How long should i take clopidogrel after a stroke

• A 10- to 21-day course of dual antiplatelet therapy reduces stroke recurrence and improves quality of life after mild stroke or high-risk TIA.

• Low-dose aspirin and a 300-mg loading dose of clopidogrel should be started as soon as imaging rules out hemorrhage.

• After 10 to 21 days of daily low-dose aspirin and clopidogrel, 75 mg, the patient should be switched to a single antiplatelet drug.

From the AFP Editors

Dual antiplatelet therapy after stroke has not previously been shown to improve outcomes over a single agent. Based on a recent randomized controlled trial followed by a systematic review, the BMJ and MAGIC group concluded that dual antiplatelet therapy use for a limited period after mild stroke is beneficial. The combination of low-dose aspirin and clopidogrel (Plavix) reduces recurrent stroke and disability compared with aspirin alone when started as soon as possible after a high-risk transient ischemic attack (TIA) or minor ischemic stroke without persistent disabling neurologic deficit and continued for 10 to 21 days.

The severity of TIA can be determined using the ABCD2 score (Table 1). Dual antiplatelet therapy is recommended for an ABCD2 score of 4 or greater. Minor stroke can be identified by a National Institutes of Health (NIH) Stroke Scale score of 3 or less. The risk of recurrence after minor stroke is similar to that after a high-risk TIA. The NIH Stroke Scale ranges from 0 to 42 and is based on measures of motor and sensory function, language and speech, vision, level of consciousness and attention, and neglect. Dual antiplatelet therapy should be started as soon as brain imaging rules out intracranial hemorrhage. Although trials used various dosing strategies, members of the BMJ and MAGIC panel recommend a loading dose of 300 mg of clopidogrel followed by 75 mg daily, and low-dose aspirin at 75 to 81 mg daily. The aspirin should be taken whole without food, but clopidogrel can be crushed or split and taken with or without food.

CriteriaScoreAge1 point if > 60 yearsBlood pressure1 point if > 140/90 mm HgClinical signs1 point if speech disturbance only2 points if unilateral weaknessDiabetes mellitus1 point if presentDuration1 point if 10 to 59 minutes2 points if ≥ 1 hour

When imaging will be performed more than 24 hours after symptom onset, treatment should be initiated as soon as minor ischemic stroke or transient TIA is diagnosed by a physician with intent to image as soon as possible.

Evidence indicates that there is no improvement in stroke-related outcomes and increased risk of bleeding with continuation of dual anti-platelet therapy in the long term (22 to 90 days) after stroke. Patients, however, should likely continue to take one agent for the forseeable future. Dual antiplatelet therapy should not be used in patients experiencing a major stroke because of the associated increased risk of intracranial bleeding.

Background

The systematic review on which this recommendation was based included three randomized controlled trials evaluating dual antiplatelet therapy compared with aspirin monotherapy in more than 10,000 patients. These studies identified that dual therapy decreased nonfatal recurrent strokes (number needed to treat [NNT] = 53), moderate to severe disability (NNT = 72), and poor quality of life (NNT = 77). Dual antiplatelet therapy had no effect on all-cause mortality or the incidence of myocardial infarction or recurrent TIA, and had some associated harms of minor (number needed to harm [NNH] = 143) and moderate to major (NNH = 500) extracranial bleeding.

The panel believed that most patients would value preventing another stroke over experiencing bleeding and thus opt for dual therapy over monotherapy. They also believed most patients would opt for shorter treatment duration because of the similar benefits provided, with less associated harm.

Editor's Note: The numbers needed to treat and to harm were calculated by the AFP medical editors based on raw data provided in the original BMJ article.

Plavix (clopidogrel) and low-dose aspirin are commonly taken after a heart attack to prevent another one from occurring.

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Coronary artery disease (CAD) is the most common type of heart disease. It's typically caused by a buildup of fat in the arteries (a type of blood vessel) of the heart. Unfortunately, CAD can cause serious health problems. In fact, heart disease is the leading cause of death in the U.S.

Many people with CAD don’t experience symptoms. But, over time, the cholesterol buildup can cause a plaque to form. If the plaque ruptures, a blood clot may form. And, if the clot blocks blood flow to the heart, a potentially deadly heart attack can occur. 

If you’ve recently had a heart attack, you’ll probably need to take medication to help prevent another one from happening. Aspirin and Plavix (clopidogrel) are two common medications that your healthcare provider may prescribe. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) and Plavix is a P2Y12 receptor blocker (inhibitor). 

Even though many people who have a heart attack will take aspirin for the rest of their lives, the same usually isn’t true for Plavix. How long you take the medication depends primarily on your medical history.

When is it recommended to take Plavix and aspirin to prevent heart problems?

Low-dose aspirin and Plavix are known to prevent blood clots from developing in certain people. Low-dose aspirin refers to doses between 75 mg to 100 mg. Most often, the recommended dose is 81 mg, which is commonly referred to as “baby aspirin.” 

If you’ve had a heart attack, your provider may recommend that you take low-dose aspirin and Plavix. These medications can prevent this serious medical event from happening again. Taking the two medications together is called dual antiplatelet therapy (DAPT).

These antiplatelet medications, as they’re called, prevent platelets from clumping together. The typical function of platelets (a type of blood cell) is to form clots and stop bleeding. But, in some situations, this can cause major health problems like heart attacks and strokes. By preventing blood from clotting, aspirin and Plavix help keep these heart-related issues from occurring again.

