DRUG INTERACTIONS
7 CYP2C19 inhibitors (e.g., omeprazole): Avoid concomitant use.
( 7.1 ) Nonsteroidal anti-inflammatory drugs (NSAIDs): Combination use increases risk of gastrointestinal bleeding.
( 7.2 ) Warfarin: Combination use increases risk of bleeding.
( 7.3 ) 7.1 CYP2C19 Inhibitors Clopidogrel is metabolized to its active metabolite in part by CYP2C19.
Concomitant use of drugs that inhibit the activity of this enzyme results in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition.
Avoid concomitant use of drugs that inhibit CYP2C19, e.g., omeprazole [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.5) ] .
Omeprazole In a crossover clinical study, 72 healthy subjects were administered Plavix (300 mg loading dose followed by 75 mg per day) alone and with omeprazole (80 mg at the same time as Plavix) for 5 days.
The exposure to the active metabolite of clopidogrel was decreased by 46% (Day 1) and 42% (Day 5) when Plavix and omeprazole were administered together.
Mean inhibition of platelet aggregation was diminished by 47% (24 hours) and 30% (Day 5) when Plavix and omeprazole were administered together.
In another study, 72 healthy subjects were given the same doses of Plavix and omeprazole but the drugs were administered 12 hours apart; the results were similar, indicating that administering Plavix and omeprazole at different times does not prevent their interaction [see Warnings and Precautions (5.1) ] .
7.2 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Coadministration of Plavix and NSAIDs increases the risk of gastrointestinal bleeding.
7.3 Warfarin (CYP2C9 Substrates) Although the administration of clopidogrel 75 mg per day did not modify the pharmacokinetics of S-warfarin (a CYP2C9 substrate) or INR in patients receiving long-term warfarin therapy, coadministration of Plavix with warfarin increases the risk of bleeding because of independent effects on hemostasis.
However, at high concentrations in vitro , clopidogrel inhibits CYP2C9.
OVERDOSAGE
10 Platelet inhibition by Plavix is irreversible and will last for the life of the platelet.
Overdose following clopidogrel administration may result in bleeding complications.
A single oral dose of clopidogrel at 1500 or 2000 mg/kg was lethal to mice and to rats and at 3000 mg/kg to baboons.
Symptoms of acute toxicity were vomiting, prostration, difficult breathing, and gastrointestinal hemorrhage in animals.
Based on biological plausibility, platelet transfusion may restore clotting ability.
DESCRIPTION
11 Plavix (clopidogrel bisulfate) is a thienopyridine class inhibitor of P2Y 12 ADP platelet receptors.
Chemically it is methyl (+)-( S )-α-(2-chlorophenyl)-6,7-dihydrothieno[3,2-c]pyridine-5(4 H )-acetate sulfate (1:1).
The empirical formula of clopidogrel bisulfate is C 16 H 16 ClNO 2 S•H 2 SO 4 and its molecular weight is 419.9.
The structural formula is as follows: Clopidogrel bisulfate is a white to off-white powder.
It is practically insoluble in water at neutral pH but freely soluble at pH 1.
It also dissolves freely in methanol, dissolves sparingly in methylene chloride, and is practically insoluble in ethyl ether.
It has a specific optical rotation of about +56°.
Plavix for oral administration is provided as either pink, round, biconvex, debossed, film-coated tablets containing 97.875 mg of clopidogrel bisulfate which is the molar equivalent of 75 mg of clopidogrel base or pink, oblong, debossed film-coated tablets containing 391.5 mg of clopidogrel bisulfate which is the molar equivalent of 300 mg of clopidogrel base.
Each tablet contains hydrogenated castor oil, hydroxypropylcellulose, mannitol, microcrystalline cellulose and polyethylene glycol 6000 as inactive ingredients.
The pink film coating contains ferric oxide, hypromellose 2910, lactose monohydrate, titanium dioxide and triacetin.
The tablets are polished with Carnauba wax.
Chemical Structure
CLINICAL STUDIES
14 The clinical evidence of the efficacy of Plavix is derived from three double-blind trials involving 77,599 patients.
The CAPRIE study (Clopidogrel vs.
Aspirin in Patients at Risk of Ischemic Events) was a comparison of Plavix to aspirin.
The CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events) and the COMMIT/CCS-2 (Clopidogrel and Metoprolol in Myocardial Infarction Trial / Second Chinese Cardiac Study) studies were comparisons of Plavix to placebo, given in combination with aspirin and other standard therapy.
