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Dual antiplatelet therapy after stenting

More than 12 months of treatment might not be necessary.

More than one million men and women in the United States undergo artery-opening angioplasty and stent placement each year as a nonsurgical alternative to open heart surgery. Afterwards, most take the combination of clopidogrel (Plavix) and aspirin (called “dual antiplatelet therapy”) to prevent platelets from sticking together and forming a blood clot inside the stent. Some people take aspirin with prasugrel (Effient) or ticagrelor (Brilinta) instead of clopidogrel.

After stenting, aspirin should be taken for life, but no one has been sure just how long dual antiplatelet therapy should be continued. Consequently, the two drugs are generally prescribed for a minimum of two years after stenting. Some doctors have been recommending they be taken indefinitely.

Debating when to stop

A recent study provides some reassurance that it may be safe to stop as early as six months after stenting. The moderate-sized study, published in the May 1, 2012 issue of Circulation, found that 24 months of dual antiplatelet therapy after stenting was no better than six months and also increased the risk of bleeding. It was the third study to reach the same conclusion, and while the finding cannot be considered definite, doctors are warming to the idea.

“Our thinking has definitely shifted,” says Dr. Christopher Cannon, a cardiologist at Brigham and Women’s Hospital and a professor at Harvard Medical School. “If someone who had a heart attack a year ago is doing well, it was our tendency to continue the clopidogrel. Now we are thinking it may be time to stop.”

Generic clopidogrel is safe to use

If you take clopidogrel, it’s likely to cost you less now than in the past. That’s because Plavix lost its patent protection on May 17 and companies lined up to sell generic clopidogrel at a much lower price. Don’t be afraid to use it, says Dr. Cannon.

“Because a generic must prove to the FDA that it has the same anticlotting effect as clopidogrel, it’s really the same drug and should be safe. I recommend that all my patients switch over, because it’s money wasted otherwise,” he says.

Why it matters

Although dual antiplatelet therapy has benefits, it also has drawbacks. Because antiplatelet drugs prevent blood from clotting, they can cause bruising and internal bleeding. Surgery for any reason becomes risky, since bleeding can be hard to stop. For these reasons, the less time antiplatelet therapy is needed, the better.

But the Circulation study was small, so Dr. Cannon is not convinced that stopping dual antiplatelet therapy at six months is right for everyone. He continues to make the decision on an individualized basis. “It’s a tough call,” he says.

He looks forward to 2014, when the results of a 26,000-participant study led by Dr. Laura Mauri, his colleague at Brigham and Women’s Hospital, will become available.

“The results will give us a definitive answer to how long dual antiplatelet therapy is needed,” he says.

Should you stop taking antiplatelet therapy?

If you have been taking clopidogrel and aspirin longer than 6–12 months after receiving a stent, it’s perfectly okay to ask your doctor if you can stop, says Dr. Cannon. “Tell your doctor that you heard about a study that found no benefit and an increased risk of bleeding after taking dual antiplatelet therapy more than six months, and a low chance of having problems after stopping it. Ask if you really need these medications, and if not, can you stop,” he advises.

Posted by: Dr.Health

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