clopidogrel by is a Prescription medication manufactured, distributed, or labeled by Viona Pharmaceuticals Inc, Zydus Lifesciences Limited. Drug facts, warnings, and ingredients follow.
Clopidogrel tablet is a P2Y12 platelet inhibitor indicated for:
- For patients with non-ST-segment elevation ACS (unstable angina [UA]/non- ST-elevation myocardial infarction [NSTEMI]), Plavix has been shown to reduce the rate of myocardial infarction (MI) and stroke. (1.1)
- For patients with ST-elevation myocardial infarction (STEMI), Plavix has been shown to reduce the rate of MI and stroke. (1.1)
- Initiate clopidogrel with a single 300 mg oral loading dose and then continue at 75 mg once daily
-Initiating clopidogrel without a loading dose will delay establishment of an antiplatelet effect by several days
Tablets: 75 mg (3)
Bleeding, including life-threatening and fatal bleeding, is the most commonly reported adverse reaction. (6.1)
To report SUSPECTED ADVERSE REACTIONS, contact Viona Pharmaceuticals Inc. at 1-888-304-5011, or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
See 17 for PATIENT COUNSELING INFORMATION and Medication Guide.
TWO LOSS-OF-FUNCTION ALLELES OF THE CYP2C19 GENE
The effectiveness of clopidogrel results from its antiplatelet activity, which is dependent on its conversion to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19 [see Warnings and Precautions (5.1), Clinical Pharmacology (12.3)]. Clopidogrel at recommended doses forms less of the active metabolite and so has a reduced effect on platelet activity in patients who are homozygous for nonfunctional alleles of the CYP2C19 gene, (termed "CYP2C19 poor metabolizers"). Tests are available to identify patients who are CYP2C19 poor metabolizers [see Clinical Pharmacology (12.5)]. Consider use of another platelet P2Y12 inhibitor in patients identified as CYP2C19 poor metabolizers.
In patients who need an antiplatelet effect within hours, initiate clopidogrel tablets with a single 300 mg oral loading dose and then continue at 75 mg once daily. Initiating clopidogrel tablets without a loading dose will delay establishment of an antiplatelet effect by several days [see Clinical Pharmacology (12.3) and Clinical Studies (14.1)].
Clopidogrel bisulfate is contraindicated in patients with hypersensitivity (e.g., anaphylaxis) to clopidogrel or any component of the product [see Adverse Reactions (6.2)].
Clopidogrel is a prodrug. Inhibition of platelet aggregation by clopidogrel is achieved through an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by genetic variations in CYP2C19 [see Boxed Warning].
The metabolism of clopidogrel can also be impaired by drugs that inhibit CYP2C19, such as omeprazole or esomeprazole. Avoid concomitant use of clopidogrel with omeprazole or esomeprazole because both significantly reduce the antiplatelet activity of clopidogrel [see Drug Interactions (7.1)].
Thienopyridines inhibit platelet aggregation for the lifetime of the platelet (7 days to 10 days). 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.
Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.
TTP, sometimes fatal, has been reported following use of clopidogrel, 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)].
Hypersensitivity including rash, angioedema or hematologic reaction has been reported in patients receiving clopidogrel, including patients with a history of hypersensitivity or hematologic reaction to other thienopyridines [see Contraindications (4.2) and Adverse Reactions (6.2)].
Because clinical trials are conducted under widely varying conditions and durations of follow up, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Clopidogrel has been evaluated for safety in more than 54,000 patients, including over 21,000 patients treated for one year or more. The clinically important adverse reactions observed in trials comparing clopidogrel plus aspirin to placebo plus aspirin and trials comparing clopidogrel tablets alone to aspirin alone are discussed below.
In CURE, clopidogrel use with aspirin was associated with an increase in major bleeding (primarily gastrointestinal and at puncture sites) compared to placebo with aspirin (see Table 1). The incidence of intracranial hemorrhage (0.1%) and fatal bleeding (0.2%) were the same in both groups. Other bleeding events that were reported more frequently in the clopidogrel group were epistaxis, hematuria, and bruise.
The overall incidence of bleeding is described in Table 1.