The CHARISMA (Clopidogrel for High Atherothrombotic Risk Ischemic Stabilization, Management, and Avoidance) study (n=15,603) also compared Plavix to placebo, given in combination with aspirin and other standard therapy.
14.1 Acute Coronary Syndrome CURE The CURE study included 12,562 patients with ACS without ST-elevation (UA or NSTEMI) and presenting within 24 hours of onset of the most recent episode of chest pain or symptoms consistent with ischemia.
Patients were required to have either ECG changes compatible with new ischemia (without ST-elevation) or elevated cardiac enzymes or troponin I or T to at least twice the upper limit of normal.
The patient population was largely Caucasian (82%) and included 38% women, and 52% patients ≥65 years of age.
Patients were randomized to receive Plavix (300-mg loading dose followed by 75 mg once daily) or placebo, and were treated for up to one year.
Patients also received aspirin (75–325 mg once daily) and other standard therapies such as heparin.
The use of GPIIb/IIIa inhibitors was not permitted for three days prior to randomization.
The number of patients experiencing the primary outcome (CV death, MI, or stroke) was 582 (9.3%) in the Plavix-treated group and 719 (11.4%) in the placebo-treated group, a 20% relative risk reduction (95% CI of 10%–28%; p < 0.001) for the Plavix-treated group (see Table 4 ).
Table 4: Outcome Events in the CURE Primary Analysis Outcome Plavix (+ aspirin) Other standard therapies were used as appropriate.
Placebo (+ aspirin) Relative Risk Reduction (%) (95% CI) (n=6259) (n=6303) Primary outcome (Cardiovascular death, MI, stroke) 582 (9.3%) 719 (11.4%) 20% (10.3, 27.9) p < 0.001 All Individual Outcome Events: The individual components do not represent a breakdown of the primary and co-primary outcomes, but rather the total number of subjects experiencing an event during the course of the study.
CV death 318 (5.1%) 345 (5.5%) 7% (-7.7, 20.6) MI 324 (5.2%) 419 (6.6%) 23% (11.0, 33.4) Stroke 75 (1.2%) 87 (1.4%) 14% (-17.7, 36.6) Most of the benefit of Plavix occurred in the first two months, but the difference from placebo was maintained throughout the course of the trial (up to 12 months) (see Figure 1 ).
Figure 1: Cardiovascular Death, Myocardial Infarction, and Stroke in the CURE Study In CURE, the use of Plavix was associated with a lower incidence of CV death, MI or stroke in patient populations with different characteristics, as shown in Figure 2.
The benefits associated with Plavix were independent of the use of other acute and long-term cardiovascular therapies, including heparin/LMWH, intravenous glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors, lipid-lowering drugs, beta-blockers, and ACE-inhibitors.
The efficacy of Plavix was observed independently of the dose of aspirin (75–325 mg once daily).
The use of oral anticoagulants, non-study anti-platelet drugs, and chronic NSAIDs was not allowed in CURE.
Figure 2: Hazard Ratio for Patient Baseline Characteristics and On-Study Concomitant Medications/Interventions for the CURE Study The use of Plavix in CURE was associated with a decrease in the use of thrombolytic therapy (71 patients [1.1%] in the Plavix group, 126 patients [2.0%] in the placebo group; relative risk reduction of 43%), and GPIIb/IIIa inhibitors (369 patients [5.9%] in the Plavix group, 454 patients [7.2%] in the placebo group, relative risk reduction of 18%).
The use of Plavix in CURE did not affect the number of patients treated with CABG or PCI (with or without stenting), (2253 patients [36.0%] in the Plavix group, 2324 patients [36.9%] in the placebo group; relative risk reduction of 4.0%).
COMMIT In patients with STEMI, the safety and efficacy of Plavix were evaluated in the randomized, placebo-controlled, double-blind study, COMMIT.
COMMIT included 45,852 patients presenting within 24 hours of the onset of the symptoms of myocardial infarction with supporting ECG abnormalities ( i.e.
, ST-elevation, ST-depression or left bundle-branch block).
Patients were randomized to receive Plavix (75 mg once daily) or placebo, in combination with aspirin (162 mg per day), for 28 days or until hospital discharge, whichever came first.
The primary endpoints were death from any cause and the first occurrence of re-infarction, stroke or death.
The patient population included 28% women, 58% age ≥ 60 years (26% age ≥ 70 years), 55% patients who received thrombolytics, 68% who received ACE-inhibitors, and only 3% who underwent PCI.
