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- Clopidogrel vs. Xarelto: What's the difference?
- What is Clopidogrel? What is Xarelto?
- What are the side effects of clopidogrel and Xarelto?
- What is the dosage for clopidogrel vs. Xarelto?
- What drugs interact with clopidogrel and Xarelto?
- Are clopidogrel and Xarelto safe to use while pregnant or breastfeeding?
Clopidogrel vs. Xarelto: What's the difference?
- Clopidogrel and Xarelto (rivaroxaban) are blood thinners used for preventing strokes, heart attacks, and death in individuals who have had a previous stroke, unstable angina, heart attack, or have peripheral arterial disease (PAD).
- Xarelto is also used to treat and reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) and reduce the risk of blood clots in the legs and lungs of patients who have just had hip or knee replacement surgery.
- A brand name for clopidogrel is Plavix.
- Side effects of clopidogrel and Xarelto that are similar include itching and increased bleeding.
- Side effects of clopidogrel that are different from Xarelto include diarrhea, rash, abdominal pain, headache, chest pain, muscle aches, dizziness, allergic reactions, pancreatitis, and liver failure.
- Side effects of Xarelto that are different from clopidogrel include back pain and elevated levels of liver enzymes.
What is Clopidogrel? What is Xarelto?
Clopidogrel is an anti-platelet drug used for preventing strokes, heart attacks, and death in high-risk individuals who have had a heart attack, unstable angina, previous stroke, or have peripheral arterial disease (PAD). It prevents blood clots by binding to the P2Y12 receptor on platelets, preventing adenosine diphosphate (ADP) from activating platelets. Clopidogrel is a P2Y12 inhibitor, a drug class that also includes ticagrelor (Brilinta) and prasugrel (Effient). Clopidogrel is similar to ticlopidine (Ticlid) in chemical structure and in the way it works.
Xarelto (rivaroxaban) is an anticoagulant (blood thinner) used to prevent and treat blood clots. Blood clots formed in the heart are dangerous since they can travel to the brain and cause a stroke. Blood clots formed in the legs or lungs can also be life threatening if not treated. Xarelto is a selective inhibitor of factor Xa, an enzyme necessary to form blood clots. It reduces the ability of blood to clot. Xarelto is used to reduce the risk of stroke and blood clots in patients with atrial fibrillation not due to a heart valve problem, to treat and reduce the risk of deep vein thrombosis (DVT, blood clots in the veins of the legs) and pulmonary embolism (PE, blood clots in the lungs) and reduce the risk of blood clots in the legs and lungs of patients who have just had hip or knee replacement surgery. In combination with aspirin, Xarelto is used to reduce the risk of major cardiovascular events in patients with chronic coronary artery disease (CAD) or peripheral artery disease (PAD).
What are the side effects of clopidogrel and Xarelto?
The tolerability of clopidogrel is similar to that of aspirin. The more common side effects of clopidogrel are:
- Abdominal pain
- chest pain,
- muscle aches,
- severe bleeding,
- allergic reactions,
- pancreatitis, and
- liver failure.
Ticlopidine (Ticlid) is an antiplatelet medication quite similar to clopidogrel. It has been associated with a severe reduction in white blood cell count in between 0.8% and 1% of persons. The risk of this dangerous side effect with clopidogrel is about 0.04%, much less than with ticlopidine but twice that of aspirin.
Clopidogrel rarely causes a condition called thrombotic thrombocytopenic purpura (TTP) in one out of every 250,000 people. TTP is a serious condition in which blood clots form throughout the body. Blood platelets, which participate in clotting, are consumed, and the result can be bleeding because enough platelets are no longer left to allow blood to clot normally. For comparison, the related drug, ticlodipine (Ticlid), causes TTP 17-50 times more frequently than clopidogrel.
The most common side effect of Xarelto is bleeding. The risk of bleeding is higher when Xarelto is taken with medicines such as aspirin or aspirin-containing products, nonsteroidal anti-inflammatory drugs (NSAIDS), warfarin (Coumadin, Jantoven), heparin, clopidogrel (Plavix), and other medicines used to prevent or treat blood clots.
