What to do with a patient on Plavix (clopidogrel) who presents with hematuria?

From the Guidelines

For a patient on Plavix (clopidogrel) who presents with hematuria, the first step is to assess the severity of bleeding while considering the risk of discontinuing antiplatelet therapy, and temporarily discontinuing Plavix should be considered in consultation with the prescribing cardiologist or vascular specialist to balance bleeding risk against thrombotic risk, as seen in a case where a patient on dual antiplatelet therapy developed major gastrointestinal bleeding and required cessation of therapy 1. When evaluating the patient, it's crucial to consider the indication for Plavix therapy, as patients with recent coronary stents (especially within 3-6 months) or recent stroke have higher thrombotic risk if Plavix is stopped. The management of antithrombotic therapy after bleeding remains uncertain, but guidelines suggest stopping either aspirin or clopidogrel in patients who develop bleeding during triple therapy, and discontinuation of antiplatelet agent when a patient develops bleeding on double therapy 1. Key considerations include:

• Assessing the severity of hematuria and its impact on the patient's hemodynamic stability
• Investigating the underlying cause of hematuria through urinalysis, imaging studies, and possibly cystoscopy
• Ensuring adequate hydration to help clear the urinary tract of blood and monitoring hemoglobin levels
• Restarting Plavix as soon as safely possible after the bleeding source is identified and controlled, if it was discontinued
• Recognizing that hematuria may indicate significant underlying pathology like malignancy or infection, necessitating a thorough urologic workup.

From the FDA Drug Label

5.2 General Risk of Bleeding P2Y12 inhibitors (thienopyridines), including clopidogrel, increase the risk of bleeding. Risk factors for bleeding include concomitant use of other drugs that increase the risk of bleeding (e.g., anticoagulants, antiplatelet agents, and chronic use of NSAIDs)

The patient on Plavix (clopidogrel) who presents with hematuria should be managed with caution due to the increased risk of bleeding associated with clopidogrel.

• Bleeding risk should be assessed, and the patient should be monitored closely for any signs of worsening bleeding.
• Consideration should be given to discontinuing clopidogrel temporarily if the hematuria is severe or if the patient is at high risk of bleeding complications 2.
• However, discontinuation of clopidogrel increases the risk of cardiovascular events, so this decision should be made carefully and with consideration of the patient's overall clinical condition.
• If clopidogrel must be discontinued, it should be restarted as soon as possible once the bleeding risk has been mitigated.

From the Research

Evaluation of Hematuria in Patients on Plavix (Clopidogrel)

• Hematuria can signify serious disease such as bladder cancer, upper urinary tract urothelial cell carcinoma (UUT-UCC), renal cell cancer, or urinary tract stones 3.
• The optimum diagnostic imaging strategy for patients with hematuria at high-risk for UCC involves the use of CT urography as a replacement for other imaging tests and as a triage test for cystoscopy 3.

Management of Patients on Antiplatelet Therapy

• Dual antiplatelet therapy with a thienopyridine (ticlopidine or clopidogrel) and aspirin is used to reduce the risk of late stent thrombosis and complications after placement of a drug-eluting stent (DES) 4.
• Early discontinuation of clopidogrel is a major predictor of stent thrombosis and is associated with significantly higher rates of long-term clinical events 4.

Considerations for Patients with Hematuria on Anticoagulant or Aspirin Treatment

• Patients taking anticoagulant or aspirin treatment who present with gross hematuria should undergo a full evaluation, including cystoscopy and imaging studies such as CT or ultrasound 5.
• The presence of excessive anticoagulation should not impede a full evaluation, as a tumor was diagnosed in about one quarter of patients and other treatable pathologic findings were diagnosed about half the time 5.

Diagnostic Approach

• The diagnostic approach to hematuria should involve answering three key questions: (1) Is it really hematuria? (2) Should this patient with hematuria be worked up, and if so, how? (3) Should this patient with hematuria be referred, and if so, to which specialty? 6.
• Patients with gross hematuria or microscopic hematuria with >5 RBCs/HPF on urinalysis should undergo further evaluation, including CT urography and cystoscopy 7.