*Life-threatening and other major bleeding.
†Led to interruption of study medication.
| Major bleeding*
|| 3.7 || 2.7
| Life-threatening bleeding|| 2.2|| 1.8
| Fatal|| 0.2|| 0.2
| 5 g/dL hemoglobin drop|| 0.9|| 0.9
| Requiring surgical intervention|| 0.7|| 0.7
| Hemorrhagic strokes|| 0.1|| 0.1
| Requiring inotropes|| 0.5|| 0.5
| Requiring transfusion (≥ 4 units)|| 1.2|| 1.0
| Other major bleeding|| 1.6|| 1.0
| Significantly disabling|| 0.4|| 0.3
| Intraocular bleeding with|
significant loss of vision
| 0.05|| 0.03
| Requiring 2-3 units of blood|| 1.3|| 0.9
| Minor bleeding†
|| 5.1|| 2.4
In COMMIT, similar rates of major bleeding were observed in the clopidogrel tablets and placebo groups, both of which also received aspirin (see Table 2).
* Major bleeds were cerebral bleeds or noncerebral bleeds thought to have caused death or that required transfusion.
| Type of Bleeding
|| Clopidogrel Tablets
(+ aspirin) (n=22,961)
(+ aspirin) (n=22,891)
| Major* noncerebral or cerebral bleeding|
| 0.6 |
| 0.5 |
| Other noncerebral bleeding (nonmajor) || 3.6|| 3.1|| 0.005
| Any noncerebral bleeding || 3.9|| 3.4|| 0.004
In CAPRIE, gastrointestinal hemorrhage occurred at a rate of 2% in those taking clopidogrel versus 2.7% in those taking aspirin; bleeding requiring hospitalization occurred in 0.7% and 1.1%, respectively. The incidence of intracranial hemorrhage was 0.4% for clopidogrel tablets compared to 0.5% for aspirin.
Other bleeding events that were reported more frequently in the clopidogrel group were epistaxis and hematoma.
Other Adverse Events
In CURE and CHARISMA, which compared clopidogrel plus aspirin to aspirin alone, there was no difference in the rate of adverse events (other than bleeding) between clopidogrel tablets and placebo.
In CAPRIE, which compared clopidogrel to aspirin, pruritus was more frequently reported in those taking clopidogrel tablets. No other difference in the rate of adverse events (other than bleeding) was reported.
The following adverse reactions have been identified during postapproval use of clopidogrel. Because these reactions are reported voluntarily from a population of an unknown size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Hemorrhages, including those with fatal outcome, have been reported in patients
treated with clopidogrel.
Maculopapular, erythematous or exfoliative rash, urticaria, bullous dermatitis, eczema, toxic epidermal necrolysis, Stevens-Johnson syndrome, acute generalized exanthematous pustulosis (AGEP), angioedema, drug induced hypersensitivity syndrome, drug rash with eosinophilia and systemic symptoms (DRESS), erythema multiforme, lichen planus,
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. [see Warnings and Precautions (5.1)]
Omeprazole or Esomeprazole
Avoid concomitant use of clopidogrel with omeprazole or esomeprazole. In clinical studies, omeprazole was shown to reduce significantly the antiplatelet activity of clopidogrel when given concomitantly or 12 hours apart. A similar reduction in antiplatelet activity was observed with esomeprazole when given concomitantly with clopidogrel. Dexlansoprazole, lansoprazole, and pantoprazole had less effect on the antiplatelet activity of clopidogrel than did omeprazole or esomeprazole [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)].
As with other oral P2Y12 inhibitors, coadministration of opioid agonists delay and reduce the absorption of clopidogrel, presumably because of slowed gastric emptying, resulting in reduced exposure to its metabolites [see Clinical Pharmacology (12.3)]. Consider the use of a parenteral antiplatelet agent in acute coronary syndrome patients requiring coadministration of morphine or other opioid agonists.
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 clopidogrel tablets with warfarin increases the risk of bleeding because of independent effects on hemostasis.
However, at high concentrations in vitro, clopidogrel inhibits CYP2C9.
