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 © 2008 Greater Rochester Independent Practice Association 1 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. © 2008 Greater Rochester Independent Practice Association 2 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 © 2008 Greater Rochester Independent Practice Association 3 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 © 2008 Greater Rochester Independent Practice Association 4 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 © 2008 Greater Rochester Independent Practice Association 5 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) © 2008 Greater Rochester Independent Practice Association 6