Coumadin vs. Plavix Differences and Similarities

• Coumadin (warfarin) and Plavix (clopidogrel bisulfate) are anticoagulant medications used to prevent blood clots, which can cause heart attacks and strokes. Coumadin and Plavix also may be prescribed for people with atrial fibrillation (AFib) because AFib increases the chance of blood clots that can cause a stroke.
• Side effects of Coumadin and Plavix that are similar and include:
  • Bleeding that may be severe
  • Rash
  • Jaundice (yellowing of eyes and skin) due to liver damage.
• Side effects of Coumadin that are different from Plavix include:
  • Gangrene (necrosis) of the skin
  • Purple and/or painful toes
  • Hair loss
  • Bloating
  • Diarrhea
• Side effects of Plavix that are different from Coumadin include:
  • Diarrhea
  • Itching
  • Abdominal pain
  • Headache
  • Chest pain
  • Muscle aches
  • Dizziness
  • Allergic reactions
  • Pancreatitis

Coumadin (warfarin) is an oral anticoagulant (a drug that inhibits the clotting of blood). Coumadin helps prevent the formation of blood clots and the extension of clots already formed, and minimizes the risk of embolization of blood clots to other vital organs such as the lungs and brain. Blood clots can occur in the veins of the lower extremities (deep venous thrombosis, DVT), and can break off and become lodged in blood vessels of the lung (pulmonary embolism), causing shortness of breath, chest pain, and even life-threatening shock. Blood clots also can occur in the atria of the heart during atrial fibrillation and around artificial heart valves. These clots also can break off and obstruct blood vessels in the brain, causing an embolic stroke with paralysis. The generic name for Coumadin is warfarin.

Plavix (clopidogrel bisulfate) is an antiplatelet drug used to prevent blood clots. Plavix is used to reduce the risk of heart attacks and strokes, particularly in people with a recent history of stroke or heart attack, and those with peripheral vascular disease (peripheral artery disease, PAD). Plavix works by irreversibly binding to the P2Y12 receptor on platelets, preventing adenosine diphosphate (ADP) from activating platelets. Plavix belongs to a class of drugs called P2Y12 inhibitors. Other P2Y12 inhibitors include ticagrelor (Brilinta) and prasugrel (Effient). Clopidogrel is similar to ticlopidine (Ticlid) in chemical structure and in the how it works. The generic name for Plavix is clopidogrel bisulfate.

Coumadin uses

• Coumadin (warfarin) is used in treating people with deep vein thrombosis (DVT) to prevent extension of the clot, and to reduce the risk of pulmonary embolism.
• People with pulmonary embolism are treated with warfarin to prevent further emboli.
• Warfarin also is used in people with atrial fibrillation or artificial heart valves to reduce the risk of strokes, and after a heart attack.
• It also is helpful in preventing blood clots from forming in certain orthopedic surgeries such as knee or hip replacements.
• Warfarin is used in preventing closure of coronary artery stents due to clotting.

Plavix uses

• Plavix (clopidogrel) is 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). The combination of clopidogrel and aspirin is better than aspirin or clopidogrel alone in preventing another heart attack but the risk of bleeding is higher.

Coumadin side effects

The two most serious side effects of warfarin include:

• Bleeding
• Necrosis (gangrene) of the skin

Bleeding can occur in any organ or tissue. Bleeding around the brain can cause severe headache and paralysis. Bleeding in the joints can cause joint pain and swelling. Bleeding in the stomach or intestines can cause weakness, fainting spells, black tarry stools, vomiting of blood, or coffee ground material. Bleeding in the kidneys can cause back pain and blood in urine.

Other side effects include:

• Purple, painful toes
• Rash
• Hair loss
• Bloating
• Diarrhea
• Jaundice (yellowing of eyes and skin)

Signs of overdose include bleeding gums, bruising, nosebleeds, heavy menstrual bleeding, and prolonged bleeding from cuts.

