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a blood thinner (trade name Plavix) approved for the treatment of mild heart attacks; works by preventing blood platelets from sticking together to form clots that would restrict blood flow (同)Plavix

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2017/08/25 08:02:36」(JST)

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Clopidogrel, sold as the brandname Plavix among others,^[1] is a medication that is used to reduce the risk of heart disease and stroke in those at high risk. It is also used together with aspirin in heart attacks and following the placement of a coronary artery stent (dual antiplatelet therapy). It is taken by mouth.^[2] Onset of effects is about 2 hours and lasts for 5 days.^[2]

Common side effects include headache, nausea, easy bruising, itching, and heartburn. More severe side effects include bleeding and thrombotic thrombocytopenic purpura.^[2] While there is no evidence of harm from use during pregnancy, such use has been poorly studied.^[3] Clopidogrel is in the thienopyridine-class of antiplatelet agent. It works by irreversibly inhibiting a receptor called P2Y₁₂, on platelets.^[2]

Clopidogrel was first written about in 1982 and was approved for medical use in 1998.^[4] It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system.^[5] The wholesale cost in the developing world is about 0.77 to 31.59 USD per month.^[6] In the United States a month of treatment costs less than 25 USD.^[7]

Medical use

Clopidogrel is used to prevent heart attack and stroke in people who are at high risk of these events, including those with a history of myocardial infarction and other forms of acute coronary syndrome, stroke, and those with peripheral artery disease.

Treatment with clopidogrel or a related drug is recommended by the American Heart Association and the American College of Cardiology for people who:

Present for treatment with a myocardial infarction with ST-elevation^[8] including

A loading dose given in advance of percutaneous coronary intervention (PCI), followed by a full year of treatment for those receiving a vascular stent
A loading dose given in advance of fibrinolytic therapy, continued for at least 14 days

Present for treatment of a non-ST elevation myocardial infarction or unstable angina^[9]

Including a loading dose and maintenance therapy in those receiving PCI and unable to tolerate aspirin therapy
Maintenance therapy for up to 12 months in those at medium to high risk for which a noninvasive treatment strategy is chosen

In those with stable ischemic heart disease,^[10] treatment with clopidogrel is described as a "reasonable" option for monotherapy in those who cannot tolerate aspirin, as is treatment with clopidogrel in combination with aspirin in certain high risk patients.

It is also used, along with acetylsalicylic acid (ASA, aspirin), for the prevention of thrombosis after placement of a coronary stent^[11] or as an alternative antiplatelet drug for people intolerant to aspirin.^[12]

Clopidogrel's benefit is primarily in those who smoke cigarettes (25% benefit), with only slight (8%) benefit in those who do not smoke cigarettes.^[13]

Consensus-based therapeutic guidelines also recommend the use of clopidogrel rather than ASA for antiplatelet therapy in people with a history of gastric ulceration, as inhibition of the synthesis of prostaglandins by ASA can exacerbate this condition. In people with healed ASA-induced ulcers, however, those receiving ASA plus the proton pump inhibitor esomeprazole had a lower incidence of recurrent ulcer bleeding than those receiving clopidogrel.^[14] However, prophylaxis with proton pump inhibitors along with clopidogrel following acute coronary syndrome may increase adverse cardiac outcomes, possibly due to inhibition of CYP2C19, which is required for the conversion of clopidogrel to its active form.^[15]^[16]^[17] The European Medicines Agency has issued a public statement on a possible interaction between clopidogrel and proton pump inhibitors.^[18] However, several cardiologists have voiced concern that the studies on which these warnings are based have many limitations and that it is not certain whether an interaction between clopidogrel and proton pump inhibitors is real.^[19]

Adverse effects

Serious adverse drug reactions associated with clopidogrel therapy include:

Thrombotic thrombocytopenic purpura (incidence: four per million patients treated)^[20]^[21]
Hemorrhage - the annual incidence of hemorrhage may be increased by the coadministration of aspirin.^[22]