As shown in Table 5 and Figures 3 and 4 below, Plavix significantly reduced the relative risk of death from any cause by 7% (p=0.029), and the relative risk of the combination of re-infarction, stroke or death by 9% (p=0.002).
Table 5: Outcome Events in the COMMIT Analysis Event Plavix (+ aspirin) (N=22961) Placebo (+ aspirin) (N=22891) Odds ratio (95% CI) p-value Composite endpoint: Death, MI, or Stroke The difference between the composite endpoint and the sum of death+non-fatal MI+non-fatal stroke indicates that 9 patients (2 clopidogrel and 7 placebo) suffered both a non-fatal stroke and a non-fatal MI.
2121 (9.2%) 2310 (10.1%) 0.91 (0.86, 0.97) 0.002 Death 1726 (7.5%) 1845 (8.1%) 0.93 (0.87, 0.99) 0.029 Non-fatal MI Non-fatal MI and non-fatal stroke exclude patients who died (of any cause).
270 (1.2%) 330 (1.4%) 0.81 (0.69, 0.95) 0.011 Non-fatal Stroke 127 (0.6%) 142 (0.6%) 0.89 (0.70, 1.13) 0.33 Figure 3: Cumulative Event Rates for Death in the COMMIT Study All treated patients received aspirin.
Figure 4: Cumulative Event Rates for the Combined End point Re-Infarction, Stroke or Death in the COMMIT Study All treated patients received aspirin.
The effect of Plavix did not differ significantly in various pre-specified subgroups as shown in Figure 5.
The effect was also similar in non-prespecified subgroups including those based on infarct location, Killip class or prior MI history (see Figure 6).
Such subgroup analyses should be interpreted cautiously.
Figure 5: Effects of Adding Plavix to Aspirin on the Combined Primary Endpoint across Baseline and Concomitant Medication Subgroups for the COMMIT Study * Three similar-sized prognostic index groups were based on absolute risk of primary composite outcome for each patient calculated from baseline prognostic variables (excluding allocated treatments) with a Cox regression model.
Figure 6: Effects of Adding Plavix to Aspirin in the Non-Prespecified Subgroups in the COMMIT Study 14.2 Recent Myocardial Infarction, Recent Stroke, or Established Peripheral Arterial Disease CAPRIE The CAPRIE trial was a 19,185-patient, 304-center, international, randomized, double-blind, parallel-group study comparing Plavix (75 mg daily) to aspirin (325 mg daily).
The patients randomized had: 1) recent histories of myocardial infarction (within 35 days); 2) recent histories of ischemic stroke (within 6 months) with at least a week of residual neurological signs; or 3) established peripheral arterial disease.
Patients received randomized treatment for an average of 1.6 years (maximum of 3 years).
The trial’s primary outcome was the time to first occurrence of new ischemic stroke (fatal or not), new myocardial infarction (fatal or not), or other vascular death.
Deaths not easily attributable to nonvascular causes were all classified as vascular.
Table 6: Outcome Events in the CAPRIE Primary Analysis Plavix aspirin Patients n=9599 n=9586 Ischemic stroke (fatal or not) 438 (4.6%) 461 (4.8%) MI (fatal or not) 275 (2.9%) 333 (3.5%) Other vascular death 226 (2.4%) 226 (2.4%) Total 939 (9.8%) 1020 (10.6%) As shown in the table, Plavix was associated with a lower incidence of outcome events, primarily MI.
The overall relative risk reduction (9.8% vs.
10.6%) was 8.7%, p=0.045.
Similar results were obtained when all-cause mortality and all-cause strokes were counted instead of vascular mortality and ischemic strokes (risk reduction 6.9%).
In patients who survived an on-study stroke or myocardial infarction, the incidence of subsequent events was lower in the Plavix group.
The curves showing the overall event rate are shown in Figure 7.
The event curves separated early and continued to diverge over the 3-year follow-up period.
Figure 7: Fatal or Non-Fatal Vascular Events in the CAPRIE Study The statistical significance favoring Plavix over aspirin was marginal (p=0.045).
However, because aspirin is itself effective in reducing cardiovascular events in patients with recent myocardial infarction or stroke, the effect of Plavix is substantial.
The CAPRIE trial included a population that was randomized on the basis of 3 entry criteria.
The efficacy of Plavix relative to aspirin was heterogeneous across these randomized subgroups (p=0.043).