Some rare but serious cases of bleeding and paralysis have been reported with the use of Xarelto in patients undergoing spinal or epidural procedures. Risk is highest in patients who have problems with their spine, use indwelling epidural catheters, have had spinal surgery, or use other medicines that prevent clotting or make them more likely to bleed.
Other common side effects of Xarelto include:
- Back pain
- Pruritus (itching)
- Elevated levels of liver enzymes
Serious side effects of Xarelto include:
- Severe bleeding
- Decreased platelets
- Allergic reactions
- Stevens-Johnson syndrome
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What is the dosage for clopidogrel vs. Xarelto?
Clopidogrel bisulfate usually is taken once daily. It can be taken with or without food. Clopidogrel is activated by enzymes in the liver to its active form. Individuals who have reduced activity of liver enzymes that activate clopidogrel due to liver disease may not adequately respond to clopidogrel. Alternative treatments should be used for these patients. The recommended dose for treating unstable angina or heart attack is 300 mg initially followed by 75 mg daily in combination with 75-325 mg of aspirin. Peripheral arterial disease or recent stroke is treated with 75 mg daily.
- To reduce the risk of stroke in nonvalvular atrial fibrillation, patients with creatinine clearance (a measure of kidney function) >50 ml/min should be given 20 mg once a day with the evening meal. (Xarelto is better absorbed if it is given with food.) Patients with creatinine clearance between 15 to 50 ml/min should be given 15 mg once a day with the evening meal.
- To treat blood DVT or pulmonary embolism, 15 mg is administered by mouth twice daily with food for the first 21 days, followed by 20 mg once daily with food for 6 months.
- To reduce the risk of recurrence of DVT or pulmonary embolism, 20 mg should be administered by mouth once daily with food.
- To prevent DVT following hip replacement surgery, 10 mg is administered by mouth once daily for 35 days.
- To prevent DVT following knee replacement surgery, 10 mg is administered by mouth once daily for 12 days.
- When switching from warfarin (Coumadin) to rivaroxaban, warfarin should be stopped and then rivaroxaban started as soon as the international normalized ratio (a measure of the effects of warfarin) is < 3.0.
- When switching from blood thinning medicines other than warfarin to rivaroxaban, rivaroxaban should be started up to 2 hours before or at the time of the next scheduled evening dose.
- Use of rivaroxaban is not recommended in patients with moderate (Child-Pugh B) and severe (Child-Pugh C) liver disease or another type of liver disease associated with blood disorders.
- To avoid serious side effects rivaroxaban should not be used in patients with significantly reduced kidney function defined as creatinine clearance <30 ml/min.
- Patients who are having difficulty swallowing whole tablets can crush the 10 mg, 15 mg, and 20 mg tablets and mix with applesauce immediately before use.
- • Note: While the 15 and 20 mg tablets should be taken with food, the 10 mg tablets can be taken with or without food.
What drugs interact with clopidogrel and Xarelto?
The combination of clopidogrel with nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin, Advil, Nuprin), naproxen (Naprosyn, Aleve), diclofenac (Voltaren), etodolac (Lodine), nabumetone (Relafen), fenoprofen (Nalfon), flurbiprofen (Ansaid), indomethacin (Indocin), ketoprofen (Orudis; Oruvail), oxaprozin (Daypro), piroxicam (Feldene), sulindac (Clinoril), tolmetin (Tolectin), and mefenamic acid (Ponstel) may increase the risk of stomach and intestinal bleeding.
Combining clopidogrel with warfarin (Coumadin) or other drugs that cause bleeding increases the risk of bleeding.
