Audit of clopidogrel use in a medical clinic in a tertiary care hospital in Sri Lanka

Abstract

Introduction Clopidogrel is a widely used anti-platelet agent. The active metabolite of clopidogrel blocks the interaction between adenosine diphosphate and P2Y12 receptor and prevents ADP mediated activation of aglycoprotein GPIIb/IIIa complex and thereby inhibits platelet aggregation. It is an irreversible inhibition. Clopidogrel is used as monotherapy or in combination with aspirin in management of cardiovascular diseases (CVD); namely coronary artery disease (CAD), ischaemic stroke and transient ischaemic attack (TIA). Several large multicentre clinical trials have shown the benefits of clopidogrel in cardiovascular diseases.1,2 American Heart Association (AHA), American College of Cardiology (ACC) and American Stroke Association (ASA) guidelines3,4,5,6,7,8,9 have given clear evidene based recommendations for clopidogrel use. The guidelines strongly recommend to start dual antiplatelet therapy (DAPT) with clopidogrel and aspirin after an acute coronary syndrome (ACS). Maximum recommended duration of DAPT after an ACS managed without percutaneous intervention is 12 months. After a minor stroke/TIA, DAPT with clopidogrel and aspirin might be considered within 24 hours and continued for 21 days; however the strength of this recommendation is weak. Clopidogrel monotherapy is generally recommended for secondary prevention of CVD only if there is aspirin intolerance. In primary prevention of CVD clopidogrel is not recommended. A summary of these recommendations is shown in table 1. However clopidogrel use is associated with an increased risk of major bleeding including haemorhagic stroke and gastro-intestinal bleeding. This risk is further increased when it is combined with aspirin. Specially, long term DAPT confers a significantly higher risk of haemorrhagic complications.10,11,12,13 Therefore it is extremely important to ensure that clopidogrel is prescribed appropriately for recommended indications and it is not used beyond the recommended duration Data about prescription pattern of clopidogrel in the local setting will be valuable to formulate a plan to minimize unnecessary use of clopidogrel. However a literature survey did not reveal any previous publications about clopidogrel use in Sri Lanka.