In the CURE trial, people with acute coronary syndrome without ST elevation were treated with aspirin plus clopidogrel or placebo and followed for up to one year. The following rates of major bleed were seen:^[21]

Any major bleeding: clopidogrel 3.7%, placebo 2.7%
Life-threatening bleeding: clopidogrel 2.2%, placebo 1.8%
Hemorrhagic stroke: clopidogrel 0.1%, placebo 0.1%

The CAPRIE trial compared clopidogrel monotherapy to aspirin monotherapy for 1.6 years in people who had recently experienced a stroke or heart attack. In this trial the following rates of bleeding were observed.^[21]

Gastrointestinal hemorrhage: clopidogrel 2.0%, aspirin 2.7%
Intracranial bleeding: clopidogrel 0.4%, aspirin 0.5%

In CAPRIE, itching was the only adverse effect seen more frequently with clopidogrel than aspirin. In CURE, there was no difference in the rate of non-bleeding adverse events.^[21]

Interactions

Clopidogrel generally has a low potential to interact with other pharmaceutical drugs. Combination with other drugs that affect blood clotting, such as aspirin, heparins and thrombolytics, showed no relevant interactions. Naproxen did increase the likelihood of occult gastrointestinal bleeding, as might be the case with other nonsteroidal anti-inflammatory drugs. As clopidogrel inhibits the liver enzyme CYP2C9 in cellular models, it has been theorized that it might increase blood plasma levels of drugs that are metabolized by this enzyme, such as phenytoin and tolbutamide. Clinical studies showed that this mechanism is irrelevant for practical purposes.^[23]

In November 2009, the FDA announced that clopidogrel should be used with caution in people using the proton pump inhibitors omeprazole or esomeprazole,^[24]^[25] but pantoprazole appears to be safe.^[26] The newer antiplatelet agent prasugrel has minimal interaction with (es)omeprazole, hence might be a better antiplatelet agent (if no other contraindications are present) in people who are on these proton pump inhibitors.^[27]

Pharmacology

Mechanism of action

Clopidogrel acts by inhibiting the ADP receptor on platelet cell membranes. It is a prodrug, which requires CYP2C19 for its activation.^[28] The drug specifically and irreversibly inhibits the P2Y₁₂ subtype of ADP receptor, which is important in activation of platelets and eventual cross-linking by the protein fibrin.^[29] Platelet inhibition can be demonstrated two hours after a single dose of oral clopidogrel, but the onset of action is slow, so a loading dose of either 600 or 300 mg is administered when a rapid effect is needed.^[30]

Pharmacokinetics and metabolism

Clopidogrel (top left) being activated: The first step is an oxidation mediated (mainly) by CYP2C19, unlike the activation of the related drug prasugrel. The two structures at the bottom are tautomers of each other; and the final step is a hydrolysis. The active metabolite (top right) has Z configuration at the double bond C3–C16 and possibly R configuration at the newly asymmetric C4.^[31]

After repeated oral doses of 75 mg of clopidogrel (base), plasma concentrations of the parent compound, which has no platelet-inhibiting effect, are very low and, in general, are below the quantification limit (0.258 µg/l) beyond two hours after dosing.^{[citation needed]}

Clopidogrel is activated in the liver by cytochrome P450 enzymes, including CYP2C19. Due to opening of the thiophene ring, the chemical structure of the active metabolite has three sites that are stereochemically relevant, making a total of eight possible isomers. These are: a stereocentre at C4 (attached to the —SH thiol group), a double bond at C3—C16, and the original stereocentre at C7. Only one of the eight structures is an active antiplatelet drug. This has the following configuration: Z configuration at the C3—C16 double bond, the original S configuration at C7,^[31] and, although the stereocentre at C4 cannot be directly determined, as the thiol group is too reactive, work with the active metabolite of the related drug prasugrel suggests the R-configuration of the C4 group is critical for P2Y₁₂ and platelet-inhibitory activity.^{[citation needed]}

The active metabolite has an elimination half-life of about 0.5 to 1.0 h, and acts by forming a disulfide bridge with the platelet ADP receptor. Patients with a variant allele of CYP2C19 are 1.5 to 3.5 times more likely to die or have complications than patients with the high-functioning allele.^[32]^[33]^[34]

Following an oral dose of ¹⁴C-labeled clopidogrel in humans, about 50% was excreted in the urine and 46% in the feces in the five days after dosing.