Taking aspirin is almost always recommended after a heart attack or stroke. And, compared to aspirin alone, DAPT can lower your chances of getting a blood clot and having a potentially fatal heart-related emergency.. 

DAPT is recommended for people who:

• Have had a heart attack

• Have unstable angina (new or worsening chest pain)

• Have had a stent placed (a tube that helps keep the blood vessels in your heart open)

• Have had coronary artery bypass graft (CABG) surgery (a procedure to improve blood flow to the heart)

Short-term DAPT is sometimes recommended for people who’ve had a stroke or transient ischemic attack (TIA). But this is only for people who meet certain criteria.

How long do I need to take Plavix and aspirin?

How long Plavix and aspirin are taken varies according to the reason they’re being taken in the first place — and a person’s risk of bleeding. Some general guidelines are:

• After a heart attack: at least 12 months 

• With unstable angina: at least 12 months 

• Following stent placement after a heart attack: at least 12 months

• Following stent placement in people with stable heart disease: at least 6 months for a drug-eluting stent and at least 1 month for a bare metal stent

• Following CABG surgery: 12 months

For people who have a high risk of bleeding, DAPT may be more short term. In these situations, a person usually stops taking Plavix earlier but continues taking aspirin. People with a higher risk of bleeding include those who:

On the other hand, some people with a high risk of blood clots and low bleeding risk may benefit from taking DAPT longer than 12 months. If you’re taking Plavix and aspirin together, talk to your healthcare provider and make sure you know exactly how long to continue treatment.

Plavix dose for antiplatelet therapy

The typical dosage of Plavix, which is only available by prescription, is 75 mg once daily. And the typical recommended dosage of aspirin, which is available over the counter, is 81 mg once daily.

In some cases, a “loading dose” of Plavix or aspirin may be recommended. A loading dose is an initial dose of a medication that’s higher than what the daily dose will be. Loading doses are used to help a medication reach adequate levels in the body quickly.

Is Plavix my only choice for antiplatelet therapy?

There are other P2Y12 inhibitors, like Brilinta (ticagrelor) and Effient (prasugrel), that can be taken as alternatives to Plavix. In fact, Brilinta is only FDA-approved to be taken with aspirin.

Brilinta and Effiient are considered to be stronger and faster acting than Plavix. This means studies have shown they are better at preventing blood clots in heart attack and unstable angina patients. So, in certain situations, these medications may be more effective in a DAPT regimen than Plavix. But they also come with a higher risk of bleeding.

A situation in which Brilinta or Effient may be preferred over Plavix is when someone has had a heart attack and is having a stent placed. In that case, Brilinta or Effient would likely be taken with aspirin as part of DAPT.

But, because of the risk of bleeding, these more potent medications aren’t recommended for certain people. Effient shouldn’t be taken by people who have previously had a stroke or TIA. And Brillinta shouldn’t be taken by those who have had a previous brain bleed, have current internal bleeding, or have severe liver disease. 

Talk to your healthcare provider if you’re not sure which P2Y12 inhibitor might be right for you. They can help you weigh the risks and benefits of these medications. 

When is the best time of day to take Plavix?

There’s no best time of the day to take Plavix, but you should take it at the same time every day (with or without food). In general, try to be consistent with how you take the medication. 

If you miss a dose of Plavix, take it as soon as you remember. But, if it’s almost time for your next dose, skip the missed one and just take a single dose at your usual time. Don’t take two doses of Plavix at once, as it can lead to serious side effects like bleeding.

Side effects of Plavix

Bleeding is the most common side effect of Plavix. This includes serious bleeding, like of the stomach and brain, and less serious kinds, like a nose bleed. Bruising and itching are other possible side effects and, like bleeding, they’re more likely to happen in older adults. 

Contact your healthcare provider if you notice any signs of unusual bleeding, such as:

• Coughing up blood

• External bleeding that won’t stop

• Blood in your stools or black, tarry stools

• Blood in your urine

• Bruises that appear for seemingly no reason and grow in size

Another potentially serious, although rare, side effect of Plavix is thrombotic thrombocytopenic purpura (TTP). This happens when multiple clots develop in smaller blood vessels, which can block blood flow to your organs, damaging them. 

Seek immediate medical attention if you notice the following TPP symptoms:

• Nausea and vomiting

• Confusion

• Fever

• Red spots under the skin (petechiae)

• Purple, red, or yellowish spots on the skin (purpura)

• Seizures

• Yellowing of your skin or eyes (jaundice)

The bottom line

Both Plavix and aspirin can prevent blood clots from forming. For certain people, including those who have had a heart attack, these medications may be recommended to help prevent additional heart-related problems..

Taking Plavix and aspirin together, known as dual antiplatelet therapy (DAPT), is recommended for a variety of situations. Depending on what you’re taking it for, you may be taking DAPT for up to a year or longer. But these antiplatelet medications raise your risk of bleeding, so some people, like those who take anticoagulants and older adults, will need to stop taking Plavix earlier.

Talk with a healthcare provider if you have questions or concerns about how long you should take Plavix.

Co-Reviewer: Alice Perlowski, MD, MA, FACC

GoodRx Health has strict sourcing policies and relies on primary sources such as medical organizations, governmental agencies, academic institutions, and peer-reviewed scientific journals. Learn more about how we ensure our content is accurate, thorough, and unbiased by reading our editorial guidelines.

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