleeding and other complications 3.
• The patient should be educated on the importance of adhering to their medication regimen and monitoring for any adverse effects 7.

Follow-up Care

• The patient should be scheduled for follow-up appointments to monitor the wound's progress and address any concerns or complications that may arise 3, 5.
• The patient should be instructed on how to contact their healthcare provider if they have any questions or concerns about their wound care 5.