From the Research
The recommended dosage of clopidogrel in triple therapy is 75 mg once daily, as supported by the most recent and highest quality study 1.
Key Considerations
- Triple therapy is usually prescribed for patients with both coronary artery disease requiring antiplatelet therapy and conditions requiring anticoagulation, such as atrial fibrillation or mechanical heart valves.
- When initiating therapy after acute coronary syndrome or stent placement, a loading dose of 300-600 mg clopidogrel may be given first, followed by the 75 mg daily maintenance dose.
- The duration of triple therapy should be kept as short as clinically necessary (often 1-6 months) due to the increased bleeding risk, as noted in studies such as 2 and 3.
- Aspirin is typically given at a low dose (75-100 mg daily) during triple therapy, while the anticoagulant (warfarin, apixaban, rivaroxaban, etc.) is dosed according to its standard regimen.
- Regular monitoring for bleeding complications is essential during triple therapy, as highlighted in 4 and 1.
Rationale
The rationale for this approach balances the need to prevent stent thrombosis and stroke while minimizing the substantial bleeding risk associated with combining multiple antithrombotic medications, as discussed in 5 and 1.
Age Considerations
The benefits of dabigatran dual therapy differed in older (≥ 75 years) and younger (< 75 years) patients, which may help dose selection when using dabigatran dual therapy, as reported in 1.
Evidence Summary
- 2: Atrial fibrillation and coronary artery disease: which antithrombotic treatment strategy?
- 5: Combining antiplatelet and antithrombotic therapy (triple therapy): what are the risks and benefits?
- 3: Triple therapy: A review of antithrombotic treatment for patients with atrial fibrillation undergoing percutaneous coronary intervention.
- 4: Efficacy and safety of aspirin, clopidogrel, and warfarin after coronary artery stenting in Korean patients with atrial fibrillation.
- 1: Comparison of the Effect of Age (< 75 Versus ≥ 75) on the Efficacy and Safety of Dual Therapy (Dabigatran + Clopidogrel or Ticagrelor) Versus Triple Therapy (Warfarin + Aspirin + Clopidogrel or Ticagrelor) in Patients With Atrial Fibrillation After Percutaneous Coronary Intervention (from the RE-DUAL PCI Trial).