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Clopidogrel
Systematic (IUPAC) name
(+)-(S)-methyl 2-(2-chlorophenyl)- 2-(6,7-dihydrothieno[3,2-c]pyridin-5(4H)-yl)acetate
Identifiers
CAS number	113665-84-2
ATC code	B01AC04
PubChem	60606
DrugBank	APRD00444
Chemical data
Formula	C16H16ClNO2S
Mol. mass	321.82 g/mol
Pharmacokinetic data
Bioavailability	>50%
Protein binding	94–98%
Metabolism	Hepatic
Half life	7–8 hours (inactive metabolite)
Excretion	50% renal 46% biliary
Therapeutic considerations
Pregnancy cat.	B1(AU) B(US)
Legal status	Prescription Only (S4)(AU) POM(UK) ℞-only(US)
Routes	Oral

Clopidogrel is a potent oral antiplatelet agent often used in the treatment of coronary artery disease, peripheral vascular disease, and cerebrovascular disease. It is marketed by Bristol-Myers Squibb and Sanofi-Aventis under the trade name Plavix. It works by blocking a receptor called P2Y12. Adverse effects include hemorrhage.

Contents 1 Pharmacology 2 Clinical use 2.1 Indications 2.2 Dosage forms 3 Pharmacokinetics and Metabolism 4 Adverse effects 5 Marketing 6 References 7 External links

The mechanism of action of clopidogrel is irreversible blockade of the adenosine diphosphate (ADP) receptor on platelet cell membranes. This receptor is named P2Y12 and is important in platelet aggregation, the cross-linking of platelets by fibrin. The blockade of this receptor inhibits platelet aggregation by blocking activation of the glycoprotein IIb/IIIa pathway.

Platelet inhibition can be demonstrated two hours after a single dose of oral clopidogrel, but the onset of action is slow, so that a loading-dose of 300-600 mg is usually administered.

Clopidogrel is indicated for:^[1]

• Prevention of vascular ischaemic events in patients with symptomatic atherosclerosis
• Acute coronary syndrome without ST-segment elevation (NSTEMI), along with aspirin
• ST elevation MI (STEMI)

It is also used, along with aspirin, for the prevention of thromboembolism after placement of intracoronary stent. ^[1]

International guidelines granted the highest grade of recommendation for NSTE-ACS, PCI and stent, for Clopidogrel in addition to Aspirin. Consensus-based therapeutic guidelines recommend also the use of clopidogrel, instead of aspirin, in patients requiring antiplatelet therapy but with a history of gastric ulceration, as inhibition of the synthesis of prostaglandins by aspirin (acetylsalicylic acid) can exacerbate this condition. A recent study has shown that in patients with healed aspirin-induced ulcers, however, patients receiving aspirin plus the proton pump inhibitor esomeprazole had a lower incidence of recurrent ulcer bleeding than patients receiving clopidogrel. ^[2]

Clopidogrel is marketed as clopidogrel bisulfate (clopidogrel hydrogen sulfate), most commonly under the trade names Plavix or Iscover, as 75 mg oral tablets.

After repeated 75-mg oral doses of clopidogrel (base), plasma concentrations of the parent compound, which has no platelet inhibiting effect, are very low and are generally below the quantification limit (0.000258 mg/L) beyond 2 hours after dosing. Clopidogrel is extensively metabolized by the liver. The main circulating metabolite is the carboxylic acid derivative, and it too has no effect on platelet aggregation. It represent about 85% of the circulating drug-related compound in plasma.

Following an oral dose of ¹⁴C-labeled clopidogrel in humans, approximately 50% was excreted in the urine and approximately 46% in the feces in the 5 days after dosing. The elimination half-life of the main circulating metabolite was 8 hours after single and repeated administration. Covalent binding to platelets accounted for 2% of radiolabel with a half-life of 11 days. Effect of Food: Administration of PLAVIX (clopidogrel bisulfate) with meals did not significantly modify the bioavailability of clopidogrel as assessed by the pharmacokinetics of the main circulating metabolite.

