Why Rehabilitation Hospitals Start Patients on Clopidogrel (Plavix)
Rehabilitation hospitals start patients on clopidogrel primarily to reduce the risk of recurrent cardiovascular events in patients recovering from acute coronary syndromes (ACS), as dual antiplatelet therapy has been demonstrated to significantly reduce mortality, reinfarction, and stroke in these high-risk patients. 1
Evidence-Based Rationale for Clopidogrel Use
For patients with ST-elevation myocardial infarction (STEMI), clopidogrel 75 mg per day orally should be added to aspirin regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy, with treatment continuing for at least 14 days (Level of Evidence: A/B) 1
For patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) treated medically without stenting, clopidogrel (75 mg per day) should be prescribed for at least 1 month (Level of Evidence: A) and ideally up to 1 year (Level of Evidence: B) 1
The CURE trial demonstrated a 20% relative risk reduction for patients treated with clopidogrel for an average of 9 months following ACS hospitalization compared to aspirin alone 1, 2
The COMMIT trial showed a 9% relative risk reduction of clopidogrel versus placebo in addition to aspirin for the combined endpoint of death, reinfarction, or stroke at 30 days among medically treated patients 1, 3
Clinical Benefits in Rehabilitation Settings
Patients in rehabilitation facilities often have recent cardiovascular events and are at high risk for recurrent events during the recovery phase 1, 2
Clopidogrel reduces the risk of subsequent cardiovascular events (cardiovascular death, MI, or stroke) in patients with atherosclerotic disease manifested by recent myocardial infarction, ischemic stroke, or symptomatic peripheral arterial disease 2, 4
The antiplatelet effects of clopidogrel complement those of aspirin through a different mechanism (ADP receptor inhibition), providing additive benefit through dual antiplatelet therapy 1, 2
Long-term maintenance therapy (e.g., 1 year) with clopidogrel is reasonable in STEMI patients regardless of whether they undergo reperfusion therapy 1
Specific Patient Populations in Rehabilitation
For patients with ACS who are treated medically without PCI and stenting (common in rehabilitation settings), dual antiplatelet therapy has been demonstrated to reduce recurrent cardiovascular events 1
Patients recovering from UA/NSTEMI benefit from clopidogrel when ASA is contraindicated or not tolerated due to hypersensitivity or gastrointestinal intolerance 1
Patients with symptomatic atherosclerosis (recent ischemic stroke, recent myocardial infarction, or symptomatic peripheral arterial disease) show an 8.7% relative risk reduction in ischemic events with clopidogrel compared to aspirin alone 4, 5
Important Considerations and Precautions
Clopidogrel increases the risk of bleeding compared to aspirin alone (3.7% vs. 2.7% for major bleeding), which must be carefully considered in rehabilitation patients who may be at risk for falls 6, 1
For patients scheduled to undergo CABG, clopidogrel should be withheld for 5-7 days prior to surgery to reduce bleeding risk 1
Clopidogrel is preferred over ticlopidine due to fewer side effects, less required monitoring, and a more favorable safety profile 1, 2
No dose adjustment is necessary based on gender, weight, race, or age (except in those ≥75 years), making it suitable for diverse rehabilitation patient populations 4, 2
Practical Implementation in Rehabilitation Settings
Rehabilitation hospitals typically continue clopidogrel therapy that was initiated during acute hospitalization rather than starting it de novo 1
The standard dosing is 75 mg once daily, with no need for routine hematological monitoring, making it practical for rehabilitation settings 2, 4
For patients who may have difficulty swallowing pills during rehabilitation, clopidogrel can be administered with food or antacids without affecting absorption 4, 5
Clopidogrel can be safely prescribed with a range of other medications commonly used in rehabilitation settings, with few clinically significant drug interactions 4, 1