Clopidogrel is converted to its active form by enzymes in the liver. Drugs that reduce the activity of these enzymes, for example, omeprazole (Prilosec, Zegerid) or esomeprazole (Nexium) may reduce the activity of clopidogrel and should not be used with clopidogrel. Other drugs that also may react with clopidogrel in a similar fashion include fluoxetine (Prozac, Sarafem), cimetidine (Tagamet), fluconazole (Diflucan), ketoconazole (Nizoral, Extina, Xolegel, Kuric), voriconazole (Vfend), ethaverine (Ethatab, Ethavex), felbamate (Felbatol), and fluvoxamine (Luvox).
The CYP3A4 liver enzymes and P-glycoprotein (P-gp) drug transporter systems are primarily responsible for metabolizing and removing Xarelto from the body. Taking Xarelto with medicines that alter the activity of both the CYP3A4 enzymes and P-gp drug transporters may affect blood levels of Xarelto. Xarelto should not be taken with:
- ketoconazole (Nizoral),
- ritonavir (Norvir),
- clarithromycin (Biaxin),
- erythromycin (Ery-Tabs),
- fluconazole (Diflucan),
- carbamazepine (Tegretol),
- phenytoin (Dilantin),
- rifampin (Rimactane), or,
- St. John's Wort.
Xarelto should not be used with other blood thinners due to the increased risk of bleeding.
Are clopidogrel and Xarelto safe to use while pregnant or breastfeeding?
There are no adequate studies of clopidogrel in pregnant women.
Studies in rats have shown that clopidogrel appears in breast milk; however, it is not known whether it also appears in human breast milk. Because of a potential for side effects in the nursing infant, the physician must weigh the potential benefits and possible risks before prescribing clopidogrel to nursing mothers.
- Due to the lack of conclusive safety data, Xarelto should be used in pregnancy only if the potential benefit justifies the potential risk to the fetus. Xarelto is classified as FDA pregnancy risk category C (animal studies show harm but there are no adequate studies in humans).
- It is not known if Xarelto is excreted in breast milk. Because many drugs enter human milk and have the potential of causing harm to the nursing baby, Xarelto should be used cautiously in nursing mothers.
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Plavix (clopidogrel) and Xarelto (rivaroxaban) are blood thinners used for preventing strokes, heart attacks, and death in individuals who have had a previous stroke, unstable angina, heart attack, or have peripheral arterial disease (PAD). Xarelto is also used to treat and reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) and reduce the risk of blood clots in the legs and lungs of patients who have just had hip or knee replacement surgery.
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Related Disease Conditions
Deep Vein Thrombosis (DVT, Blood Clot in the Legs)
Deep vein thrombosis (DVT) is a blood clot in the deep veins, and can be caused by broken bones, trauma to a limb, immobility, medications, smoking, cancer, genetic predisposition, and cancer. Symptoms of a deep vein thrombosis in a leg are swelling, tenderness, redness, warmth, and pain. Treatments for DVT include medications and surgery.
A stroke is an interruption of the blood supply to part of the brain caused by either a blood clot (ischemic) or bleeding (hemorrhagic). Symptoms of a stroke may include: weakness, numbness, double vision or vision loss, confusion, vertigo, difficulty speaking or understanding speech. A physical exam, imaging tests, neurological exam, and blood tests may be used to diagnose a stroke. Treatment may include administration of clot-busting drugs, supportive care, and in some instances, neurosurgery. The risk of stroke can be reduced by controlling high blood pressure, high cholesterol, diabetes, and stopping smoking.
Stroke vs. Mini-Stroke (TIA) Differences
A stroke or "brain attack" occurs when a blood clot or artery ruptures within the brain. The rupture or clot causes brain cell damage or death. A mini-stroke (TIA, transient ischemic attack) is caused by brain cells that dysfunctional over a short period. Stroke and mini-stroke warning signs of stroke and mini stroke are the same, and include, speech problems, weakness, numbness, and facial droop. Side effects of stroke may be permanent and you may never regain full function of the parts of the body affected. Mini-stroke side effects usually resolve within minutes to a couple of days. A transient ischemic attack (mini-stroke) is a precursor for stroke because 40% of individuals who have a mini-stroke will have a stroke within a year. Treatment of stroke depends upon the type and parts of the body affected.