Effect of food: Administration of 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-milligram clopidogrel (base), with peak plasma levels (about 3 mg/l) of the main circulating metabolite occurring around one hour after dosing. The pharmacokinetics of the main circulating metabolite are linear (plasma concentrations increased in proportion to dose) 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 not saturable 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.

In March 2010, the U.S. FDA added a boxed warning to Plavix alerting that the drug can be less effective in people unable to metabolize the drug to convert it to its active form.^[35]^[36]

Pharmacogenetics

CYP2C19 is an important drug-metabolizing enzyme that catalyzes the biotransformation of many clinically useful drugs, including antidepressants, barbiturates, proton pump inhibitors, and antimalarial and antitumor drugs. Clopidogrel is one of the drugs metabolized by this enzyme.

Several recent landmark studies have proven the importance of 2C19 genotyping in treatment using clopidogrel. In March 2010, the FDA put a black box warning on Plavix to make patients and healthcare providers aware that CYP2C19-poor metabolizers, representing up to 14% of patients, are at high risk of treatment failure and that testing is available.^[35] Patients with variants in cytochrome P-450 2C19 (CYP2C19) have lower levels of the active metabolite of clopidogrel, less inhibition of platelets, and a 3.58-times greater risk for major adverse cardiovascular events such as death, heart attack, and stroke; the risk was greatest in CYP2C19 poor metabolizers.^[37]

Marketing and litigation

A box of Plavix

Plavix is marketed worldwide in nearly 110 countries, with sales of US$6.6 billion in 2009.^[38] It had been the second-top-selling drug in the world for a few years as of 2007^[39] and was still growing by over 20% in 2007. U.S. sales were US$3.8 billion in 2008.^[40]

Before the expiry of its patent, clopidogrel was the second best-selling drug in the world. In 2010, it grossed over US$9 billion in global sales.^[41]

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.^[42] The court ruled that Bristol-Myers Squibb's patent was valid and provided protection until November 2011.^[43] The FDA extended the patent protection of clopidogrel by six months, giving exclusivity that would expire on May 17, 2012.^[44] The FDA approved generic versions of Plavix on May 17, 2012.^[45]

Generic clopidogrel is marketed by many companies worldwide under many brand names, including combination drugs with acetylsalicylic acid (aspirin).^[1]