It is not clear whether this difference is real or a chance occurrence.
Although the CAPRIE trial was not designed to evaluate the relative benefit of Plavix over aspirin in the individual patient subgroups, the benefit appeared to be strongest in patients who were enrolled because of peripheral vascular disease (especially those who also had a history of myocardial infarction) and weaker in stroke patients.
In patients who were enrolled in the trial on the sole basis of a recent myocardial infarction, Plavix was not numerically superior to aspirin.
14.3 Lack of Established Benefit of Plavix plus Aspirin in Patients with Multiple Risk Factors or Established Vascular Disease CHARISMA The CHARISMA trial was a 15,603 subject, randomized, double-blind, parallel group study comparing Plavix (75 mg daily) to placebo for prevention of ischemic events in patients with vascular disease or multiple risk factors for atherosclerosis.
All subjects were treated with aspirin 75–162 mg daily.
The mean duration of treatment was 23 months.
The study failed to demonstrate a reduction in the occurrence of the primary endpoint, a composite of CV death, MI, or stroke.
A total of 534 (6.9%) patients in the Plavix group versus 573 (7.4%) patients in the placebo group experienced a primary outcome event (p=0.22).
Bleeding of all severities was more common in the subjects randomized to Plavix.
Figure Figure Figure Figure Figure Figure Figure
HOW SUPPLIED
16 /STORAGE AND HANDLING Plavix (clopidogrel bisulfate) 75 mg tablets are available as pink, round, biconvex, film-coated tablets debossed with “75” on one side and “1171” on the other.
Tablets are provided as follows: NDC 67046-604-30 Blisters of 30 Store at 25° C (77° F); excursions permitted to 15°–30° C (59°–86° F) [see USP Controlled Room Temperature].
RECENT MAJOR CHANGES
Boxed Warning 03/2010 Dosage and Administration ( 2.3 ) 03/2010 Warnings and Precautions ( 5.1 , 5.2 , 5.3 ) 03/2010
GERIATRIC USE
8.5 Geriatric Use Of the total number of subjects in the CAPRIE and CURE controlled clinical studies, approximately 50% of patients treated with Plavix were 65 years of age and older, and 15% were 75 years and older.
In COMMIT, approximately 58% of the patients treated with Plavix were 60 years and older, 26% of whom were 70 years and older.
The observed risk of thrombotic events with clopidogrel plus aspirin versus placebo plus aspirin by age category is provided in Figures 2 and 5 for the CURE and COMMIT trials, respectively [see Clinical Studies (14.1) ] .
The observed risk of bleeding events with clopidogrel plus aspirin versus placebo plus aspirin by age category is provided in Tables 1 and 2 for the CURE and COMMIT trials, respectively [see Adverse Reactions (6.1) ] .
No dosage adjustment is necessary in elderly patients.
DOSAGE FORMS AND STRENGTHS
3 75 mg tablets: Pink, round, biconvex, film-coated tablets debossed with “75” on one side and “1171” on the other 300 mg tablets: Pink, oblong, film-coated tablets debossed with “300” on one side and “1332” on the other Tablets: 75 mg, 300 mg ( 3 )
MECHANISM OF ACTION
12.1 Mechanism of Action Clopidogrel is an inhibitor of platelet activation and aggregation through the irreversible binding of its active metabolite to the P2Y 12 class of ADP receptors on platelets.
INDICATIONS AND USAGE
1 Plavix is a P2Y 12 platelet inhibitor indicated for: Acute coronary syndrome Recent myocardial infarction (MI), recent stroke, or established peripheral arterial disease.
Plavix has been shown to reduce the combined endpoint of new ischemic stroke (fatal or not), new MI (fatal or not), and other vascular death.
( 1.2 ) 1.1 Acute Coronary Syndrome (ACS) For patients with non-ST-segment elevation ACS [unstable angina (UA)/non-ST-elevation myocardial infarction (NSTEMI)], including patients who are to be managed medically and those who are to be managed with coronary revascularization, Plavix has been shown to decrease the rate of a combined endpoint of cardiovascular death, myocardial infarction (MI), or stroke as well as the rate of a combined endpoint of cardiovascular death, MI, stroke, or refractory ischemia.
For patients with ST-elevation myocardial infarction (STEMI), Plavix has been shown to reduce the rate of death from any cause and the rate of a combined endpoint of death, re-infarction, or stroke.
The benefit for patients who undergo primary percutaneous coronary intervention is unknown.
