Do you hold Plavix (clopidogrel) during heparin infusion?

Management of Clopidogrel (Plavix) During Heparin Infusion

Clopidogrel (Plavix) should not be routinely held during heparin infusion unless there are specific bleeding concerns, as the combination can be safely administered in most clinical scenarios.

Rationale for Continuing Clopidogrel with Heparin

• Clopidogrel and heparin are frequently used together in various clinical scenarios, particularly in patients undergoing percutaneous coronary interventions (PCI) and other endovascular procedures 1
• The combination of antiplatelet therapy (like clopidogrel) and anticoagulation (heparin) provides complementary mechanisms of action that are often therapeutically necessary 1, 2
• Discontinuing clopidogrel prematurely can increase the risk of stent thrombosis and other thrombotic complications in patients with recent stent placement 1

Specific Clinical Scenarios

Endovascular Procedures

• For patients undergoing percutaneous transluminal angioplasty (PTA) or stenting, the combination of aspirin and clopidogrel should be continued for at least 4 weeks after the procedure, even when heparin is administered during the procedure 1
• During procedures, heparin is typically administered as a bolus to maintain appropriate ACT levels (300-350 seconds), while clopidogrel is continued 1
• After procedures, heparin may be discontinued while clopidogrel (75 mg daily) is maintained 1

Acute Coronary Syndromes

• In patients with acute coronary syndromes, the combination of clopidogrel and heparin is standard practice 1, 2
• Studies have shown that clopidogrel can be safely administered with recombinant tissue plasminogen activator (rt-PA) and heparin in acute myocardial infarction patients 2

Exceptions: When to Consider Holding Clopidogrel

Surgical Procedures

• For patients requiring coronary artery bypass grafting (CABG) surgery, clopidogrel should be discontinued 5-7 days before elective surgery 1, 3
• In-hospital mortality was significantly higher in patients exposed to clopidogrel within 5 days before CABG, with the highest risk when given within 48 hours of surgery 3

Severe Bleeding

• In cases of severe or life-threatening bleeding while on both medications, consider holding both agents and administering appropriate reversal agents 1
• For non-severe bleeding, local measures to control bleeding should be attempted first before considering discontinuation of antiplatelet therapy 1

Drug Interaction Considerations

• The FDA drug label for heparin specifically mentions that drugs interfering with platelet aggregation (including thienopyridines like clopidogrel) may induce bleeding when used with heparin 4
• When bleeding risk is a concern, a reduction in the dose of either the antiplatelet agent or heparin is recommended rather than complete discontinuation 4

Monitoring Recommendations

• When administering both medications concurrently, monitor for signs of bleeding 1, 4
• For patients on dual therapy, more frequent monitoring of coagulation parameters may be warranted 1
• If bleeding occurs, assess severity to determine appropriate management strategy 1

Conclusion

The decision to continue or hold clopidogrel during heparin infusion should be based on:

1. The indication for dual therapy
2. The patient's bleeding risk
3. The thrombotic risk if clopidogrel is discontinued

In most non-surgical settings, continuing both medications is appropriate and supported by clinical evidence and guidelines 1, 2.