List of brand names

As of March 2017, brands included Aclop, Actaclo, Agregex, Agrelan, Agrelax, Agreless, Agrelex, Agreplat, Anclog, Angiclod, Anplat, Antiagrex, Antiban, Antigrel, Antiplaq, Antiplar, Aplate, Apolets, Areplex, Artepid, Asogrel, Atelit, Atelit, Ateplax, Atervix, Atheros, Athorel, Atrombin, Attera, Bidogrel, Bigrel, Borgavix, Carder, Cardogrel, Carpigrel, Ceraenade, Ceruvin, Cidorix, Clatex, Clavix, Clentel, Clentel, Clidorel, Clodel, Clodelib, Clodian, Clodil, Cloflow, Clofre, Clogan, Clogin, Clognil, Clogrel, Clogrelhexal, Clolyse, Clont, Clood, Clopacin, Clopcare, Clopeno, Clopex Agrel, Clopez, Clopi, Clopid, Clopida, Clopidep, Clopidexcel, Clopidix, Clopidogrel, Clopidogrelum, Clopidomed, Clopidorex, Clopidosyn, Clopidoteg, Clopidowel, Clopidra, Clopidrax, Clopidrol, Clopigal, Clopigamma, Clopigrel, Clopilet, Clopimed, Clopimef, Clopimet, Clopinovo, Clopione, Clopiright, Clopirite, Clopirod, Clopisan, Clopistad, Clopistad, Clopitab, Clopithan, Clopitro, ClopiVale, Clopivas, Clopivaz, Clopivid, Clopivin, Clopix, Cloplat, Clopra, Cloprez, Cloprez, Clopval, Clorel, Cloriocard, Cloroden, Clotix, Clotiz, Clotrombix, Clova, Clovas, Clovax, Clovelen, Clovex, Clovexil, Clovix, Clovvix, Copalex, Copegrel, Copidrel, Copil, Cordiax, Cordix, Corplet, Cotol, CPG, Cugrel, Curovix, Dapixol, Darxa, Dasogrel-S, Dclot, Defrozyp, Degregan, Deplat, Deplatt, Diclop, Diloxol, Dilutix, Diporel, Doglix, Dogrel, Dogrel, Dopivix, Dorel, Dorell, Duopidogrel, DuoPlavin, Eago, Egitromb, Espelio, Eurogrel, Expansia, Farcet, Flucogrel, Fluxx, Freeclo, Globel, Glopenel, Grelet, Greligen, Grelix, Grepid, Grepid, Grindokline, Heart-Free, Hemaflow, Hyvix, Idiavix, Insigrel, Iscover, Iskimil, Kafidogran, Kaldera, Kardogrel, Karum, Kerberan, Keriten, Klepisal, Klogrel, Klopide, Klopidex, Klopidogrel, Klopik, Klopis, Kogrel, Krossiler, Larvin, Lodigrel, Lodovax, Lofradyk, Lopigalel, Lopirel, Lyvelsa, Maboclop, Medigrel, Miflexin, Mistro, Mogrel, Monel, Monogrel, Moytor, Myogrel, Nabratin, Nadenel, Nefazan, Niaclop, Nivenol, Noclog, Nofardom, Nogreg, Nogrel, Noklot, Norplat, Novigrel, Oddoral, Odrel, Olfovel, Opirel, Optigrel, Panagrel, Pedovex, Pegorel, Piax, Piclokare, Pidgrel, Pidogrel, Pidogul, Pidovix, Pigrel, Pingel, Placta, Pladel, Pladex, Pladogrel, Plagerine, Plagrel, Plagril, Plagrin, Plahasan, Plamed, Planor, PlaquEx, Plasiver, Plataca, Platarex, Platec, Platel, Platelex, Platexan, Platil, Platless, Platogrix, Platrel, Plavedamol, Plavicard, Plavictonal, Plavidosa, Plavigrel, Plavihex, Plavitor, Plavix, Plavocorin, Plavogrel, Plavos, Pleyar, Plogrel, Plvix, Pravidel, Pregrel, Provic, Psygrel, Q.O.L, Ravalgen, Replet, Respekt, Revlis, Ridlor, Roclas, Rozak, Sanvix, Sarix, Sarovex, Satoxi, Shinclop, Sigmagrel, Simclovix, Sintiplex, Stazex, Stroka, Stromix, Sudroc, Synetra, Talcom, Tansix, Tessyron, Thinrin, Throimper, Thrombifree, Thrombo, Timiflo, Tingreks, Torpido, Triosal, Trogran, Troken, Trombex, Trombix, Tuxedon, Unigrel, Unplaque, Vaclo, Vasocor, Vatoud, Venicil, Vidogrel, Vivelon, Vixam, Xydrel, Zakogrel, Zillt, Zopya, Zylagren, Zyllt, and Zystol.^[1]