Since selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) affect platelet activation, the concomitant administration of SSRIs and SNRIs with clopidogrel may increase the risk of bleeding.
The acyl-β-glucuronide metabolite of clopidogrel is a strong inhibitor of CYP2C8. Plavix can increase the systemic exposure to drugs that are primarily cleared by CYP2C8, thereby needing dose-adjustment and appropriate monitoring.
Clopidogrel increased repaglinide exposures by 3.9-fold to 5.1-fold [see Clinical Pharmacology (12.3)]. Avoid concomitant use of repaglinide with Plavix. If concomitant use cannot be avoided, initiate repaglinide at 0.5 mg before each meal and do not exceed a total daily dose of 4 mg. Increased frequency of glucose monitoring may be required during concomitant use.
Available data from cases reported in published literature and postmarketing surveillance with clopidogrel use in pregnant women have not identified any drug-associated risks for major birth defects or miscarriage [see Data].There are risks to the pregnant woman and fetus associated with myocardial infarction and stroke [see Clinical Considerations]. No evidence of fetotoxicity was observed when clopidogrel was administered to pregnant rats and rabbits during organogenesis at doses corresponding to 65 and 78 times the recommended daily human dose [see Data].
The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. All pregnancies have a background risk of birth defects, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
Disease-associated maternal and/or embryo/fetal risk Myocardial infarction and stroke are medical emergencies. Therapy for the pregnant woman should not be withheld because of potential concerns regarding the effects of clopidogrel on the fetus.
Labor or delivery
Clopidogrel use during labor or delivery will increase the risk of maternal bleeding and hemorrhage. Avoid neuraxial blockade during clopidogrel use because of the risk of spinal hematoma. When possible, discontinue clopidogrel 5 to 7 days prior to labor, delivery, or neuraxial blockade.
The available data from published case reports over two decades of postmarketing use have not identified an association with clopidogrel use in pregnancy and major birth defects, miscarriage, or adverse fetal outcomes.
Embryo-fetal developmental toxicology studies were performed in pregnant rats and rabbits with doses up to 500 and 300 mg/kg/day, respectively, administered during organogenesis. These doses, corresponding to 65 and 78 times the recommended daily human dose, respectively, on a mg/m2 basis, revealed no evidence of impaired fertility or fetotoxicity due to clopidogrel.
There are no data on the presence of clopidogrel in human milk or the effects on milk production. No adverse effects on breastfed infants have been observed with maternal clopidogrel use during lactation in a small number of postmarketing cases. Studies in rats have shown that clopidogrel and/or its metabolites are present in the milk. When a drug is present in animal milk, it is likely that the drug will be present in human milk. The developmental and health benefits of breastfeeding should be considered along with mother's clinical need for clopidogrel and any potential adverse effects on the breastfed infant from clopidogrel or from underlying maternal condition.
A randomized, placebo-controlled trial (CLARINET) did not demonstrate a clinical benefit of clopidogrel in neonates and infants with cyanotic congenital heart disease palliated with a systemic-to-pulmonary arterial shunt. Possible factors contributing to this outcome were the dose of clopidogrel, the concomitant administration of aspirin and the late initiation of therapy following shunt palliation. It cannot be ruled out that a trial with a different design would demonstrate a clinical benefit in this patient population.
Of the total number of subjects in the CAPRIE and CURE controlled clinical studies, approximately 50% of patients treated with clopidogrel tablets were 65 years of age and older, and 15% were 75 years and older. In COMMIT, approximately 58% of the patients treated with clopidogrel tablets were 60 years and older, 26% of whom were 70 years and older.
The observed risk of bleeding events with clopidogrel plus aspirin versus placebo plus aspirin by age category is provided in Table 1 and Table 2 for the CURE and COMMIT trials, respectively [see Adverse Reactions (6.1)]. No dosage adjustment is necessary in elderly patients.
Experience is limited in patients with severe and moderate renal impairment [see Clinical Pharmacology (12.2)].
No dosage adjustment is necessary in patients with hepatic impairment [see Clinical Pharmacology (12.2)].