Pulmonary Embolism (Blood Clot in the Lung)
A pulmonary embolism (PE) occurs when a piece of a blood clot from deep vein thrombosis (DVT) breaks off and travels to an artery in the lung where it blocks the artery and damages the lung. The most common symptoms of a pulmonary embolism are shortness of breath, chest pain, and a rapid heart rate. Causes of pulmonary embolism include prolonged immobilization, certain medications, smoking, cancer, pregnancy, and surgery. Pulmonary embolism can cause death if not treated promptly.
Early Warning Signs and Symptoms of Stroke (FAST)
Stroke is a serious medical condition. If you think you or someone you know is having a stroke call 911 immediately. There are two main types of strokes, hemorrhagic and ischemic (the most common type). A hemorrhagic stroke occurs due to a blood vessel rupture in the brain. An ischemic stroke occurs when a blood clot becomes lodged in a blood vessel in the brain, which causes a loss of blood supply to the brain, possibly causing brain tissue death. FAST is an acronym that helps people identify stroke signs and symptoms so they can act fast and call 911. Face drooping, Arm weakness, and Speech difficulty are indicators that a person may be having a stroke and it is Time to seek emergency medical treatment. Additional signs and symptoms of stroke may include weakness, difficulty walking, blurred vision, dizziness, headache, confusion, difficulty speaking, and loss of sensation. Stroke is a major cause of death and disability in the U.S. Early identification and treatment of stroke helps reduce the risk of morbidity and mortality.
Blood Clots (in the Leg)
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for causes of blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
Transient Ischemic Attack (TIA, Mini-Stroke)
When a portion of the brain loses blood supply, through a blood clot or embolus, a transient ischemic attack (TIA, mini-stroke) may occur. If the symptoms do not resolve, a stroke most likely has occurred. Symptoms of TIA include: confusion, weakness, lethargy, and loss of function to one side of the body. Risk factors for TIA include vascular disease, smoking, high blood pressure, high cholesterol, and diabetes. Treatment depends upon the severity of the TIA, and whether it resolves.
Heart Attack vs. Stroke Symptoms, Differences, and Similarities
Heart attack usually is caused by a clot that stops blood flow supplying oxygen to an area of heart muscle, which results in heart muscle death. Stroke or "brain attack" is caused by a loss of blood supply to the brain (usually a blood clot) or by hemorrhagic stroke (bleeding within the brain), which results in brain tissue death. Both heart attack and stroke usually come on suddenly, produce similar symptoms, can be disabling, and can be fatal. The classic symptoms and warning signs of heart attack are different. Classic heart attack warning signs are chest pain or discomfort, shortness of breath, pain that radiates to the shoulders, back, arms, belly, jaw, or teeth, sweating, fainting, and nausea and vomiting. Moreover, woman having a heart attack may have additional symptoms like abdominal pain or discomfort, dizziness, clammy skin, and moderate to severe fatigue. The classic symptoms and warning signs that a person is having a stroke are confusion or loss of consciousness, sudden severe headache, speech problems, problems seeing out of one or both eyes, and numbness or weakness of only one side of the body. Moreover, a woman having a stroke may have additional warning symptom and signs like shortness of breath, disorientation, agitation, behavioral changes, weakness, nausea, vomiting, seizures, and hiccups. Recognition of stroke symptoms is vital for emergency treatment. The acronym "FAST" stands for recognition of Facial drooping, Arm weakness, Speech difficulty, and a Time for action. If you experience the symptoms heart attack or stroke (FAST) or see them develop in another person, then contact 911 immediately.
Stroke is the third leading killer in the United States. Some of the warning signs of stroke include sudden confusion, trouble seeing with one or both eyes, dizziness, loss of balance, and more. Stroke prevention and reatable risk factors for stroke include lowering high blood pressure, quit smoking, heart disease, diabetes control and prevention.
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