As of 2017 it was marketed as a combination drug with acetylsalicylic acid (aspirin) under the brand names Anclog Plus, Antiban-ASP, Asclop, Asogrel-A, Aspin-Plus, Cargrel-A, Clas, Clasprin, Clavixin Duo, Clodrel Forte, Clodrel Plus, Clofre AS, Clognil Plus, Clontas, Clopid-AS, Clopid-AS, Clopida A, Clopil-A, Clopirad-A, Clopirin, Clopitab-A, Clorel-A, Clouds, Coplavix, Coplavix, Combiplat, Cugrel-A, Dorel Plus, DuoCover, DuoCover, DuoPlavin, DuoPlavin, Ecosprin Plus, Grelet-A, Lopirel Plus, Myogrel-AP, Noclog Plus, Noklot Plus, Norplat-S, Odrel Plus, Pidogul A, Pladex-A, Plagerine-A, Plagrin Plus, Replet Plus Plavix Plus, Stromix-A, and Thrombosprin.^[1]

Research

Use in cats

Clopidogrel has also been shown to be effective at decreasing platelet aggregation in cats, so its use in prevention of feline aortic thromboembolism has been advocated.^[46]

References

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External links

Bristol-Myers Squibb official website Bristol-Myers Squibb/Sanofi
Plavix prescribing information Bristol-Myers Squibb/Sanofi
Plavix, Aspirin and Stents : Patients' Forum : Angioplasty.Org
Drug promises end to migraine misery
U.S. National Library of Medicine: Drug Information Portal - Clopidogrel
Krka official website

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1. クロピドグレル耐性とクロピドグレル治療不奏効 clopidogrel resistance and clopidogrel treatment failure
2. クロピドグレルへの過敏反応 hypersensitivity reactions to clopidogrel
3. 待機的経皮的冠動脈インターベンションのための抗血栓療法：一般的使用 antithrombotic therapy for elective percutaneous coronary intervention general use
4. 脳卒中の二次予防のための抗血小板療法 antiplatelet therapy for secondary prevention of stroke
5. Long-term antiplatelet therapy after coronary artery stenting in stable patients

English Journal

Pannexin1 Single Nucleotide Polymorphism and Platelet Reactivity in a Cohort of Cardiovascular Patients.

Stierlin FB1,2,3, Molica F1,2, Reny JL3,4, Kwak BR1,2, Fontana P3,5.
Cell communication & adhesion.Cell Commun Adhes.2017 Dec;23(1):11-15. doi: 10.1080/15419061.2017.1282469.
PMID 28142297

Effects of clopidogrel therapy on whole blood platelet aggregation, the Plateletworks® assay and coagulation parameters in cats with asymptomatic hypertrophic cardiomyopathy: a pilot study.

den Toom ML1, van Leeuwen MW1, Szatmári V1, Teske E1.
The Veterinary quarterly.Vet Q.2017 Dec;37(1):8-15. Epub 2016 Oct 27.
PMID 27786603

Rationale and Design for a Randomized Comparison of Efficacy and Safety between Aspirin and Clopidogrel in Atrial Fibrillation Patients with Low Stroke Risk: CESAC-AF trial.

Park SM1, Jeong H2, Jung MH2, Hong KS2, Hong MK3, Bang CS4, Kim CY5.
Contemporary clinical trials.Contemp Clin Trials.2017 Sep;60:51-55. doi: 10.1016/j.cct.2017.06.011. Epub 2017 Jun 19.
PMID 28642210

Japanese Journal

前多血期に主幹動脈閉塞を伴う脳梗塞を発症し，数年後にcrescendo TIAを呈したJAK2V617F 変異遺伝子陽性真性多血症の1 例

脳卒中, 2017
NAID 130005398505

Recent Update of Korea Acute Myocardial Infarction Registry (KAMIR)

