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How To Withdraw From Plavix Inspite Of Having Side Effects?
Question: Father has atrial fibrillation and is 85 yrs old. He does not have stents, but has been on Plavix as an anti-coagulant for about 10 years. He is experiencing mental decline similar to Alzheimer's, and has lost muscle tone to support his legs and cannot walk un-assisted. My son tells me plavix is mainly for use with stents, and for typically1 year to 18 months. I suspect he is experiencing side-effects from Plavix and it is contributing to his mental, nervous, and physical deterioration. My question is, can he be tapered off of the Plavix in favor of Coumadin, Warfarin, or some newer drug ? Is there experience with how to taper or discontinue Plavix while starting on a different regimen ? Is a switch advisable ? Are these side effects likely / possible from extended use of Plavix ?
Brief Answer:
please see below
Detailed Answer:
Dear sir
1. The side effects of plavix or clopidogrel may include must let pain, headache, joint pains, acute weakness and confusional state. Alzheimer's like illness is not reported in literature. Incidence of neurological side effects is very low.
2. Why he was started on plavix because it is not drug of choice in AF. We either use aspirin or warfarin. Was he allergic to aspirin? Yes one may think of shifting to aspirin or warfarin, depending upon risk profile. If he has diabetes, high BP, anginal heart disease, smoking or any other medical illness?
3. The experience of this switch over will not be available from literature as this is an atypical clinical scenario, however it will not be difficult for any seasoned cardiologist.
Waiting for your reply.
Sincerely
Sukhvinder
please see below
Detailed Answer:
Dear sir
1. The side effects of plavix or clopidogrel may include must let pain, headache, joint pains, acute weakness and confusional state. Alzheimer's like illness is not reported in literature. Incidence of neurological side effects is very low.
2. Why he was started on plavix because it is not drug of choice in AF. We either use aspirin or warfarin. Was he allergic to aspirin? Yes one may think of shifting to aspirin or warfarin, depending upon risk profile. If he has diabetes, high BP, anginal heart disease, smoking or any other medical illness?
3. The experience of this switch over will not be available from literature as this is an atypical clinical scenario, however it will not be difficult for any seasoned cardiologist.
Waiting for your reply.
Sincerely
Sukhvinder
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Well, he is displaying the acute weakness side effect since his muscle strength in his legs and pelvic area is insufficient to stand up and walk. Can't say conclusively this is due to the Plavix, but he also exhibits confusion, sometimes thinking he is still in the hospital when he was re-located to the nursing home. He has moments of clarity and lucidity however, which leads me to suspect a drug-induced cause as opposed to permanent neurological damage due to aging or Alzheimers.
Also, studies may not show all side effects because with the maximum time for treatment with Plavix being about 18 months (he has been on it for many years), these long-term effects may not have been found in studies.
As far as tapering off from Plavix, it doesn't sound that simple, because unless one risks waiting until Plavix has disappeared from his system (which risks clotting), one must slowly increase the dosage of the warfarin, while propotionally allowing the dosage of Plavix to decrease, or letting it wear off at a known rate. If you continue to dose with both drugs, the hemmorage risk increases.
If he can regain his strength so he is not bed-ridden anymore, and eliminate the acute weakness, does it seem like a sensible risk to take him off Plavix ? Is Plavix considered "milder" and "safer" than Warfarin in terms of hemmorage risk ?
Is there any good reason to continue him with Plavix ?
Also, studies may not show all side effects because with the maximum time for treatment with Plavix being about 18 months (he has been on it for many years), these long-term effects may not have been found in studies.
As far as tapering off from Plavix, it doesn't sound that simple, because unless one risks waiting until Plavix has disappeared from his system (which risks clotting), one must slowly increase the dosage of the warfarin, while propotionally allowing the dosage of Plavix to decrease, or letting it wear off at a known rate. If you continue to dose with both drugs, the hemmorage risk increases.
If he can regain his strength so he is not bed-ridden anymore, and eliminate the acute weakness, does it seem like a sensible risk to take him off Plavix ? Is Plavix considered "milder" and "safer" than Warfarin in terms of hemmorage risk ?