Platelet inhibition by clopidogrel 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 1,500 or 2,000 mg/kg was lethal to mice and to rats and at 3,000 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.
Clopidogrel bisulfate is a thienopyridine class inhibitor of P2Y12 ADP platelet receptors. Chemically it is methyl (+)-(S)-α-(2-chlorophenyl)-6,7-dihydrothieno[3,2-c]pyridine-5(4H)acetate sulfate (1:1). The molecular formula of clopidogrel bisulfate is C16H16ClNO2SH2SO4 and its molecular weight is 419.9.
The structural formula is as follows:
Clopidogrel bisulfate, USP 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°.
Each clopidogrel tablet intended for oral administration is provided as pink-colored, biconvex, round-shaped, film-coated tablets contains 97.830 mg of clopidogrel bisulfate, which is molar equivalent to 75 mg of clopidogrel base. In addition, each tablet contains the following inactive ingredients: citric acid, colloidal silicon dioxide, corn starch, crospovidone, hydrogenated castor oil, hydroxypropyl cellulose, hypromellose, iron oxide black, iron oxide red, iron oxide yellow, lactose anhydrous, lactose monohydrate, magnesium stearate, polyethylene glycol and titanium dioxide.
Clopidogrel must be metabolized by CYP450 enzymes to produce the active metabolite that inhibits platelet aggregation. The active metabolite of clopidogrel selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet P2Y12 receptor and the subsequent ADP-mediated activation of the glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation. This action is irreversible. Consequently, platelets exposed to clopidogrel’s active metabolite are affected for the remainder of their lifespan (about 7 to 10 days). Platelet aggregation induced by agonists other than ADP is also inhibited by blocking the amplification of platelet activation by released ADP.
Dose-dependent inhibition of platelet aggregation can be seen 2 hours after single oral doses of clopidogrel tablets. Repeated doses of 75 mg clopidogrel bisulfate per day inhibit ADP-induced platelet aggregation on the first day, and inhibition reaches steady state between Day 3 and Day 7. At steady state, the average inhibition level observed with a dose of 75 mg clopidogrel bisulfate per day was between 40% and 60%. Platelet aggregation and bleeding time gradually return to baseline values after treatment is discontinued, generally in about 5 days.
Elderly ( ≥ 75 years) and young healthy subjects had similar effects on platelet aggregation.
After repeated doses of 75 mg clopidogrel bisulfate per day, patients with severe renal impairment (creatinine clearance from 5 to 15 mL/min) and moderate renal impairment (creatinine clearance from 30 to 60 mL/min) showed low (25%) inhibition of ADP-induced platelet aggregation.
After repeated doses of 75 mg clopidogrel bisulfate per day for 10 days in patients with severe hepatic impairment, inhibition of ADP-induced platelet aggregation was similar to that observed in healthy subjects.
In a small study comparing men and women, less inhibition of ADP-induced platelet aggregation was observed in women.
After single and repeated oral doses of 75 mg per day, clopidogrel is rapidly absorbed. Absorption is at least 50%, based on urinary excretion of clopidogrel metabolites.
Effect of food
Clopidogrel tablets can be administered with or without food. In a study in healthy male subjects when clopidogrel tablets 75 mg per day was given with a standard breakfast, mean inhibition of ADP-induced platelet aggregation was reduced by less than 9%. The active metabolite AUC0-24 was unchanged in the presence of food, while there was a 57% decrease in active metabolite Cmax. Similar results were observed when a clopidogrel tablets 300 mg loading dose was administered with a high-fat breakfast.
Clopidogrel is extensively metabolized by two main metabolic pathways: one mediated by esterases and leading to hydrolysis into an inactive carboxylic acid derivative (85% of circulating metabolites) and one mediated by multiple cytochrome P450 enzymes. Cytochromes first oxidize clopidogrel to a 2 oxoclopidogrel intermediate metabolite. Subsequent metabolism of the 2-oxoclopidogrel intermediate metabolite results in formation of the active metabolite, a thiol derivative of clopidogrel. The active metabolite is formed mostly by CYP2C19 with contributions from several other CYP enzymes, including CYP1A2, CYP2B6 and CYP3A. The active thiol metabolite binds rapidly and irreversibly to platelet receptors, thus inhibiting platelet aggregation for the lifespan of the platelet.
