What are the doses of Plavix (clopidogrel) and Apixaban for a patient with Non-ST-Elevation Myocardial Infarction (NSTEMI) post Percutaneous Coronary Intervention (PCI)?

Dosing of Plavix (Clopidogrel) and Apixaban for NSTEMI Post-PCI

For patients with NSTEMI post-PCI, the recommended dose of clopidogrel is 75 mg daily for at least 12 months, while apixaban is not part of standard therapy for this indication. 1

Antiplatelet Therapy Post-PCI for NSTEMI

Loading Doses

• For patients not already on P2Y12 inhibitor therapy, a loading dose of clopidogrel 600 mg should be given as early as possible before or at the time of PCI 1
• For patients already on daily aspirin therapy, they should take 81 mg to 325 mg non-enteric-coated aspirin before PCI 1
• For patients not on aspirin therapy, non-enteric coated aspirin 325 mg should be given as soon as possible before PCI 1

Maintenance Doses

• Clopidogrel: 75 mg daily for at least 12 months post-PCI 1
• Aspirin: 81 mg daily is preferred over higher maintenance doses 1
• Duration: P2Y12 inhibitor therapy should be continued for at least 12 months in patients receiving a stent during PCI for NSTEMI 1

Alternative P2Y12 Inhibitors

• Ticagrelor may be a reasonable alternative to clopidogrel (loading dose: 180 mg; maintenance: 90 mg twice daily) 1, 2
• Prasugrel may be considered over clopidogrel in patients not at high risk of bleeding (loading dose: 60 mg; maintenance: 10 mg daily) 1

Important Considerations

Apixaban in NSTEMI

• Apixaban is not part of standard therapy for NSTEMI post-PCI unless there is a specific indication for anticoagulation (such as atrial fibrillation) 1
• If anticoagulation is indicated along with antiplatelet therapy, the duration of triple antithrombotic therapy (vitamin K antagonist, aspirin, and P2Y12 inhibitor) should be minimized to limit bleeding risk 1

Special Considerations

• Prasugrel should not be administered to patients with a prior history of stroke or transient ischemic attack 1
• For patients ≥75 years or <60 kg, prasugrel is generally not recommended due to increased bleeding risk 1, 2
• If the risk of bleeding outweighs the anticipated benefit, earlier discontinuation of P2Y12 inhibitor therapy (e.g., <12 months) may be reasonable 1

Bleeding Risk Management

• When using ticagrelor, the recommended maintenance dose of aspirin is specifically 81 mg daily 1, 2
• Consider adding a proton pump inhibitor in patients requiring dual antiplatelet therapy who are at increased risk for gastrointestinal bleeding 1, 2

Algorithm for P2Y12 Inhibitor Selection

1. First-line: Clopidogrel 75 mg daily for most patients 1, 3
2. Consider ticagrelor (90 mg twice daily) over clopidogrel if patient has high-risk features and low bleeding risk 1
3. Consider prasugrel (10 mg daily) over clopidogrel if patient has no history of stroke/TIA, is <75 years old, weighs >60 kg, and has low bleeding risk 1