Under what circumstances do you prescribe aspirin and Plavix (clopidogrel)?

From the Guidelines

I prescribe aspirin and Plavix (clopidogrel) together primarily for patients with acute coronary syndrome, after coronary stent placement, or following certain types of heart attacks, as recommended by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1. The typical regimen involves low-dose aspirin (75-100 mg daily) combined with Plavix (75 mg daily), with the duration depending on the specific indication.

• For patients with drug-eluting stents, this dual antiplatelet therapy (DAPT) is usually continued for 6-12 months,
• while bare metal stents may require only 1 month of combined therapy. Some high-risk patients with acute coronary syndrome might need DAPT for up to 12 months regardless of stent type. This combination works by inhibiting platelet aggregation through different mechanisms - aspirin blocks the cyclooxygenase pathway while Plavix blocks the ADP receptor pathway, providing more complete protection against clot formation. However, this combination increases bleeding risk, so I carefully assess each patient's bleeding risk versus thrombotic risk before prescribing, as suggested by the 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1. Patients should be monitored for signs of bleeding, and the therapy may need adjustment before surgical procedures. Proton pump inhibitors are sometimes added for gastrointestinal protection in high-risk patients, as recommended by the 2010 ACCF/ACG/AHA expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines 1. It is also important to consider the primary and secondary prevention of cardiovascular disease, as outlined in the 2012 American College of Chest Physicians evidence-based clinical practice guidelines 1.

From the FDA Drug Label

1.1 Acute Coronary Syndrome (ACS) 1.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease 14.1 Acute Coronary Syndrome 14.2 Recent Myocardial Infarction, Recent Stroke, or Established Peripheral Arterial Disease 7.7 Other Antiplatelet Agents 14.3 No Demonstrated Benefit of Clopidogrel plus Aspirin in Patients with Multiple Risk Factors or Established Vascular Disease

The circumstances under which to prescribe aspirin and Plavix (clopidogrel) include:

• Acute Coronary Syndrome (ACS): Aspirin and clopidogrel may be prescribed together for the treatment of ACS.
• Recent MI, Recent Stroke, or Established Peripheral Arterial Disease: Aspirin and clopidogrel may be prescribed together for patients with these conditions. However, it is noted that there is No Demonstrated Benefit of Clopidogrel plus Aspirin in patients with multiple risk factors or established vascular disease 2. Key considerations for prescribing aspirin and clopidogrel together include the potential for increased bleeding risk and the need to carefully weigh the benefits and risks of combination therapy.

From the Research

Aspirin and Plavix (Clopidogrel) Prescription Circumstances

• Aspirin is prescribed in almost all coronary patients, with the dose varying depending on the clinical circumstances 3.
• In acute coronary syndromes, a high initial dose of aspirin (162.5 mg to 325 mg) is recommended, followed by a lower dose (less than 100 mg) for long-term prevention 3, 4.
• Clopidogrel is added to aspirin in patients with acute coronary syndromes to further reduce the risk of important vascular events, but not mortality, and causes more side effects, especially bleeding 4.
• The optimal daily dose of aspirin when used in combination with clopidogrel may be between 75 and 100 mg, as bleeding risks increase with increasing aspirin dose without any increase in efficacy 5.
• Dual antiplatelet therapy with aspirin and a P2Y(12) antagonist, such as clopidogrel, is required after the insertion of a coronary artery stent, especially in patients with acute coronary syndrome 6.

Specific Patient Groups

• Patients with unstable angina pectoris/non-ST-elevation myocardial infarction (NSTEMI) should be treated with dual antiplatelet therapy with aspirin plus either clopidogrel, prasugrel, or ticagrelor, depending on the clinical circumstances 7.
• Patients undergoing percutaneous coronary interventions should receive aspirin and a P2Y(12) antagonist, with the choice of agent depending on the patient's bleeding risk and other factors 6.
• Patients at high risk of gastrointestinal bleeding should receive a proton pump inhibitor (PPI) in combination with aspirin and clopidogrel, but the choice of PPI should be made carefully to minimize negative pharmacokinetic and pharmacodynamic interactions 6.