The Cmax of the active metabolite is twice as high following a single 300 mg clopidogrel loading dose as it is after four days of 75 mg maintenance dose. Cmax occurs approximately 30 to 60 minutes after dosing. In the 75 to 300 mg dose range, the pharmacokinetics of the active metabolite deviates from dose proportionality: 4-fold the dose results in 2.0- fold and 2.7- fold the Cmax and AUC, respectively.
Following an oral dose of 14C-labeled clopidogrel in humans, approximately 50% of total radioactivity was excreted in urine and approximately 46% in feces over the 5 days post-dosing. After a single, oral dose of 75 mg, clopidogrel has a half-life of approximately 6 hours. The half-life of the active metabolite is about 30 minutes.
Effect of other drugs on clopidogrel
Clopidogrel is metabolized to its active metabolite in part by CYP2C19. Concomitant use of certain inhibitors of this enzyme results in reduced plasma concentrations of the active metabolite of clopidogrel and a reduction in platelet inhibition.
Proton pump inhibitors (PPI)
The effect of proton pump inhibitors (PPI) on the systemic exposure to the clopidogrel active metabolite following multiple doses of clopidogrel 75 mg evaluated in dedicated drug interaction studies is presented in Figure 1.
Figure 1:Exposure to Clopidogrel Active Metabolite Following Multiple Doses of Clopidogrel 75 mg Alone or with Proton Pump Inhibitors (PPIs)
Coadministration of 5 mg intravenous morphine with 600 mg loading dose of clopidogrel in healthy adults decreased the AUC and Cmax of clopidogrel's thiol metabolites by 34%. Mean platelet aggregation was higher up to 2 to 4 hours with morphine co-administration.
Effect of clopidogrel on other drugs
In vitro studies have shown that the glucuronide metabolite of clopidogrel is a strong inhibitor of CYP2C8. Concomitant administration of repaglinide with clopidogrel increased the systemic exposure to repaglinide (AUC0-∞) by 5.1-fold following the loading dose (300 mg) and by 3.9-fold on day 3 of the maintenance dose (75 mg) of clopidogrel [see Drug Interactions (7.6)].
CYP2C19 is involved in the formation of both the active metabolite and the 2- oxo-clopidogrel intermediate metabolite. Clopidogrel active metabolite pharmacokinetics and antiplatelet effects, as measured by ex vivo platelet aggregation assays, differ according to CYP2C19 genotype. Patients who are homozygous for nonfunctional alleles of the CYP2C19 gene are termed "CYP2C19 poor metabolizers". Approximately 2% of White and 4% of Black patients are poor metabolizers; the prevalence of poor metabolism is higher in Asian patients (e.g., 14% of Chinese). Tests are available to identify patients who are CYP2C19 poor metabolizers.
A crossover study in 40 healthy subjects, 10 each in the four CYP2C19 metabolizer groups, evaluated pharmacokinetic and antiplatelet responses using 300 mg followed by 75 mg per day and 600 mg followed by 150 mg per day, each for a total of 5 days. Decreased active metabolite exposure and diminished inhibition of platelet aggregation were observed in the poor metabolizers as compared to the other groups.
* Intermediate metabolizers have one but not two nonfunctional alleles.
† Ultrarapid metabolizers have at least one gain-of-function allele.
‡ Inhibition of platelet aggregation with 5mcM ADP; larger value indicates greater platelet inhibition.
