Should a patient with diabetes mellitus and coronary artery disease use aspirin and Plavix (clopidogrel)?

From the Guidelines

For a patient with diabetes mellitus and coronary artery disease, the use of aspirin and Plavix (clopidogrel) is recommended after acute coronary syndromes and coronary revascularization with stenting, as indicated by current guidelines 1. When considering the use of dual antiplatelet therapy, it is essential to weigh the benefits of reducing ischemic events against the increased risk of bleeding.

• The combination of aspirin and a P2Y12 receptor antagonist, such as clopidogrel, has been shown to be effective in reducing the risk of recurrent ischemic events, including cardiovascular and CHD death, in people with diabetes and prior MI 1.
• However, the addition of clopidogrel to aspirin also increases the risk of major bleeding, including intracranial hemorrhage, as noted in the guidelines 1.
• The net clinical benefit of dual antiplatelet therapy is improved in individuals with a history of percutaneous coronary intervention, while no net benefit is seen in those without prior percutaneous coronary intervention 1.
• Aspirin 81 mg daily should be used long-term, while clopidogrel 75 mg daily is usually prescribed for a specific duration based on the clinical scenario, such as 12 months after an acute coronary syndrome or coronary stent placement.
• Patients should take these medications with food to reduce gastrointestinal side effects and should not discontinue them without consulting their physician, as sudden cessation can increase cardiovascular risk.
• Regular monitoring for bleeding complications is essential during treatment, and an interprofessional team approach, including a cardiovascular specialist, should be used to determine the indications for dual antiplatelet therapy and length of treatment 1.

From the FDA Drug Label

Clopidogrel tablets are indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non–ST-segment elevation ACS (unstable angina [UA]/non–ST-elevation myocardial infarction [NSTEMI]), including patients who are to be managed medically and those who are to be managed with coronary revascularization Clopidogrel tablets should be administered in conjunction with aspirin. In patients with established peripheral arterial disease or with a history of recent myocardial infarction (MI) or recent stroke clopidogrel tablets are indicated to reduce the rate of MI and stroke.

Key Points:

• Clopidogrel is indicated for patients with coronary artery disease to reduce the rate of myocardial infarction and stroke.
• Clopidogrel should be administered in conjunction with aspirin.
• There is no direct contraindication for patients with diabetes mellitus.

Answer: A patient with diabetes mellitus and coronary artery disease can use aspirin and Plavix (clopidogrel) as the drug label indicates that clopidogrel should be administered in conjunction with aspirin for patients with coronary artery disease, and there is no direct contraindication for patients with diabetes mellitus 2, 2.

From the Research

Aspirin and Plavix (Clopidogrel) Use in Diabetes Mellitus and Coronary Artery Disease

• The use of aspirin in patients with diabetes mellitus and coronary artery disease is a common practice to prevent cardiovascular events 3.
• However, the efficacy of once-daily aspirin treatment in patients with diabetes has been observed to be modest, possibly due to the short inhibitory window provided by once-daily aspirin 3.
• Alternative aspirin regimens, such as twice-daily dosing, have been proposed to overcome the limited efficacy of conventional aspirin in patients with diabetes 4, 3.
• The addition of clopidogrel to aspirin therapy has been shown to reduce the risk of cardiovascular events in patients with coronary artery disease, but also increases the risk of bleeding 5.
• In patients with diabetes and acute coronary syndromes managed without revascularization, the use of dual antiplatelet therapy with aspirin and clopidogrel did not show a significant difference in treatment-related outcomes compared to aspirin and prasugrel 6.
• The cost-utility of ticagrelor plus aspirin in diabetic patients with stable coronary artery disease has been evaluated, and the results suggest that ticagrelor plus aspirin is likely to be a cost-effective option in patients with a history of percutaneous coronary intervention 7.

Considerations for Aspirin and Clopidogrel Use

• The decision to use aspirin and clopidogrel in patients with diabetes mellitus and coronary artery disease should be based on individual patient risk factors and medical history 5.
• The potential benefits of dual antiplatelet therapy should be weighed against the increased risk of bleeding 5.
• Alternative antiplatelet regimens, such as ticagrelor plus aspirin, may be considered in certain patient populations, such as those with a history of percutaneous coronary intervention 7.
• Further research is needed to determine the optimal antiplatelet therapy regimen for patients with diabetes mellitus and coronary artery disease 4, 6, 3, 5, 7.