What is the recommended dose of Plavix (clopidogrel) for a patient with a history of stroke or transient ischemic attack (TIA)?

Plavix (Clopidogrel) Dosing for Stroke

For patients with a history of stroke or TIA, the standard maintenance dose of clopidogrel is 75 mg once daily without a loading dose for long-term secondary prevention. 1, 2

Acute Phase: First 21-30 Days After Minor Stroke or High-Risk TIA

If the patient presents within 24-72 hours of a minor stroke (NIHSS ≤3-5) or high-risk TIA (ABCD2 score ≥4), initiate dual antiplatelet therapy with a clopidogrel loading dose of 300-600 mg plus aspirin 160-325 mg, followed by clopidogrel 75 mg daily plus aspirin 75-100 mg daily for exactly 21 days. 3, 4

Loading Dose Protocol

• Clopidogrel 300 mg loading dose is the standard recommendation for stroke/TIA patients 3, 5
• Some guidelines support up to 600 mg loading dose, though 300 mg is more commonly recommended for stroke (the 600 mg dose is specifically validated for PCI patients, not stroke) 3, 5
• Administer within 12-24 hours of symptom onset for optimal benefit 3
• Recent evidence from the INSPIRES trial demonstrates consistent benefit when dual antiplatelet therapy is initiated even between 48-72 hours after symptom onset 4

Maintenance During Dual Therapy Phase

• Clopidogrel 75 mg daily plus aspirin 75-100 mg daily for exactly 21 days 3, 5
• This reduces recurrent ischemic stroke by 25-32% compared to aspirin alone 3
• After 21 days, immediately transition to single antiplatelet therapy 3, 5

Long-Term Secondary Prevention: After Day 21

Switch to clopidogrel 75 mg once daily as monotherapy indefinitely. 1, 3, 2

Monotherapy Options (All Equally Acceptable)

• Clopidogrel 75 mg once daily (preferred if aspirin intolerance) 1, 3
• Aspirin 75-100 mg once daily 1, 3
• Aspirin 25 mg + extended-release dipyridamole 200 mg twice daily 1, 3

Why No Loading Dose for Long-Term Prevention?

The FDA label explicitly states that for "recent MI, recent stroke, or established peripheral arterial disease: 75 mg once daily orally without a loading dose" 2. This is because:

• The acute high-risk period has passed after the first few weeks 3
• Standard 75 mg daily dosing achieves steady-state platelet inhibition within 5 days, which is acceptable for chronic prevention 3
• Loading doses are reserved for acute situations requiring immediate platelet inhibition 2

Critical Contraindications and Warnings

Never continue dual antiplatelet therapy (clopidogrel + aspirin) beyond 21-30 days for routine stroke prevention. 3, 5

• Prolonged dual therapy beyond 90 days increases major bleeding risk (HR 2.22-2.42) without additional stroke prevention benefit 3, 5
• The MATCH trial demonstrated that long-term dual therapy significantly increases life-threatening bleeding 5

Do not initiate clopidogrel until intracranial hemorrhage is ruled out on neuroimaging. 3

If the patient received IV alteplase, delay antiplatelet therapy until 24 hours post-thrombolysis. 3

Special Populations

Cardioembolic Stroke (Atrial Fibrillation)

Switch to oral anticoagulation (apixaban, dabigatran, or warfarin INR 2.0-3.0) instead of clopidogrel. 1, 5

• Anticoagulation is superior to antiplatelet therapy for cardioembolic stroke prevention 1
• Clopidogrel may only be used if anticoagulation is absolutely contraindicated 5

CYP2C19 Poor Metabolizers

Consider using an alternative antiplatelet agent (aspirin/dipyridamole or ticagrelor) in patients identified as CYP2C19 poor metabolizers. 2

• Clopidogrel requires conversion to active metabolite by CYP2C19 2
• Genetic testing is available to identify poor metabolizers 2

Common Pitfalls to Avoid

• Never use clopidogrel as a substitute for thrombolysis or mechanical thrombectomy in eligible patients 3
• Never continue dual antiplatelet therapy indefinitely - the bleeding risk dramatically increases after 21-30 days without additional benefit 3, 5
• Never delay aspirin beyond 48 hours in favor of waiting to start clopidogrel - early aspirin (within 24-48 hours) is a Grade 1A recommendation 1
• Never use therapeutic-dose anticoagulation (enoxaparin, heparin) for acute stroke treatment - it increases bleeding without proven benefit 6