When to Use Aspirin with Clopidogrel Pharmacy Tidbit Plavix with ASA

When to Use Aspirin with Clopidogrel
Pharmacy Tidbit
Plavix with ASA
When is it appropriate?
Cori Wyman, Pharm.D., CDE
Consulting Clinical Pharmacist, GRIPA
CASE STUDY
•85 y/o female with weight
loss, early satiety
•PMH significant for:
•Medications include:

Digoxin 0.125mg qd

Levothyroxine 0.075mg qd
Fosamax 70mg qweek

HTN


AFib

Calcium/Vit D 500mg bid

Hyperlipidemia

Diovan/HCTZ 160/12.5mg qd

Hypothyroidism

Simvastatin 20mg qd

Osteoporosis

Plavix 75mg qd

Stable angina

ASA 81mg qd

Glaucoma

Coreg 25mg bid with food

Xalantan 0.005% gtt ou qd
•Work-up included colonoscopy,
upper endoscopy
•Diagnosis: GI bleed
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Practice Association
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When to Use Aspirin with Clopidogrel
Pharmacy Tidbit
Is Plavix with ASA appropriate for the
prevention of thromboembolism in
patients with AFib?
ACTIVE W Trial: ASA with Plavix vs. warfarin
warfarin
ASA with Plavix
p-value
Major ischemic
event
3.93%
5.6%
0.0003
Major bleed rate
2.21%
2.42%
0.53
Minor bleed rate
11.45%
13.58%
0.0009
•Conclusion

Warfarin is superior to Plavix with ASA for prevention of
vascular events in patients with AFib at high risk of stroke
without an increase in major bleeding
Reference: ACTIVE W study group. Clopidogel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation
Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006;367:190312.
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Practice Association
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When to Use Aspirin with Clopidogrel
Pharmacy Tidbit
Anticoagulation use in AFib
•Rate of stroke in untreated AFib is approximately 5% per year
•Warfarin is underused in patients > 75 with AFib
•Deterrents

Fall risk

Risk of bleeding

Non-adherence concerns

Dementia

Perception of the greater risk of hemorrhage
•The risk of falls is overrated

To outweigh the benefit of warfarin in patients >75 with
AFib, patient would have to fall about 300 times per year
Arch Intern Med 1999;159:677-685
CASE STUDY (cont.)
•Plavix with ASA is NOT indicated in this patient
•Plavix with ASA is NOT appropriate in patients with AFib
•In patients >75, 300mg of ASA would suffice if the patient
could not take warfarin Age and Aging. 2007;36:151-56
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Practice Association
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When to Use Aspirin with Clopidogrel
Pharmacy Tidbit
Inappropriate uses of Plavix with ASA
•Atrial fibrillation
•Primary prevention of CAD
•Established CV disease/multiple CV risk factors
•Chronic stable angina
•Secondary prevention of stroke or TIA

No difference in CV death, MI, stroke or CV hospitalization
vs. Plavix alone

Increased life-threatening bleeding (NNH = 50), major and
minor bleeding (NNH = 100)

MATCH (Management of AtheroThrombosis with Clopidogrel
in High-risk patients) trial
GRIPA Connect Portal Home Page
Click on
Clinical
Care
Guidelines
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Practice Association
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When to Use Aspirin with Clopidogrel
Pharmacy Tidbit
GRIPA Connect Clinical Care Guidelines
Select guideline
you would like to
view
GRIPA Connect Clinical Care Guideline for
Secondary Prevention of Ischemic Stroke/TIA
Guideline
recommendation
for antiplatelet
therapy for
Secondary
Prevention of
Stroke/TIA
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Practice Association
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When to Use Aspirin with Clopidogrel
Pharmacy Tidbit
Plavix with ASA: Summary of Recommendations
PLAVIX + ASPIRIN
YES
NO
•PCI (with or without stent)
•Primary Prevention of CAD
•ACS
•Chronic Stable Angina
•Unstable Angina
•Secondary Prevention of
Stroke/TIA
•NSTEMI
•Atrial Fibrillation
•Acute STEMI
•Established CV disease/CV
risk factors
•PVD
Antiplatelet Therapy: A Summary of the Evidence
Clinical Setting
Suggested Treatment
Evidence
Primary Prevention
ASA for patients with a
USPSTF
10-year risk of CHD ≥ 6%
Recent discharge
after ACS or stent
insertion
ASA with PLAVIX for up
to one year
CURE, COMMIT,
CLARITY, CREDO
Prior MI (> 1 year)
ASA
ATC
Secondary
prevention of
stroke/TIA
ASA
ATC
Dipyridamole + ASA
ESPS-2
PLAVIX
CAPRIE
PLAVIX
CAPRIE
PVD (claudication or
surgery)
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Practice Association
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