Is it safe to administer Plavix (clopidogrel) to a stroke patient at risk for aspiration?

Administration of Clopidogrel in Stroke Patients with Aspiration Risk

Clopidogrel (Plavix) can be safely administered to stroke patients at risk for aspiration by using alternative administration routes such as rectal administration or through an enteral tube, rather than oral tablets. 1

Assessment of Aspiration Risk in Stroke Patients

Aspiration is a common and serious complication in acute stroke patients:

• 81% of acute stroke patients have endoscopically proven aspiration risk 2
• Aspiration significantly increases morbidity, mortality, and cost of care 3

Screening for Aspiration Risk

1. Clinical swallowing assessment before any oral intake 1
2. Bedside swallowing tests have limitations:
   • Sensitivity of 86% but specificity of only 30% 3
   • False negative rate of 14% (patients with aspiration risk missed) 3
3. Video endoscopic evaluation is more reliable for identifying medication swallowing difficulties 4

Antiplatelet Therapy in Stroke Patients

Antiplatelet therapy is essential for secondary stroke prevention in non-cardioembolic stroke:

• Long-term antiplatelet therapy is indicated for patients with non-cardioembolic ischemic stroke 1
• Options include aspirin (81-325 mg daily), clopidogrel (75 mg daily), or aspirin + dipyridamole 1
• Clopidogrel has been shown to have a relative risk reduction of 8.7% compared to aspirin for the composite outcome of ischemic stroke, myocardial infarction, or vascular death 5

Safe Administration Options for Patients with Aspiration Risk

For stroke patients with impaired swallowing:

1. Enteral tube administration: Clopidogrel 75 mg daily can be administered via enteral tube 1
2. Alternative antiplatelet: Rectal aspirin 325 mg daily is a reasonable alternative 1
3. Positioning: The bed should be elevated at least 30° when administering any medication to patients at risk of aspiration 1

Important Considerations

• Solid oral dosage forms significantly increase the risk of penetration and aspiration in stroke patients with dysphagia 4
• 40-43% of stroke patients experience severe difficulties swallowing tablets and capsules 4
• Patients should be kept NPO until swallowing ability is properly assessed 1
• Inappropriate crushing of medications occurs in about 20.8% of cases when alternative formulations could be used 4

Clinical Decision Algorithm

1. Assess aspiration risk using bedside swallowing assessment
2. If aspiration risk is identified:
   • For patients with feeding tubes: Administer clopidogrel 75 mg daily via enteral tube
   • For patients without feeding tubes but unable to swallow safely: Consider rectal aspirin 325 mg daily
3. Position patient with head of bed elevated at least 30° during medication administration
4. Monitor for signs of aspiration pneumonia
5. Reassess swallowing function regularly to determine when oral administration can be resumed

Remember that the benefits of antiplatelet therapy for secondary stroke prevention outweigh the risks in most cases, and alternative administration routes can ensure patients receive appropriate therapy while minimizing aspiration risk.