§ Vasodilator-stimulated phosphoprotein – platelet reactivity index; smaller value indicates greater
Values are mean (SD)
|| Poor (n=10)
|| Intermediate* (n=10)
| Ultrarapid† (n=10)
| Cmax (ng/mL)|| 300 mg (24 h)|| 11 (4)|| 23 (11)|| 32 (21)|| 24 (10)
| 600 mg (24 h)|| 17 (6)|| 39 (23)|| 44 (27)|| 36 (13)
| 75 mg (Day 5)|| 4 (1)|| 12 (5)|| 13 (7)|| 12 (6)
| 150 mg (Day 5)|| 7 (2)|| 18 (7)|| 19 (5)|| 16 (9)
| IPA (%)‡
|| 300 mg (24 h)|| 24 (26)|| 37 (21)|| 39 (28)|| 40 (21)
| 600 mg (24 h)|| 32 (25)|| 56 (22)|| 49 (23)|| 51 (28)
| 75 mg (Day 5)|| 37 (23)|| 60 (18)|| 58 (19)|| 56 (13)
| 150 mg (Day 5)|| 61 (14)|| 74 (14)|| 73 (9)|| 68 (18)
| VASP-PRI (%)§
|| 300 mg (24 h)|| 91 (12)|| 78 (12)|| 68 (16)|| 73 (12)
| 600 mg (24 h)|| 85 (14)|| 56 (26)|| 48 (20)|| 51 (20)
| 75 mg (Day 5)|| 83 (13)|| 50 (16)|| 39 (14)|| 40 (9)
| 150 mg (Day 5)|| 61 (18)|| 29 (11)|| 24 (10)|| 20 (10)
There was no evidence of tumorigenicity when clopidogrel was administered for 78 weeks to mice and 104 weeks to rats at dosages up to 77 mg/kg per day, which afforded plasma exposures > 25 times that in humans at the recommended daily dose of 75 mg.
Clopidogrel was not genotoxic in four in vitro tests (Ames test, DNA-repair test in rat hepatocytes, gene mutation assay in Chinese hamster fibroblasts, and metaphase chromosome analysis of human lymphocytes) and in one in vivo test (micronucleus test by oral route in mice).
Clopidogrel was found to have no effect on fertility of male and female rats treated prior to pairing and throughout gestation at oral doses up to 400 mg/kg per day (52 times the recommended human dose on a mg/m2 basis).
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.
Patients were randomized to receive clopidogrel bisulfate (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 to 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 patient population was largely White (82%) and included 38% women, and 52% age ≥ 65 years of age. Only about 20% of patients underwent revascularization during the initial hospitalization and few underwent emergent or urgent revascularization.
The number of patients experiencing the primary outcome (CV death, MI, or stroke) was 582 (9.3%) in the clopidogrel-treated group and 719 (11.4%) in the placebo-treated group, a 20% relative risk reduction (95% CI of 10% to 28%; p < 0.001) for the clopidogrel-treated group (see Table 4).
| Relative Risk
| Primary outcome |
(Cardiovascular death, MI, stroke)
| 582 (9.3%)|| 719 (11.4%)|| 20%
p < 0.001
| All Individual Outcome Events:†
| CV death || 318 (5.1%)|| 345 (5.5%)|| 7%
| MI || 324 (5.2%)|| 419 (6.6%)|| 23%
| Stroke|| 75 (1.2%)|| 87 (1.4%)|| 14%
Figure 2: Cardiovascular Death, Myocardial Infarction, and Stroke in the CURE Study
The effect of Plavix did not differ significantly in various subgroups, as shown in Figure 3. The benefits associated with clopidogrel 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 clopidogrel was observed independently of the dose of aspirin (75 to 325 mg once daily). The use of oral anticoagulants, nonstudy antiplatelet drugs, and chronic NSAIDs was not allowed in CURE.
Figure 3: Hazard Ratio for Patient Baseline Characteristics and On-Study Concomitant Medications/Interventions for the CURE Study
The use of clopidogrel in CURE was associated with a decrease in the use of thrombolytic therapy (71 patients [1.1%] in the clopidogrel tablets group, 126 patients [2%] in the placebo group; relative risk reduction of 43%), and GPIIb/IIIa inhibitors (369 patients [5.9%] in the clopidogrel tablets group, 454 patients [7.2%] in the placebo group, relative risk reduction of 18%). The use of clopidogrel in CURE did not affect the number of patients treated with CABG or PCI (with or without stenting) (2,253 patients [36%] in the clopidogrel group, 2,324 patients [36.9%] in the placebo group; relative risk reduction of 4%).