Plavix side effects

The tolerability of clopidogrel is similar to that of aspirin. The more common side effects of clopidogrel include:

• diarrhea,
• rash,
• itching,
• Abdominal pain
• headache,
• chest pain,
• muscle aches,
• dizziness.
• 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.

Coumadin dosage

• Warfarin may be taken with or without food.
• Treatment usually is started at 2 to 5 mg once daily and the dose is adjusted based in INR tests.
• Patients typically require 2 to 10 mg of warfarin daily.

Frequent blood tests (INR test) are performed to measure the effect of warfarin and to adjust dosing. There are published INR ranges for the various uses of warfarin.

Since warfarin is metabolized (inactivated) by the liver and then excreted by the kidneys, dosages need to be lowered in patients with liver and kidney dysfunction.

Plavix dosage

• Clopidogrel bisulfate usually is taken once daily. It can be taken with or without food.
• 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.

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.

Coumadin drug interactions

Many drugs, both prescription and nonprescription (OTC), can affect the anticoagulant action of warfarin or increase the risk of bleeding. Patients on warfarin should regularly consult their doctor before instituting any medications on their own. It also is advisable for patients on warfarin to carry identification such as bracelets to alert other health professionals to the presence of anticoagulation.

Drugs that increase the effect of warfarin by reducing the breakdown of warfarin include:

• amiodarone (Cordarone)
• trimethoprim/sulfamethoxazole (Bactrim)
• fluconazole (Diflucan)
• itraconazole (Sporanox)
• fluvastatin
• fluvoxamine
• metronidazole
• miconazole
• voriconazole (Vfend)
• zafirlukast (Accolate)
• ciprofloxacin (Cipro)
• cimetidine
• atorvastatin (Lipitor)
• clarithromycin (Biaxin)
• fluoxetine (Prozac)
• indinavir (Crixivan)
• ritonavir (Norvir)

Drugs and herbal products that may reduce the effect of warfarin by increasing its breakdown include:

• St. John's wort
• carbamazepine (Tegretol, Tegretol XR, Equetro, Carbatrol)
• rifampin
• bosentan (Tracleer)
• prednisone

Bleeding is increased by other anticoagulants, for example, heparin, argatroban (Acova), dabigatran (Pradaxa).

Bleeding is increased by antiplatelet drugs such as aspirin and other nonsteroidal anti-inflammatory drugs (for example, ibuprofen [Motrin], naproxen [Alleve]), clopidogrel (Plavix), and prasugrel (Effient); serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and paroxetine (Paxil).

Garlic and ginkgo also increase the risk of bleeding because they cause bleeding when taken alone.

Foods with high vitamin K content (for example, green leafy vegetables) reduce the effect of warfarin. Maintenance of a consistent intake of vitamin K containing foods is important to avoid fluctuations in the effect of warfarin.

Plavix drug interactions

The combination of clopidogrel with nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk of bleeding. Examples of NSAIDs include:

• Ibuprofen (Motrin, Advil, Nuprin)
• naproxen (Naprosyn, Aleve)
• diclofenac (Voltaren)
• etodolac (Lodine)
• nabumetone (Relafen)
• fenoprofen (Nalfon)
• flurbiprofen (Ansaid)
• indomethacin (Indocin)
• detoprofen (Orudis, Oruvail),
• oxaprozin (Daypro)
• piroxicam (Feldene)
• sulindac (Clinoril)
• tolmetin (Tolectin)
• mefenamic acid (Ponstel)

Combining Plavix 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 way include:

• fluoxetine (Prozac, Sarafem)
• cimetidine (Tagamet)
• fluconazole (Diflucan)
• ketoconazole (Nizoral, Extina, Xolegel, Kuric)
• voriconazole (Vfend)
• ethaverine (Ethatab, Ethavex)
• felbamate (Felbatol)
• fluvoxamine (Luvox)

Coumadin safety

• Warfarin should be avoided by pregnant women or women who may become pregnant. Birth defects and fetal bleeding have been reported.
• Available evidence suggests that warfarin is not secreted in breast milk.

Plavix safety

• 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.