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- Plavix (clopidogrel) vs. Coumadin (warfarin): What's the difference?
- What is clopidogrel? What is warfarin?
- What are the side effects of clopidogrel and warfarin?
- What is the dosage of clopidogrel vs. warfarin?
- What drugs interact with clopidogrel and warfarin?
- Are clopidogrel and warfarin safe to use while pregnant or breastfeeding?
Plavix (clopidogrel) vs. Coumadin (warfarin): What's the difference?
- Clopidogrel and warfarin are blood thinners used to prevent blood clots.
- A brand name for clopidogrel is Plavix.
- Brand names for warfarin include Coumadin and Jantoven.
- Side effects of clopidogrel and warfarin that are similar include increased bleeding, rash, and diarrhea.
- Side effects of clopidogrel that are different from warfarin include itching, abdominal pain, headache, chest pain, muscle aches, dizziness, allergic reactions, pancreatitis, and liver failure.
- Side effects of warfarin that are different from clopidogrel include necrosis (gangrene) of the skin, purple and painful toes, hair loss, bloating, and yellowing of eyes and skin (jaundice).
What is clopidogrel? What is warfarin?
Clopidogrel is an anti-platelet drug, which is a type of blood thinner, used to prevent strokes, heart attacks, and death in high-risk patients who have had a previous stroke, unstable angina, heart attack, or have peripheral arterial disease (PAD). Clopidogrel works to prevent blood clots by binding to P2Y12 receptors on platelets and preventing adenosine diphosphate (ADP) from activating them. Clopidogrel belongs to the P2Y12 inhibitor drug class, which also includes ticagrelor (Brilinta) and prasugrel (Effient). Clopidogrel is similar to ticlopidine (Ticlid) in chemical structure and in the way it works.
Warfarin is an anticoagulant (blood thinner) prevents the formation of blood clots by reducing the production of factors by the liver that promote clotting, factors II, VII, IX, and X, and the anticoagulant proteins C and S. The production of these factors by the liver are dependent on adequate amounts of vitamin K. Warfarin reduces the production of the factors because it antagonizes vitamin K. Warfarin is used to treat deep vein thrombosis (DVT) to prevent extension of the clot and to reduce the risk of pulmonary embolism, pulmonary embolism to prevent further emboli, and in patients with atrial fibrillation or artificial heart valves to reduce the risk of strokes, and after a heart attack. Warfarin 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.
What are the side effects of clopidogrel and warfarin?
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 two most serious side effects of warfarin are:
- 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:
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What is the dosage of clopidogrel vs. warfarin?
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.
- Warfarin may be taken with or without food.
- 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.
- 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.
- 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.
What drugs interact with clopidogrel and warfarin?
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).
- 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.
- A few examples of drugs that interact with warfarin are:
- 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), and ritonavir (Norvir).
- Drugs 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), and prednisone.
- Bleeding is increased by other anticoagulants such as heparin, argatroban (Acova), dabigatran (Pradaxa), and others; 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
Are clopidogrel and warfarin 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.
• 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 (clopidogrel) and Coumadin (warfarin) are blood thinners used to prevent blood clots. Side effects of clopidogrel and warfarin that are similar include increased bleeding, rash, and diarrhea.
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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.
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.
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.
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.
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.
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Migraine and Stroke
Migraine headache is a type of headache in which the exact cause is not known; however, they may be inherited, and certain foods and environmental factors can trigger and may contribute them. A stroke (brain attack) happens when a blood vessel in the brain leaks, bursts, or becomes blocked, which can be caused by many other health problems. Both migraines and strokes can can cause severe head pain (migraine pain usually is only on one side of the head). Migraine aura symptoms may mimic or feel like a stroke or mini-stroke (transient ischemic attack, TIA) because they have similar symptoms and signs like severe headache, numbness in the legs, feet, arms, hands, or face, nausea, vomiting, and dizziness. Other migraine aura symptoms include vision problems like flashing lights or blind spots in one eye. The main difference between migraine headache and stroke symptoms and signs is that a migraine headaches usually come on gradually while a stroke symptoms come on suddenly and unexpectedly.
DVT (Deep Vein Thrombosis) During Pregnancy
Deep vein thrombosis or DVT is a condition in which a blood clot becomes embedded in one of the deep veins of the arms, thighs, pelvis, or lower legs. Warning signs and symptoms of DVT include pain, warmth, redness, swelling, leg cramps, and worsening leg pain in the affected extremity. Many conditions and other factors can cause DVTs, for example, during pregnancy including postpartum (6-8 weeks after delivery of the baby), obesity, heart attacks or heart failure, cancer, birth control pills (oral contraceptives), recent surgery, high altitudes, and advanced age. Treatment guidelines for DVT diagnosed during pregnancy is anticoagulation (anti-clotting) drugs, usually, low-molecular-weight heparins. DVT treatment may need to be continued postpartum. Warfarin (Coumadin, Jantoven) should not be used to treat DVT during pregnancy because it can harm the developing fetus.
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.
DVT and Birth Control Pills (Oral Contraceptives)
Deep vein thrombosis (DVT) is a blood clot that has traveled deep into the veins of the arm, pelvis, or lower extremities. Oral contraceptives or birth control pills can slightly increase a woman's risk for developing blood clots, including DVT. DVT symptoms and signs in the leg include leg or calf pain, redness, swelling, warmth, or leg cramps, and skin discoloration. If a blood clot in the leg is not treated, it can travel to the lungs, which can cause a pulmonary embolism (blood clot in the lung) or post-thrombotic syndrome, both of which can be fatal if not treated immediately. Increased risk factors for DVT and birth control pills include over 40 years of age, family history, smoking, and obesity. Other medical problems that increase the risks of blood clots, for example, lung or heart disease, or inflammatory bowel disease or IBD (Crohn's disease and ulcerative colitis (UC). Other options for preventing pregnancy include IUDs, birth control shots, condoms, diaphragms, and progestin-only oral contraceptives.
Stroke vs Aneurysm (Differences and Similarities)
A stroke or "brain attack" is caused because blood flow to an area of the brain has been cut off by a blood clot or by a weakened or damaged blood vessel (for example, head trauma). The damaged area of the brain dies, which results in loss of function like speech capabilities, muscle movement, or muscles of an extremity like an arm or leg is reduced or lost completely. An aneurysm is a weakness in an artery wall. This weakness in the wall causes the artery to widen or balloon out, and then they rupture or break open.
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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