In patients with STEMI, the safety and efficacy of clopidogrel 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 clopidogrel (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 was 28% women and 58% age ≥ 60 years (26% age ≥ 70 years). Fifty-five percent (55%) of patients received thrombolytics and only 3% underwent PCI.
As shown in Table 5 and Figure 4 and Figure 5 below, clopidogrel 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).
* 9 patients (2 clopidogrel and 7 placebo) suffered both a nonfatal stroke and a nonfatal MI.
†Nonfatal MI and nonfatal stroke exclude patients who died (of any cause).
(+ aspirin) (N=22,961)
(+ aspirin) (N=22,891)
| Odds ratio
| Composite endpoint: Death, MI, or Stroke*
|| 2,121 (9.2%)|| 2,310 (10.1%)|| 0.91 (0.86, 0.97)|| 0.002
| 1,726 (7.5%)|
| 1,845 (8.1%)|
| 0.93 (0.87, 0.99)|
0.81 (0.69, 0.95)
0.89 (0.70, 1.13)
Cumulative Event Rates for Death in the COMMIT Study*
Cumulative Event Rates for the Combined Endpoint Re-Infarction, Stroke or Death in the COMMIT Study*
The effect of clopidogrel tablets did not differ significantly in various prespecified subgroups as shown in Figure 6. The effect was also similar in non-prespecified subgroups including those based on infarct location, Killip class or prior MI history (see Figure 7). Such subgroup analyses should be interpreted cautiously.
Effects of Adding clopidogrel to Aspirin on the Combined Primary Endpoint across Baseline and Concomitant Medication Subgroups for the COMMIT Study
The CAPRIE trial was a 19,185-patient, 304-center, international, randomized, double-blind, parallel-group study comparing clopidogrel (75 mg daily) to aspirin (325 mg daily). To be eligible to enroll, patients had to have: 1) recent history of myocardial infarction (within 35 days); 2) recent histories of ischemic stroke (within 6 months) with at least a week of residual neurological signs; and/or 3) established peripheral arterial disease (PAD). 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.
| 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%)|| 1,020 (10.6%)
As shown in Table 6, clopidogrel tablets were 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 clopidogrel tablets 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.
Fatal or Nonfatal Vascular Events in the CAPRIE Study
The statistical significance favoring clopidogrel 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 clopidogrel is substantial.
The CAPRIE trial enrolled a population that had recent MI, recent stroke, or PAD. The efficacy of clopidogrel relative to aspirin was heterogeneous across these subgroups (p=0.043) (see Figure 8). Nonetheless, this difference may be a chance occurrence because the CAPRIE trial was not designed to evaluate the relative benefit of clopidogrel over aspirin in the individual patient subgroups. The benefit was most apparent in patients who were enrolled because of peripheral arterial disease and less apparent in stroke patients. In patients who were enrolled in the trial on the sole basis of a recent myocardial infarction, clopidogrel was not numerically superior to aspirin.
Figure 8 Fatal or Non-Fatal Vascular Events in the CAPRIE Study
The CHARISMA trial was a 15,603 subject, randomized, double-blind, parallel group study comparing clopidogrel bisulfate (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 to 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 clopidogrel tablets 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 clopidogrel tablets.
Clopidogrel tablets, USP equivalent to 75 mg of clopidogrel are pink-colored, biconvex, round-shaped, film-coated tablets debossed with '379' on one side and plain on the other side and are supplied as follows:
NDC: 72578-012-06 in bottle of 30 tablets
NDC: 72578-012-16 in bottle of 90 tablets
NDC: 72578-012-05 in bottle of 500 tablets
NDC: 72578-012-10 in bottle of 1,000 tablets
Store at 20° to 25°C (68° to 77°F) [See USP Controlled Room Temperature].
Dispense in a tight container.
Advise patients not to discontinue clopidogrel tablets without first discussing it with the healthcare provider who prescribed it [see Warnings and Precautions (5.3)].
Advise patients that they:
Instruct patients to get prompt medical attention if they experience symptoms of TTP that cannot otherwise be explained [see Warnings and Precautions (5.4)].
