Wednesday, November 7, 2007

Plavix

I felt like writing about my least favorite medicine today. It's called Plavix and it is probably the most dangerous med to have on board when dealing with surgical patients. Plavix (clopidogrel bisulfate) is an anti-platelet drug (like aspirin) that inhibits the binding of ADP to its platelet receptor, thus shutting down platelet aggegation. It's used a lot in patients who have had strokes or myocardial infarctions. After coronary angioplasty and stenting, plavix is used to prevent restenosis. Platelet aggregation leads to thrombosis; shut down platelet aggregation and, theoretically, long term patient outcomes will be better. Now the data to support Plavix, in my humble opinion, is a little suspect. The CAPRIE and CURE trials have established a "statistically significant" but atoundingly modest benefit of Plavix over aspirin. Combined Plavix/aspirin therapy seems to have a more substantial benefit. I'll leave the specifics to the professionals. All I know is that whenever someone shows up in the office for hernia/gallbladder/etc., one the first things I look for is whether the box for "Plavix use" is checked yes or no. I hate the stuff. Platelets are a surgeon's friend. During an operation, it doesn't take long to see the effects of Plavix use; skin edges that won't stop bleeding, the raw liver of the gallbladder fossa that persistently oozes like a skinned knee, taple lines that have to be oversewn. It's a royal pain in the ass. But it doesn't end there. The worst part is the long term effects. Platelets aren't just for clotting. They're actually the intial mediators of the entire inflammatory cascade. Dysfunctional platelets can impair wound healing and infection-fighting capabilities. I've had two seromas for inguinal hernias over the past 6 months. Both were in patients on Plavix. Now, I usually stop it 7 days in advance of an operation, but maybe that's not long enough; lately I keep them off it for 10 days. The other problem is when patients come in with acute surgical illnesses and are on Plavix. You can give platelet transfusions or just bite the bullet. Either way, your stress quotient gets amped up significantly. And non-surgeons won't touch these patients for any interventions. I have a lady in the hospital now with choledocholithiasis who needs an ERCP prior to her lap chole, but the GI guy wants to wait a week before doing a sphincterotomy (reasonable, as she isn't toxic). So I hope this magic pill is preventing thousands of strokes and heart attacks every year because it doesn't do me any favors.

18 comments:

rlbates said...

Buckeye, it seems that Plavix like so many other things in life have a good/bad thing going on. It's nice when we have time to ask them to stop taking Plavix and ASA ahead of time. Tough for all iinvolved when we can't.

On another front, have you submitted any of your posts lately to SurgeXperiences (http://surgexperiences.wordpress.com/2007/11/02/surgexperiences-108-to-be-hosted-at-aggravated-docsurg/)?

enrico said...

It's also used for intermittent claudication in lower extremities, meaning that you have even more people on it for even lesser reasons (morbidity-wise).

Is there a problem with giving FFP (I assume) beforehand on an acute case where you know you might run into issues?

Buckeye Surgeon said...

Ramona- I just posted one. Thanks for the reminder.

Enrico- I agree. The data on plavix for peripheral vascular disease is severely lacking. FFP isn't going to do a lot of good for platelet dysfunction. I have given pooled platelet transfusions prior to a case though.

Anonymous said...

How does the this problem compare to people on the rat poison going in for surgery? I assume coumadin isn't a problem because people tend to control their dosage better and this anticoagulant is different?

Buckeye Surgeon said...

surprisingly, Id rather operate emergently on someone with an INR of 2 rather than someone with platelet dysfunction. In addition to clotting, the plavix effects healing AND infectious issues...

2badatmath4medschool said...

Plavix...grrrrr. At age 72 years, my mother was taking Plavix, had persistent anemia, known GI bleeding of several months (oddly enough, coincided with the anemia~ yes, sarcasm here), and a colonoscopy that two months prior had shown diverticulitis in the descending colon. She awoke one morning with brisk bleeding, and was operated on an emergent basis that night. She nearly died, and was in intensive care for 4 weeks. I had not been privy to all of the above until after the surgery. As a lay person, I was, um, ...puzzled... as to how the relation had not been made between the diverticulitis, months-long GI bleeding, persistent anemia and Plavix.

Anonymous said...

Hi Buckeye

My husband has been diagnosed with anemia, and has been on Plavix for just over four years since having a TIA. They have just done a colonoscopy and gastroscopy and found nothing. Next is a camera pill. What are your opinions regarding Plavix causing anemia; have you had patients like this?
Tx
Jenny from Australia

Buckeye Surgeon said...

Anon-
I agree with the capsule endoscopy. WOuld also check guaic positivity on the stool samples (positive tests seen in occult GI bleeds). Plavixcan certainly potentiate an underlying GI lesion (AVM, polyp, ulcer, etc) and cause bleeding. Sounds like your docs are doing the right things.....