日本冠疾患学会雑誌, 2017
NAID 130005316472

新規抗血小板薬

循環器内科 = Cardioangiology 79(4), 364-369, 2016-04
NAID 40020826768

Related Pictures

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★リンクテーブル★

リンク元	「クロピドグレル」「Plavix」
拡張検索	「clopidogrel sulfate」

「クロピドグレル」

Clopidogrel
Clinical data
Trade names	Plavix, others
AHFS/Drugs.com	Monograph
MedlinePlus	a601040
License data	US FDA: Plavix;
Pregnancy; category	AU: B1; US: B (No risk in non-human studies); ;
Routes of; administration	by mouth
ATC code	B01AC04 (WHO);
Legal status
Legal status	AU: S4 (Prescription only); UK: POM (Prescription only); US: ℞-only;
Pharmacokinetic data
Bioavailability	>50%
Protein binding	94–98%
Metabolism	liver
Onset of action	2 hours
Biological half-life	7–8 hours (inactive metabolite)
Duration of action	5 days
Excretion	50% kidney; 46% biliary
Identifiers
	IUPAC name (+)-(S)-methyl 2-(2-chlorophenyl)-2-(6,7-dihydrothieno[3,2-c]pyridin-5(4H)-yl)acetate;
CAS Number	113665-84-2 ;
PubChem CID	60606;
IUPHAR/BPS	7150;
DrugBank	DB00758 ;
ChemSpider	54632 ;
UNII	A74586SNO7;
KEGG	D07729 ;
ChEBI	CHEBI:37941 ;
ChEMBL	CHEMBL1771 ;
ECHA InfoCard	100.127.841
Chemical and physical data
Formula	C16H16ClNO2S
Molar mass	321.82 g/mol
3D model (JSmol)	Interactive image;
	SMILES COC(=O)[C@H](c1ccccc1Cl)N2CCc3c(ccs3)C2 ;
	InChI InChI=1S/C16H16ClNO2S/c1-20-16(19)15(12-4-2-3-5-13(12)17)18-8-6-14-11(10-18)7-9-21-14/h2-5,7,9,15H,6,8,10H2,1H3/t15-/m0/s1 ; Key:GKTWGGQPFAXNFI-HNNXBMFYSA-N ;
(verify)

　　[★]

英: clopidogrel、clopidogrel sulfate
商: プラビックス Plavix
化: 硫酸クロピドグレル

「Plavix」

　　[★]

プラビックス

関: clopidogrel

「clopidogrel sulfate」

　　[★]

硫酸クロピドグレル

関: clopidogrel

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[pmid.3D19258584-16] Ho PM, Maddox TM, Wang L, Fihn SD, Jesse RL, Peterson ED, Rumsfeld JS (2009). "Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome". Journal of the American Medical Association. 301 (9): 937–44. PMID 19258584. doi:10.1001/jama.2009.261.

[17] Stockl KM, Le L, Zakharyan A, Harada AS, Solow BK, Addiego JE, Ramsey S (April 2010). "Risk of rehospitalization for patients using clopidogrel with a proton pump inhibitor" (PDF). Arch Intern Med. 170 (8): 704–10. ISSN 1538-3679. PMID 20421557. doi:10.1001/archinternmed.2010.34.

[18] Wathion, Noël. "Public statement on possible interaction between clopidogrel and proton pump inhibitors" (PDF). Retrieved 31 March 2011.

[19] Hughes, Sue. "EMEA issues warning on possible clopidogrel-PPI interaction, but is there really a problem?". Retrieved 31 March 2011.

[20] Zakarija A, Bandarenko N, Pandey DK, Auerbach A, Raisch DW, Kim B, Kwaan HC, McKoy JM, Schmitt BP, Davidson CJ, Yarnold PR, Gorelick PB, Bennett CL (2004). "Clopidogrel-Associated TTP An Update of Pharmacovigilance Efforts Conducted by Independent Researchers, Pharmaceutical Suppliers, and the Food and Drug Administration" (PDF). Stroke. 35 (2): 533–8. PMID 14707231. doi:10.1161/01.STR.0000109253.66918.5E.

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[30] Clopidogrel Multum Consumer Information

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clopidogrel