Is there any good reason to continue him with Plavix ?
Brief Answer:
please see details
Detailed Answer:
Dear Sir
I asked a few questions about his clinical profile in my last answer which have not been answered. They are important to understand his risk profile and decide therapy.
These complaints may not relate to clopidogrel therapy at all as the incidence of neurological complications is very low.
The switch over will depend upon the drug chosen by your cardiologist. Warfarin takes about 5 days to be totally effective and nearly this much of time will be taken by clopidogrel to wane off. So overlap of effects is not likely to be a problem. The question is What drug is actually required which can be answered only by knowing his clinical status.
Plavix alone is not given in AF unless patient is allergic to aspirin. Plavix with aspirin is given to those who are candidates for warfarin but can not be given same for some reason. Plavix has not been compared to warfarin and two have entirely different mechanism of action. Hope these facts provide you more insight.
Waiting for your reply.
Sincerely
Sukhvinder
please see details
Detailed Answer:
Dear Sir
I asked a few questions about his clinical profile in my last answer which have not been answered. They are important to understand his risk profile and decide therapy.
These complaints may not relate to clopidogrel therapy at all as the incidence of neurological complications is very low.
The switch over will depend upon the drug chosen by your cardiologist. Warfarin takes about 5 days to be totally effective and nearly this much of time will be taken by clopidogrel to wane off. So overlap of effects is not likely to be a problem. The question is What drug is actually required which can be answered only by knowing his clinical status.
Plavix alone is not given in AF unless patient is allergic to aspirin. Plavix with aspirin is given to those who are candidates for warfarin but can not be given same for some reason. Plavix has not been compared to warfarin and two have entirely different mechanism of action. Hope these facts provide you more insight.
Waiting for your reply.
Sincerely
Sukhvinder
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
He has type-2 diabetes which has been treated in the past with Avandia (they have recently discontinued the Avandia), no high blood pressure, or other hesrt conditions that I know of other than afib. Does not smoke, but has been under treatment for prostate cancer for about 24 years. Also has genital herpes. Not allergic to aspirin. Aren't there some newer meds coming out that have advantages over Warfarin ? Would any of these be good choices ?
Brief Answer:
please see details.
Detailed Answer:
Dear Sir
The CHADS2 Vasc risk score of your father is 3 which is moderate to high risk for stroke. It is recommended by some regulatory authorities to use anticoagulants (warfarin like drugs) in this group. However the risk of bleeding also increases with increasing age. So it is a double-edged sword, more benefit by more reduction in ischemic stroke but higher incidence of major bleed. Major bleed also increases with deteriorating renal functions and history of stomach ulcers.
There are four more agents available which can be used in place of warfarin in non-valvular AF. The most commonly used by me is debigatran. But still it had higher incidence of bleeding in age more than 75, although risk benefit ratio still was in its favor. Most of the trials of these drugs excluded patients more than 80 years, hence definite is not available. These drugs do not require day to day monitoring like warfarin. The particular agent should be your physicians choice as per his comfort.
Hope this gives you more insight into the issue and you can discuss it better with your physician.
Sincerely
Sukhvinder
please see details.
Detailed Answer:
Dear Sir
The CHADS2 Vasc risk score of your father is 3 which is moderate to high risk for stroke. It is recommended by some regulatory authorities to use anticoagulants (warfarin like drugs) in this group. However the risk of bleeding also increases with increasing age. So it is a double-edged sword, more benefit by more reduction in ischemic stroke but higher incidence of major bleed. Major bleed also increases with deteriorating renal functions and history of stomach ulcers.
There are four more agents available which can be used in place of warfarin in non-valvular AF. The most commonly used by me is debigatran. But still it had higher incidence of bleeding in age more than 75, although risk benefit ratio still was in its favor. Most of the trials of these drugs excluded patients more than 80 years, hence definite is not available. These drugs do not require day to day monitoring like warfarin. The particular agent should be your physicians choice as per his comfort.
Hope this gives you more insight into the issue and you can discuss it better with your physician.
Sincerely
Sukhvinder
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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