Anonymous said...

Plavix is known to produce anemia as a side effect. Do you know how common this is, and how severe? I know someone who received a drug-eluding stint after a heart attack, and is now required to take plavix. She recently had to be given a blood transfusion because her hemoglobin levels had dropped to about 5.6 grams per milligram. She is also taking blood thinners. Could plavix and/or these blood thinners be the cause for her anemia? If you or anyone wants to respond by email, I can be reached at michael.overlin@gmail.com

Anonymous said...

(i meant 5.6 grams per 100 millileters)

Anonymous said...

Hi again Buckeye

My husband (anon from Australia)with anemia, is wanting to stop taking Plavix and take low dose Aspirin (Cartia or Cardiprin) instead. What is your opinion? He has had headaches since he started Plavix four years ago (besides the anemia) and he is really wanting to change to see if the headaches go, and maybe reduce the anemia. His mum has had anemia bouts all her life, and he feels that he may have inherited that, but by taking the Plavix has aggrevated it.
Regards
Jenny, Australia

Anonymous said...

Dr. Parks--I was very interested in your Plavix comments--as a lay person I had reached the same conclusions on Plavix affecting wound healing. I have cerebral aneurysm--stents & coils, and have taken Plavix and aspirin regime for years. More recently, had plastic surgery--off Plavix for 21 days pre surgery, then back on immediately---having terrible time with healing. When second procedure was scheduled to address the non-healing (excize wound, etc.), went back off Plavix again to get ready for procedure, and suddenly after 3 months of no healing--started getting remarkable healing.. Question--are you aware of any major studies on this affect of Plavix, and do you keep patients off Plavix post surgery to assist with healing? I would be interested in sharing this info with my surgeons.. in case needed in the future..

Thanks!

Anonymous said...

My husband is taking plavix...he is also on PD dialysis and suddenly is having a hard time with anemia. He just had a hospital stay because of his anemia where he had to get 2 units of blood and IV iron...and he's still getting IV iron. Could Plavix cause anemia?

Anonymous said...

Please stop Plavix, take fish oil, drink apple cider vinegar, eat garlic, they are all found to thin blood. Aspirin is much safer as well. My dad has taken Plavix for about one month after a DES placement and his hemoglobin dropped from 130 g/L to 65 g/L. He has severe anemia. This drug is a killer please find an alternative. Please

Anonymous said...

I've been on Plavix since August 1st when I had a stent put in a vein. On March 14th I was in the ER, so weak, and they discovered I needed a blood transfusion.

Since then I have had 2 iron infusions, and last week an endoscopy, colonoscopy, cat scan, and tomorrow a hidascan. At every appointment I write down the drugs I am on, starting with Plavix.

NOBODY has mentioned that there's a connection between Plavix and anemia -- no one -- not the hematologist, cardiologist, gastroenterologist, or GP. My sister in law (not a medical person) suggested I explore the link.

I live in a small town in upstate New York -- is it possible that the doctors here aren't staying current? How could my sister-in-law know this and no one else has mentioned it?

On Friday I see the hematologist to look at my numbers to see if a bone marrow biopsy is next. If this has been caused by Plavix, on the one hand I'd be relieved, but on the other I will be very upset if these doctors don't know it could be responsible. I also underwent a second angiogram when my weakness started (end of February).

This has wreaked havoc with my work (I'm self-employed). Is this plavix/anemia connection something that's just been discovered?

Thanks if you can answer.
Christine

Michael said...

This was very helpful. I am a male 55yrs and have 6 stents as of now. I've had 2 heart attacks due to artery clogging but my heart is strong. I've been on Plavix for 8 moths now. I went into the hospital for what they think may be anemia. I've been having rectal bleeding since I've been on the medication but attributed it to hemoroids. What used to be a simple walk for me just about kills me or at least it feels like it. What I need to know is...can it? Should I excercise even though my hemoglobin is low (11.6) and I suffer from shortness of breath and chest tightening?

Anonymous said...

I shall NO longer doubt my doctor's expertise and advise. I attempted (by myself)to go off of my statin medication (Lipitor) and Plavix because of the side effects and low and behold, one month later, I suffered a mini stroke! Playing doctor is STUPID! Playing with so-called natural "cures" is even dumber! There is NO natural cure for anything! Your doctor means well. And don't believe the bulls*** that your doc is in the pockets of the drug companies. It's NOT true. Your doctor dedicated his/her life with MANY years of education. Too many people are just plain stupid and never even set foot on a college campus. LISTEN TO YOUR DOCTOR! THEY KNOW MUCH MORE THAN YOU DO!!!!!!

Anonymous said...

I have been on plavix/cartia regime for 6 yrs after stenting.
two years after commencing plavix I was rushed to hospital emergency with perforated small intestine also have an inflamed digestive system - all since commencing plavix