What is the typical regimen for dual antiplatelet therapy with Plavix (clopidogrel) and aspirin?

Dual Antiplatelet Therapy with Clopidogrel (Plavix) and Aspirin

The standard regimen for dual antiplatelet therapy (DAPT) with clopidogrel (Plavix) and aspirin consists of clopidogrel 75 mg daily plus low-dose aspirin 75-100 mg daily, typically for 12 months in patients with acute coronary syndrome (ACS) or after percutaneous coronary intervention (PCI) with stent placement. 1

Dosing Regimen

• Loading doses:

  • Clopidogrel: 300-600 mg loading dose (600 mg preferred for PCI patients) 1
  • Aspirin: 160-325 mg loading dose 1

• Maintenance doses:

  • Clopidogrel: 75 mg once daily 1
  • Aspirin: 75-100 mg once daily (low-dose recommended to minimize bleeding risk) 1

Duration of Therapy Based on Clinical Scenario

Acute Coronary Syndrome (ACS)

• ACS with or without PCI: 12 months of DAPT is recommended 1
• ACS with medical management only: 12 months of DAPT (preferably ticagrelor over clopidogrel unless bleeding risk is high) 1

PCI with Stent Placement

• Bare-metal stents: Minimum 1 month of DAPT, but 12 months suggested 1
• Drug-eluting stents: Minimum 3-6 months of DAPT, but 12 months suggested 1

Stable Coronary Artery Disease

• After elective PCI: Clopidogrel 75 mg daily plus aspirin 75-100 mg daily for at least 1 month (bare-metal stents) or 3-6 months (drug-eluting stents), with suggestion to continue for 12 months 1

Minor Stroke or High-Risk TIA

• Combination therapy: Clopidogrel 75 mg daily plus aspirin 75-100 mg daily for 21-30 days only 1
• Loading dose: 300-600 mg clopidogrel and 160 mg aspirin 1
• Timing: Start within 24 hours of symptom onset, ideally within 12 hours 1

Special Considerations

• Proton Pump Inhibitor (PPI): Recommended in combination with DAPT to reduce gastrointestinal bleeding risk 1
• Bleeding risk: Consider shorter duration of DAPT in patients with high bleeding risk (e.g., PRECISE-DAPT score ≥25) 1
• Surgery: If possible, delay elective surgery until completion of DAPT, especially within the first month after stent placement 1
• Switching between P2Y12 inhibitors: When switching from clopidogrel to ticagrelor, administer a 180 mg loading dose of ticagrelor regardless of timing and dose of clopidogrel 1

Common Pitfalls and Caveats

• Premature discontinuation: Stopping DAPT prematurely, especially within the first month after stent placement, significantly increases the risk of stent thrombosis and should be avoided 1
• Extended DAPT: Continuing DAPT beyond 12 months may be considered in selected high-risk patients but must be balanced against increased bleeding risk 1
• Drug interactions: Omeprazole and esomeprazole may reduce clopidogrel's effectiveness; consider alternative PPIs 2
• Monotherapy after DAPT: After completing the recommended duration of DAPT, transition to single antiplatelet therapy (either aspirin or clopidogrel alone) 1
• Recent evidence: Long-term clopidogrel monotherapy after completing DAPT may be more effective than aspirin monotherapy in reducing composite outcomes of death, MI, stroke, and bleeding 3

Algorithm for DAPT Management

1. Assess patient's indication for DAPT:

   • ACS (with or without PCI)
   • Elective PCI with stent placement
   • Minor stroke/high-risk TIA
   • Stable CAD

2. Administer appropriate loading doses based on clinical scenario 1

3. Maintain on appropriate doses:

   • Clopidogrel 75 mg daily
   • Aspirin 75-100 mg daily 1

4. Determine appropriate duration based on clinical scenario and bleeding risk 1

5. Add PPI for gastroprotection 1

6. After completing DAPT, transition to single antiplatelet therapy (either aspirin or clopidogrel) indefinitely 1, 3