Can a patient with a history of coronary artery disease and type 1 diabetes taking Plavix (clopidogrel) take aspirin concurrently?

Can Patients Take Plavix and Aspirin Together?

Yes, patients with coronary artery disease and type 1 diabetes should take Plavix (clopidogrel) and aspirin concurrently—this combination is specifically indicated and recommended for secondary prevention of cardiovascular events. 1, 2

FDA-Approved Indications for Dual Antiplatelet Therapy

The FDA label for clopidogrel explicitly states that clopidogrel should be administered in conjunction with aspirin for patients with acute coronary syndrome and those with established coronary artery disease. 2 This is not optional—it is the standard of care for your patient population.

Specific Dosing Recommendations

For patients with established coronary artery disease (like your patient):

• Aspirin: 75-162 mg daily (with 81 mg being the most common low-dose in the U.S.) 1
• Clopidogrel: 75 mg daily 1, 2
• Duration: Indefinitely for secondary prevention in patients with established CAD 1

The AHA/ACC guidelines specifically recommend starting and continuing aspirin 75-162 mg daily indefinitely in all patients with coronary and atherosclerotic vascular disease unless contraindicated. 1 For patients with diabetes and established CAD, antiplatelet therapy with either aspirin or clopidogrel (or both) is indicated to reduce MI and stroke. 1

Why This Combination Works

Aspirin and clopidogrel have complementary mechanisms that provide superior protection compared to either agent alone:

• Aspirin irreversibly inhibits cyclooxygenase, preventing thromboxane A2 production 3
• Clopidogrel irreversibly blocks the P2Y12 ADP receptor on platelets 3
• This dual inhibition targets different platelet activation pathways, providing additive antithrombotic benefit 4, 3

Evidence Supporting Combination Therapy

The combination of aspirin and clopidogrel has been shown to reduce cardiovascular events more effectively than aspirin alone in patients with established atherosclerotic disease. 1 While the CHARISMA trial showed that dual antiplatelet therapy in the overall population had similar rates of cardiovascular events compared to aspirin alone, a prespecified subgroup analysis of patients with prior MI, ischemic stroke, or symptomatic peripheral vascular disease demonstrated significant benefit (hazard ratio 0.83,95% CI: 0.72-0.96). 1

Critical Safety Considerations

Bleeding risk is the primary concern with dual antiplatelet therapy:

• The combination increases bleeding risk compared to aspirin alone 1
• Proton pump inhibitors (PPIs) should be prescribed routinely to reduce gastrointestinal bleeding risk 1
• Use pantoprazole or esomeprazole preferentially rather than omeprazole, as omeprazole significantly reduces clopidogrel's antiplatelet activity through CYP2C19 inhibition 2, 1
• The FDA label explicitly warns to avoid concomitant use of clopidogrel with omeprazole or esomeprazole 2

Special Considerations for Diabetes

Your patient's type 1 diabetes is actually an additional indication for aggressive antiplatelet therapy. The AHA/ACC guidelines specifically state that patients with diabetes and coronary artery disease should receive vigorous modification of risk factors, including antiplatelet therapy. 1 The 2019 ADA guidelines recommend aspirin therapy for secondary prevention in patients with diabetes and established cardiovascular disease. 1

Duration of Therapy

For stable coronary artery disease without recent stenting or acute coronary syndrome:

• Aspirin should be continued indefinitely 1
• Clopidogrel continuation beyond 12 months after an acute event is reasonable but not universally required 1
• However, combination therapy may be considered in patients with stable CAD, though this is a Class IIb recommendation (less well established) 1

If your patient had recent PCI with stenting:

• Bare metal stent: minimum 1 month of dual therapy 1
• Drug-eluting stent: minimum 12 months of dual therapy 1
• After the minimum period, aspirin should continue indefinitely 1

Common Pitfalls to Avoid

Do not discontinue clopidogrel abruptly without compelling reason, as this increases cardiovascular event risk. 2 If temporary discontinuation is necessary (e.g., for surgery with high bleeding risk), resume as soon as hemostasis permits. 2

Do not use NSAIDs concurrently with dual antiplatelet therapy, as this substantially increases bleeding risk without providing cardiovascular benefit. 1

Do not assume all patients respond equally to clopidogrel. Approximately 2-14% of patients are CYP2C19 poor metabolizers who form less active metabolite and have reduced antiplatelet effect. 2 Consider genetic testing if recurrent events occur despite adherence, though this is not routinely recommended for all patients.

Monitor for bleeding complications including gastrointestinal bleeding, intracranial hemorrhage, and other major bleeding events. 1 Risk factors include advanced age, renal dysfunction, anemia, and concomitant anticoagulation. 1

When Anticoagulation Is Also Required

If your patient develops atrial fibrillation or another indication for anticoagulation, triple therapy (aspirin + clopidogrel + anticoagulant) should be kept as short as possible—typically 1 month maximum—followed by dual therapy with clopidogrel and anticoagulant. 1 Use a NOAC rather than warfarin when possible, and always prescribe a PPI. 1