Absorption and Distribution: Clopidogrel is rapidly absorbed after oral administration of repeated doses of 75 mg clopidogrel (base), with peak plasma levels (appx. 3 mg/L) of the main circulating metabolite occurring approximately 1 hour after dosing. The pharmacokinetics of the main circulating metabolite are linear (plasma concentrations increased in proportion to does) in the dose range of 50 to 150 mg of clopidogrel. Absorption is at least 50% based on urinary excretion of clopidogrel-related metabolites. Clopidogrel and the main circulating metabolite bind reversibly in vitro to human plasma proteins (98% and 94%, respectively). The binding is nonsaturable in vitro up to a concentration of 110 μg/mL.

Metabolism and Elimination: In vitro and in vivo, clopidogrel undergoes rapid hydrolysis into its carboxylic acid derivative. In plasma and urine, the glucuronide of the carboxylic acid derivative is also observed.

Serious adverse drug reactions associated with clopidogrel therapy include:

• Severe neutropenia (Incidence: 5/10,000)
• Thrombotic thrombocytopenic purpura (TTP) (Incidence: 4/1,000,000 patients treated)
• Hemorrhage - The incidence of hemorrhage may be increased by the co-administration of aspirin.
  • Gastrointestinal Hemorrhage (Incidence: 2.0%)
  • Cerebral Hemorrhage (Incidence: 0.1 to 0.4%)
• Erectile Dyfunction (Incidence as yet unknown)

In 2006, generic clopidogrel was briefly marketed by Apotex, a Canadian generic pharmaceutical company before a court order halted further production until resolution of a patent infringement case brought by Bristol-Myers Squibb.^[3] The court ruled that Bristol-Myers Squibb's patent was valid and has patent protection until November 2011.^[4] In 2007, the production was halted to many retail pharmacies and will be changing back to Plavix. In 2005 it was reported that Plavix was the world's second highest selling pharmaceutical with sales of US$5.9 billion.^[5]

1. ^ ^{a b} Rossi S, editor. Australian Medicines Handbook 2006. Adelaide: Australian Medicines Handbook; 2006. ISBN 0-9757919-2-3
2. ^ Chan FK, Ching JY, Hung LC, et al (2005). "Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding". N. Engl. J. Med. 352 (3): 238-44. doi:10.1056/NEJMoa042087. PMID 15659723. 
3. ^ Preliminary Injunction Against Apotex Upheld on Appeal - Press Release. Retrieved on 2007-09-05.
4. ^ U.S. judge upholds Bristol, Sanofi patent on Plavix. Retrieved on 2007-09-05.
5. ^ IMS HEALTH. Retrieved on 2007-09-05.

• 3418 drug label/data at Daily Med from U.S. National Library of Medicine, National Institutes of Health.
• Plavix : Information for the General Public
• Plavix, Aspirin and Stents : Patients' Forum : Angioplasty.Org

v • d • e Antithrombotics (thrombolytics, anticoagulants and antiplatelet drugs) (B01)
Vitamin K antagonists	Acenocoumarol • Clorindione • Coumatetralyl • Dicumarol (Dicoumarol) • Diphenadione • Ethyl biscoumacetate • Phenprocoumon • Phenindione • Tioclomarol • Warfarin
Heparin group	Antithrombin III • Danaparoid • Heparin • Sulodexide • low molecular weight heparin (Bemiparin, Dalteparin, Enoxaparin, Nadroparin, Parnaparin, Reviparin, Tinzaparin)
Glycoprotein IIb/IIIa inhibitors	Abciximab • Eptifibatide • Tirofiban
Other platelet aggregation inhibitors	Acetylsalicylic acid/Aspirin • Aloxiprin • Ditazole • Carbasalate calcium • Cloricromen • Dipyridamole • Indobufen • Picotamide • Triflusal • ADP receptor inhibitors (Clopidogrel, Ticlopidine, Prasugrel) • prostaglandin analogue (Beraprost, Prostacyclin, Iloprost, Treprostinil)
Enzymes	plasminogen activators (Alteplase/Reteplase/Tenecteplase, Streptokinase, Urokinase/Saruplase, Anistreplase) • other serine endopeptidases (Ancrod, Drotrecogin alfa/Protein C, Fibrinolysin) • Brinase
Direct thrombin inhibitors	Argatroban • Bivalirudin • Dabigatran • Desirudin • Hirudin • Lepirudin • Melagatran • Ximelagatran
Other antithrombotics	Defibrotide • Dermatan sulfate • Fondaparinux • Rivaroxaban
Non-medicinal	Citrate • EDTA • Oxalate