Stroke Prevention (Plavix + Aggrenox)

[BustyPharmD]

I had a patient come into the pharmacy and ask me about taking Plavix and Aggrenox together. I was unsure if the patient should take both at the same time. So I recommended that the patient take one or the other due to increase risk of bleeding. And then to follow up with the MD. Here's what I know, that they are both used as antiplatelet therapy. Also, Aggrenox has aspirin in it. I was unsure if the patient should take both together. I believe the MD changed Aggrenox to Plavix but didn't communicate that to the patient. I also think the Aggrenox was not covered under the patients plan and Plavix was.

So my question is....

Can Plavix and Aggrenox be used together at the same time?
If so...what's the major advantage? (better stoke prevention?)
What's the major side effect? (increase bleeding?)

Any insight would be greatly appreciated Thanks!

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[Quiksilver]

Yes you absoluteley can take these drugs together. You can take ASA and clopidogrel together all the time, its part of many regimens for patients suffering an MI or CVA.

There is an increased risk of bleeding but it comes with better protection. Someone who has had a series of strokes or TIAs might be good candidates because they likely failed on single agent therapy. So whenever you might have a secondary event, adding an agent might be the key. However usually Plavix is the workhorse and Aggrenox is usually added as a secondary agent.

 

[lactonerx]

It would be inappropriate to be on both therapies for secondary stroke prevention... except possibly in a pt with recent MI.

PRoFESS: Aggrenox = Plavix with respect to stroke prevention, but Plavix was better tolerated

MATCH: Plavix + ASA is no better than ASA monotherapy except in patients with recent MI; increased risk of fatal bleeding with combo therapy

CHARISMA: similar findings as MATCH; no benefit and more risk to combo therapy

AHA 2008 stroke prevention guidelines:

"New recommendation: Aspirin (50 to 325 mg/d) monotherapy, the combination of aspirin and extended-release dipyridamole, and clopidogrel monotherapy
are all acceptable options for initial therapy (Class I, Level of Evidence A)"

"The addition of aspirin to clopidogrel increases the risk of hemorrhage. Combination therapy of aspirin and clopidogrel is not routinely recommended for ischemic
stroke or TIA patients unless they have a specific indication for this therapy (ie, coronary stent or acute coronary syndrome) (Class III, Level of Evidence A)." [emphasis added]

http://stroke.ahajournals.org/content/39/5/1647.full.pdf

 

[PharmDstudent]

We were taught, for stroke (not hemorrhagic stroke) prevention, aspirin = plavix < aspirin + plavix. In other words, aspirin + plavix was first line therapy.

 

[bacillus1]

According to recent clinical trials, if the patient is just taking the drugs for secondary stroke prevention, there is no need for both Plavix and Aggrenox.

 

[All4MyDaughter]

Yes, they can be used together. But the important issue here for me is why was a student handling this (apparently) without the knowledge he or she needed to make the recommendation? I would not want one of my students to tell a patient to "take one or the other" if the student didn't know the answer to the questions you've posed. Where was your pharmacist?

Before telling a patient to stop a medication (outside of something that is a clear cut emergency like an allergy, severe intolerance, etc) my expectation is that students will consult (at minimum) with the pharmacist/preceptor. There are times when it would also be appropriate to consult with the prescribing MD(s) before advising the patient.

OP, I hope your pharmacists/preceptors are actually teaching you and giving you guidance, not just throwing you out there to figure things out on your own.

 

[psychoandy]

wait, hold the phone. ASA and clopidogrel is very established for dual antiplatelet therapy, and ASA OR aggrenox OR plavix are acceptable for secondary prevention of stroke.

But how is Aggrenox AND Plavix together ok to use? why would you use 2 expensive agents when you could just use one on it's own or combine with cheap ASA? wouldn't the bleeding risk be higher compared to a single agent (technically this is triple antiplatelet therapy)?

 

[Carboxide]

Whoa whoa whoa. No! You NEVER use those two together for post-stroke. In fact, you wouldn't even use clopidogrel+ASA together post-stroke. That's reserved only for post-ACS.

 

[spacecowgirl]

Yes, they can be used together. But the important issue here for me is why was a student handling this (apparently) without the knowledge he or she needed to make the recommendation? I would not want one of my students to tell a patient to "take one or the other" if the student didn't know the answer to the questions you've posed. Where was your pharmacist?

Before telling a patient to stop a medication (outside of something that is a clear cut emergency like an allergy, severe intolerance, etc) my expectation is that students will consult (at minimum) with the pharmacist/preceptor. There are times when it would also be appropriate to consult with the prescribing MD(s) before advising the patient.

OP, I hope your pharmacists/preceptors are actually teaching you and giving you guidance, not just throwing you out there to figure things out on your own.

This is what I want to know. It doesn't even sound like the OP knows the indication. Even as a pharmacist (not a student) I cannot think of a situation where I would tell someone to change therapy (except like A4MD says, an allergic rxn), especially without access to their records. You tell them to consult the prescriber!

 

[BustyPharmD]

Thanks everyone for your perspectives!