ClopidogrelClopidogrel Bisulfate

About Clopidogrel

Clopidogrel is a prodrug: the body converts it, mainly through the enzyme CYP2C19, into an active form that binds permanently to the P2Y12 receptor on platelets and stops them from clumping. The label covers acute coronary syndrome without ST elevation (unstable angina or that type of heart attack), whether treated with medicines or with a procedure to reopen the arteries, and ST-elevation heart attack treated with medicines, in both cases with aspirin, to lower the rate of heart attack and stroke; it also lowers that rate in people with a recent heart attack, a recent stroke or established peripheral artery disease. For acute coronary syndrome, when an effect is needed within hours, it starts with a single 300 mg loading dose and continues at 75 mg once a day; without the loading dose its effect is delayed by several days. For the other uses it is 75 mg once a day with no loading dose, with or without food. Safety and effectiveness in children have not been established.

The boxed warning: clopidogrel works through its active form, so people with two nonfunctional copies of the CYP2C19 gene (poor metabolizers) make less of it and get less effect; tests can identify them, and the label says to consider another P2Y12 inhibitor for them. For a related reason, omeprazole and esomeprazole, which block CYP2C19, are avoided. It must not be taken with active bleeding, such as a peptic ulcer or bleeding in the brain, or after an allergy to it. Bleeding, including life-threatening and fatal bleeding, is the most commonly reported side effect. Thrombotic thrombocytopenic purpura (TTP), a sometimes fatal blood disorder, has been reported, sometimes after less than two weeks, and needs urgent treatment, including plasma exchange; fever, purple spots under the skin, yellow skin or eyes, pale skin, headache, confusion or speech changes call for help right away. Allergic reactions have occurred, including in people who had reacted to other thienopyridine drugs.

Stopping clopidogrel raises the risk of cardiovascular events, so it is not stopped without the prescriber; when possible it is paused for five days before surgery with a major bleeding risk and restarted as soon as bleeding is controlled, and every doctor and dentist should know it is taken. Opioids such as morphine delay and reduce its absorption. In pregnancy the label says treatment should not be withheld because of concerns about the baby, but its use during labor or delivery will increase the risk of the mother’s bleeding, so when possible it is stopped five to seven days before labor and spinal or epidural anesthesia is avoided; for breastfeeding, its benefits are weighed against the mother’s need for the drug. Reports since approval include acquired hemophilia A, DRESS and severe skin reactions such as Stevens-Johnson syndrome.

Taking Clopidogrel

How to take it

Once a day at about the same time, with or without food. Do not stop it without talking to the prescriber, and tell every doctor and dentist you take it before any surgery or procedure.

If you miss a dose

Take it as soon as you remember. If it is almost time for the next dose, skip the missed dose; do not take two doses at the same time unless your doctor says to.

Storage

At room temperature, about 77°F (25°C), in a tightly closed container away from excess heat and moisture (not in a bathroom), out of reach of children. Do not flush it; use a medicine take-back program.

Interactions to know about

Omeprazole and esomeprazole are avoided because they reduce its effect (dexlansoprazole, lansoprazole and pantoprazole affected it less), and repaglinide is avoided or used only at a limited dose. Opioids delay and reduce its absorption. NSAIDs, warfarin, other antiplatelet drugs and SSRI or SNRI antidepressants raise bleeding risk.

This summarizes the official prescribing information. Your prescriber’s and pharmacist’s instructions, and the leaflet that comes with your medicine, take priority.

Why the cash price for Clopidogrel differs from pharmacy to pharmacy

Generic clopidogrel 75 mg comes from many makers, and quotes for the same tablet can differ between pharmacies. A prescription that names Plavix and blocks substitution is priced as a brand.

The 300 mg tablet, used as a single loading dose, has fewer generic makers, and Plavix 300 mg comes in unit-dose packages of 30.

Ways to pay less for Clopidogrel without insurance

• Ask for generic clopidogrel, and make sure the prescription does not block substitution.
• Ask whether clopidogrel 75 mg is on the pharmacy’s flat-price generic list, and compare more than one pharmacy.
• Once you are on the daily 75 mg dose, ask for a ninety-day supply, and refill early enough never to run out, since stopping raises the risk of cardiovascular events.
• Upload the prescription to Script Unlock so licensed pharmacies can quote their cash price. You pay the pharmacy directly.

Questions to ask your pharmacist about Clopidogrel

1. 1.Do any of my acid reducers, pain relievers or antidepressants interact with it?
2. 2.Should I keep taking aspirin with it, and for how long?
3. 3.Which signs of bleeding or TTP mean I should get help right away?
4. 4.How long before my surgery or dental work should it be stopped, and who decides?

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