The optimal duration of Plavix therapy in ACS is unknown.
1.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease For patients with a history of recent myocardial infarction (MI), recent stroke, or established peripheral arterial disease, Plavix has been shown to reduce the rate of a combined endpoint of new ischemic stroke (fatal or not), new MI (fatal or not), and other vascular death.
PEDIATRIC USE
8.4 Pediatric Use Safety and effectiveness in the pediatric population have not been established.
PREGNANCY
8.1 Pregnancy Pregnancy Category B Reproduction studies performed in rats and rabbits at doses up to 500 and 300 mg/kg/day, respectively (65 and 78 times the recommended daily human dose, respectively, on a mg/m 2 basis), revealed no evidence of impaired fertility or fetotoxicity due to clopidogrel.
There are, however, no adequate and well-controlled studies in pregnant women.
Because animal reproduction studies are not always predictive of a human response, Plavix should be used during pregnancy only if clearly needed.
NUSRING MOTHERS
8.3 Nursing Mothers Studies in rats have shown that clopidogrel and/or its metabolites are excreted in the milk.
It is not known whether this drug is excreted in human milk.
Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from clopidogrel, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.
BOXED WARNING
WARNING: DIMINISHED EFFECTIVENESS IN POOR METABOLIZERS The effectiveness of Plavix is dependent on its activation to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19 [see Warnings and Precautions (5.1) ] .
Plavix at recommended doses forms less of that metabolite and has a smaller effect on platelet function in patients who are CYP2C19 poor metabolizers.
Poor metabolizers with acute coronary syndrome or undergoing percutaneous coronary intervention treated with Plavix at recommended doses exhibit higher cardiovascular event rates than do patients with normal CYP2C19 function.
Tests are available to identify a patient’s CYP2C19 genotype; these tests can be used as an aid in determining therapeutic strategy [see Clinical Pharmacology (12.5) ] .
Consider alternative treatment or treatment strategies in patients identified as CYP2C19 poor metabolizers [see Dosage and Administration (2.3) ] .
WARNING: DIMINISHED EFFECTIVENESS IN POOR METABOLIZERS See full prescribing information for complete boxed warning.
Effectiveness of Plavix depends on activation to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19.
( 5.1 ) Poor metabolizers treated with Plavix at recommended doses exhibit higher cardiovascular event rates following acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) than patients with normal CYP2C19 function.
( 12.5 ) Tests are available to identify a patient’s CYP2C19 genotype and can be used as an aid in determining therapeutic strategy.
( 12.5 ) Consider alternative treatment or treatment strategies in patients identified as CYP2C19 poor metabolizers.
( 2.3 , 5.1 )
WARNING AND CAUTIONS
5 WARNINGS AND PRECAUTIONS Reduced effectiveness in impaired CYP2C19 function: Avoid concomitant use with drugs that inhibit CYP2C19 (e.g., omeprazole).
( 5.1 ) Bleeding: Plavix increases risk of bleeding.
Discontinue 5 days prior to elective surgery.
( 5.2 ) Discontinuation of Plavix: Premature discontinuation increases risk of cardiovascular events.
( 5.3 ) Recent transient ischemic attack or stroke: Combination use of Plavix and aspirin in these patients was not shown to be more effective than Plavix alone, but was shown to increase major bleeding.
( 5.4 ) Thrombotic thrombocytopenic purpura (TTP): TTP has been reported with Plavix, including fatal cases.
( 5.5 ) 5.1 Diminished Antiplatelet Activity Due to Impaired CYP2C19 Function Clopidogrel is a prodrug.
Inhibition of platelet aggregation by clopidogrel is entirely due to an active metabolite.
The metabolism of clopidogrel to its active metabolite can be impaired by genetic variations in CYP2C19 [see Boxed Warning] and by concomitant medications that interfere with CYP2C19.
Avoid concomitant use of Plavix and drugs that inhibit CYP2C19 activity.
Co-administration of Plavix with omeprazole, a proton pump inhibitor that is an inhibitor of CYP2C19, reduces the pharmacological activity of Plavix if given concomitantly or if given 12 hours apart [see Drug Interactions (7.1) ] .
5.2 General Risk of Bleeding Thienopyridines, including Plavix, increase the risk of bleeding.
If a patient is to undergo surgery and an antiplatelet effect is not desired, discontinue Plavix 5 days prior to surgery.