Advise patients to inform physicians and dentists that they are taking clopidogrel tablets before any surgery or dental procedure [see Warnings and Precautions (5.2, 5.3)].
Proton Pump Inhibitors
Advise patients not to take omeprazole or esomeprazole while taking clopidogrel tablets. Dexlansoprazole, lansoprazole, and pantoprazole had less pronounced effects on the antiplatelet activity of clopidogrel tablets than did omeprazole or esomeprazole [see Drug Interactions (7.1)].
Cadila Healthcare Ltd.
Viona Pharmaceuticals Inc.
Cranford, NJ 07016
Clopidogrel Bisulfate (kloe pid' oh grel bye sul' fate) Tablets, USP
Read this Medication Guide before you start taking clopidogrel and each time you get a refill. There may be new information. This Medication Guide does not take the place of talking with your doctor about your medical condition or your treatment.
What is the most important information I should know about clopidogrel?
1. Clopidogrel may not work as well in people who:
2. Clopidogrel can cause bleeding which can be serious and can sometimes lead to death. Clopidogrel is a blood thinner medicine that lowers the chance of blood clots forming in your body. While you take clopidogrel:
Do not stop taking clopidogrel without talking to the doctor who prescribes it for you. People who stop taking clopidogrel too soon have a higher risk of having a heart attack or dying. If you must stop clopidogrel because of bleeding, your risk of a heart attack may be higher.
What is clopidogrel?
Clopidogrel is a prescription medicine used to treat people who have any of the following:
Platelets are blood cells that help your blood clot normally. Clopidogrel helps to prevent platelets from sticking together and forming a clot that can block an artery.
It is not known if clopidogrel is safe and effective in children.
Who should not take clopidogrel?
Do not take clopidogrel if you:
Before you take clopidogrel, tell your doctor if you:
Tell your doctor about all the medicines you take, including prescription, non-prescription medicines, vitamins and herbal supplements.
Clopidogrel may affect the way other medicines work, and other medicines may affect how clopidogrel works. See "What is the most important information I should know about clopidogrel?"
Clopidogrel may increase blood levels of other medicines such as repaglinide (Prandin
Taking clopidogrel with certain other medicines may increase your risk of bleeding. Especially tell your doctor if you take:
How should I take clopidogrel?
Clopidogrel can cause serious side effects including:
Tell your doctor if you develop an allergic reaction including skin reactions while taking clopidogrel tablets.
These are not all the possible side effects of clopidogrel. For more information, ask your doctor or pharmacist.
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
How should I store clopidogrel?
General information about clopidogrel
Medicines are sometimes used for purposes other than those listed in a Medication Guide. Do not take clopidogrel for a condition for which it was not prescribed. Do not give clopidogrel to other people, even if they have the same symptoms that you have. It may harm them.
This Medication Guide summarizes the most important information about clopidogrel. If you would like more information, talk to your doctor. Ask your doctor or pharmacist for information about clopidogrel that was written for healthcare professionals. Address medical inquiries to, Telephone: 1-877-993-8779 or MedicalAffair@zydususa.com.
What are the ingredients in clopidogrel tablets?
Active ingredient: clopidogrel bisulfate, USP
citric acid, colloidal silicon dioxide, corn starch, crospovidone, hydrogenated castor oil, hydroxypropyl cellulose, hypromellose, iron oxide black, iron oxide red, iron oxide yellow, lactose anhydrous, lactose monohydrate, magnesium stearate, polyethylene glycol and titanium dioxide.
This Medication Guide has been approved by the U.S. Food and Drug Administration.
All other trademarks are property of their respective owners.
Cadila Healthcare Ltd.
Zydus Pharmaceuticals (USA) Inc.
Pennington, NJ 08534
NDC: 72578-012-16 in bottle of 90 Tablets
Clopidogrel Tablets USP, 75 mg
clopidogrel tablet, film coated
|Labeler - Viona Pharmaceuticals Inc (081468959)|
|Registrant - Zydus Lifesciences Limited (650199482)|
|Zydus Lifesciences Limited||918596198||ANALYSIS(72578-012) , MANUFACTURE(72578-012)|