Is a regimen of clopidogrel (Plavix) 75 mg once daily and aspirin 81 mg once daily appropriate for a patient with a personal history of transient ischemic attack (TIA) and cerebral infarction?

Dual Antiplatelet Therapy for Stroke Prevention After TIA

The current regimen of clopidogrel 75 mg daily plus aspirin 81 mg daily is not appropriate for long-term management of a patient with history of TIA and cerebral infarction from 2013, and should be changed to monotherapy with either clopidogrel or aspirin alone.

Current Evidence on Dual Antiplatelet Therapy (DAPT)

The most recent guidelines from the American Heart Association indicate that DAPT with aspirin and clopidogrel should only be used for a short duration (21-30 days) following a TIA or minor stroke 1. This short-term approach is supported by multiple clinical trials showing benefit in the acute phase but increased bleeding risk with long-term use.

Acute Management vs. Long-term Management

• Acute phase (first 21-30 days): DAPT with aspirin plus clopidogrel is recommended immediately after TIA/minor stroke

  • Reduces risk of recurrent stroke by 25-32% compared to aspirin alone 2, 3
  • Should be initiated within 24 hours of symptom onset 1

• Long-term management (beyond 30 days): Monotherapy is preferred

  • Long-term DAPT increases bleeding risk without additional benefit in stroke prevention 1, 4
  • The number needed to harm for major bleeding with long-term DAPT is 113 4

Assessment of Current Regimen

This patient has been on DAPT for many years following a stroke in 2013 that caused temporary blindness. This extended duration of DAPT contradicts current guidelines:

1. Duration concern: DAPT should only be continued for 21-30 days after the event 1
2. Bleeding risk: Long-term DAPT significantly increases risk of major bleeding (RR 1.90) and intracranial hemorrhage (RR 1.55) compared to monotherapy 4
3. No additional benefit: Studies show no incremental benefit of long-term DAPT compared to monotherapy for secondary stroke prevention 5

Recommended Management

Based on the most recent evidence:

1. Convert to monotherapy:

   • Either clopidogrel 75 mg daily OR
   • Aspirin 81 mg daily (not both)

2. Medication selection factors:

   • If patient has had no recurrent events on current therapy, aspirin 81 mg daily is a reasonable choice
   • If patient has coronary artery disease or peripheral arterial disease, clopidogrel may be preferred 6
   • If patient has a history of aspirin-related GI issues, clopidogrel would be preferred

3. Additional management:

   • Ensure appropriate blood pressure control (target <140/90 mmHg) 1
   • Initiate or continue high-intensity statin therapy 1
   • Address other modifiable risk factors (smoking, diabetes, etc.)

Implementation Plan

1. Discuss with patient the rationale for changing from dual to single antiplatelet therapy
2. Select either clopidogrel OR aspirin based on patient's comorbidities and risk factors
3. Monitor for any new neurological symptoms after transition
4. Continue other stroke prevention measures (statins, blood pressure control)

Common Pitfalls to Avoid

1. Continuing DAPT indefinitely: This increases bleeding risk without additional benefit
2. Abrupt discontinuation: When transitioning, do not stop both medications simultaneously
3. Overlooking other risk factors: Ensure comprehensive management of hypertension, hyperlipidemia, and diabetes
4. Medication interactions: If continuing clopidogrel, avoid concurrent use of omeprazole or esomeprazole as they reduce its effectiveness 1

The evidence clearly shows that while DAPT is beneficial in the acute phase after TIA/stroke, long-term therapy increases bleeding risk without providing additional protection against recurrent events. This patient should be transitioned to monotherapy with either clopidogrel or aspirin.