In patients who stopped therapy more than five days prior to CABG the rates of major bleeding were similar (event rate 4.4% Plavix + aspirin; 5.3% placebo + aspirin).
In patients who remained on therapy within five days of CABG, the major bleeding rate was 9.6% for Plavix + aspirin, and 6.3% for placebo + aspirin.
Thienopyridines inhibit platelet aggregation for the lifetime of the platelet (7–10 days), so withholding a dose will not be useful in managing a bleeding event or the risk of bleeding associated with an invasive procedure.
Because the half-life of clopidogrel’s active metabolite is short, it may be possible to restore hemostasis by administering exogenous platelets; however, platelet transfusions within 4 hours of the loading dose or 2 hours of the maintenance dose may be less effective.
5.3 Discontinuation of Plavix Avoid lapses in therapy, and if Plavix must be temporarily discontinued, restart as soon as possible.
Premature discontinuation of Plavix may increase the risk of cardiovascular events.
5.4 Patients with Recent Transient Ischemic Attack (TIA) or Stroke In patients with recent TIA or stroke who are at high risk for recurrent ischemic events, the combination of aspirin and Plavix has not been shown to be more effective than Plavix alone, but the combination has been shown to increase major bleeding.
5.5 Thrombotic Thrombocytopenic Purpura (TTP) TTP, sometimes fatal, has been reported following use of Plavix, sometimes after a short exposure (<2 weeks).
TTP is a serious condition that requires urgent treatment including plasmapheresis (plasma exchange).
It is characterized by thrombocytopenia, microangiopathic hemolytic anemia (schistocytes [fragmented RBCs] seen on peripheral smear), neurological findings, renal dysfunction, and fever [see Adverse Reactions (6.2) ] .
INFORMATION FOR PATIENTS
17 PATIENT COUNSELING INFORMATION 17.1 Benefits and Risks Summarize the effectiveness features and potential side effects of Plavix.
Tell patients to take Plavix exactly as prescribed.
Remind patients not to discontinue Plavix without first discussing it with the physician who prescribed Plavix.
17.2 Bleeding Inform patients that they: will bruise and bleed more easily.
will take longer than usual to stop bleeding.
should report any unanticipated, prolonged, or excessive bleeding, or blood in their stool or urine.
17.3 Other Signs and Symptoms Requiring Medical Attention Inform patients that TTP is a rare but serious condition that has been reported with Plavix and other drugs in this class of drugs.
Instruct patients to get prompt medical attention if they experience any of the following symptoms that cannot otherwise be explained: fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin or eyes, or neurological changes.
17.4 Invasive Procedures Instruct patients to: inform physicians and dentists that they are taking Plavix before any invasive procedure is scheduled.
tell the doctor performing the invasive procedure to talk to the prescribing health care professional before stopping Plavix.
17.5 Concomitant Medications Ask patients to list all prescription medications, over-the-counter medications, or dietary supplements they are taking or plan to take, including prescription or over-the-counter omeprazole, so the physician knows about other treatments that may affect how Plavix works ( e.g.
, warfarin and NSAIDs) [see Warnings and Precautions (5) ] .
DOSAGE AND ADMINISTRATION
2 Acute coronary syndrome ( 2.1 ) Recent MI, recent stroke, or established peripheral arterial disease: 75 mg once daily ( 2.2 ) 2.1 Acute Coronary Syndrome Plavix can be administered with or without food [see Clinical Pharmacology (12.3) ] For patients with non-ST-elevation ACS (UA/NSTEMI), initiate Plavix with a single 300 mg oral loading dose and then continue at 75 mg once daily.
Initiate aspirin (75–325 mg once daily) and continue in combination with Plavix [see Clinical Studies (14.1) ] .
For patients with STEMI, the recommended dose of Plavix is 75 mg once daily orally, administered in combination with aspirin (75–325 mg once daily), with or without thrombolytics.
Plavix may be initiated with or without a loading dose [see Clinical Studies (14.1) ] .
2.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease The recommended daily dose of Plavix is 75 mg once daily orally, with or without food [see Clinical Pharmacology (12.3) ] .
2.3 CYP2C19 Poor Metabolizers CYP2C19 poor metabolizer status is associated with diminished antiplatelet response to clopidogrel.
Although a higher dose regimen (600 mg loading dose followed by 150 mg once daily) in poor metabolizers increases antiplatelet response [see Clinical Pharmacology (12.5) ] , an appropriate dose regimen for this patient population has not been established in clinical outcome trials.