Anticoagulant Use (Aspirin, Clopidogrel, Warfarin)

Nisha K. Patel, PharmD, MBA, BCPS, Sheldon H. Gottlieb, M.D.
Anticoagulant Use (Aspirin, Clopidogrel, Warfarin) is a topic covered in the Johns Hopkins Diabetes Guide.

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INDICATIONS

FDA

  • Aspirin:
    • In patients who have undergone revascularization procedures (ie. coronary artery bypass graft, percutaneous coronary angioplasty, carotid endarterectomy)
    • To reduce the combined risk of death and nonfatal stroke in patients who have had a stroke or transient ischemic attack
    • To reduce the risk of vascular mortality in patients with suspected myocardial infarction (MI)
    • To reduce the combined risk of death and nonfatal MI in patients with a previous MI or unstable angina (UA)
    • To reduce the combined risk of MI and sudden death in patients with chronic stable angina
  • Clopidogrel (Plavix):
    • Acute coronary syndrome:
      • STEMI: to reduce the rate of MI and stroke in conjunction with aspirin in patients with acute ST elevation MI (STEMI) who are to be managed medically
      • UA/Non-STEMI: to decrease the rate of MI and stroke in conjunction with aspirin in in patients with Non-STEMI/UA, including patients who are to be managed medically and those who are to be managed with coronary revascularization
    • To reduce the rate of MI and stroke in patients with a history of recent MI, stroke, or established peripheral arterial disease
  • Warfarin:
    • Prophylaxis and treatment of thromboembolic disorders and embolic complications arising from atrial fibrillation or cardiac valve replacement
    • Adjunct to reduce the risk of systemic embolism after MI
  • Dabigatran (Pradaxa):
    • Primary and secondary prevention of stroke and systemic embolism (SSE) in non-valvular atrial fibrillation
    • Treatment and prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE)
    • VTE prophylaxis after hip arthroplasty
  • Rivaroxaban (Xarelto):
    • Primary and secondary prevention of SSE in non-valvular atrial fibrillation
    • Reduction of risk of major cardiovascular events in patients with coronary artery disease or peripheral artery disease
    • Reduction in the risk of recurrent VTE in patients at continued risk of VTE following at least 6 months of initial full therapeutic anticoagulant treatment
    • Treatment of VTE
    • VTE prophylaxis after hip or knee arthroplasty
  • Apixaban (Eliquis):
    • Treatment of VTE
    • Reduction in the risk of recurrent VTE following initial therapy
    • Reduction in the risk of SSE in patients with non-valvular atrial fibrillation
    • Postoperative VTE prophylaxis following hip or knee arthroplasty
  • Edoxaban (Savaysa):
    • To reduce the risk of SSE in patients with non-valvular atrial fibrillation
    • Treatment of VTE following 5 to 10 days of initial therapy with a parenteral anticoagulant

NON-FDA APPROVED USES

  • Aspirin: primary prevention of cardiovascular events in patients with diabetes (see Routine Preventive Care), primary prophylaxis in coronarty arteriosclerosis, peripheral artery disease
  • Clopidogrel (Plavix): primary prevention not established.
  • Warfarin: primary prevention not established.
  • Pradaxa, Rivaroxaban, Apixaban: primary prevention not established. Note FDA warnings re: mechanical heart valves.

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INDICATIONS

FDA

  • Aspirin:
    • In patients who have undergone revascularization procedures (ie. coronary artery bypass graft, percutaneous coronary angioplasty, carotid endarterectomy)
    • To reduce the combined risk of death and nonfatal stroke in patients who have had a stroke or transient ischemic attack
    • To reduce the risk of vascular mortality in patients with suspected myocardial infarction (MI)
    • To reduce the combined risk of death and nonfatal MI in patients with a previous MI or unstable angina (UA)
    • To reduce the combined risk of MI and sudden death in patients with chronic stable angina
  • Clopidogrel (Plavix):
    • Acute coronary syndrome:
      • STEMI: to reduce the rate of MI and stroke in conjunction with aspirin in patients with acute ST elevation MI (STEMI) who are to be managed medically
      • UA/Non-STEMI: to decrease the rate of MI and stroke in conjunction with aspirin in in patients with Non-STEMI/UA, including patients who are to be managed medically and those who are to be managed with coronary revascularization
    • To reduce the rate of MI and stroke in patients with a history of recent MI, stroke, or established peripheral arterial disease
  • Warfarin:
    • Prophylaxis and treatment of thromboembolic disorders and embolic complications arising from atrial fibrillation or cardiac valve replacement
    • Adjunct to reduce the risk of systemic embolism after MI
  • Dabigatran (Pradaxa):
    • Primary and secondary prevention of stroke and systemic embolism (SSE) in non-valvular atrial fibrillation
    • Treatment and prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE)
    • VTE prophylaxis after hip arthroplasty
  • Rivaroxaban (Xarelto):
    • Primary and secondary prevention of SSE in non-valvular atrial fibrillation
    • Reduction of risk of major cardiovascular events in patients with coronary artery disease or peripheral artery disease
    • Reduction in the risk of recurrent VTE in patients at continued risk of VTE following at least 6 months of initial full therapeutic anticoagulant treatment
    • Treatment of VTE
    • VTE prophylaxis after hip or knee arthroplasty
  • Apixaban (Eliquis):
    • Treatment of VTE
    • Reduction in the risk of recurrent VTE following initial therapy
    • Reduction in the risk of SSE in patients with non-valvular atrial fibrillation
    • Postoperative VTE prophylaxis following hip or knee arthroplasty
  • Edoxaban (Savaysa):
    • To reduce the risk of SSE in patients with non-valvular atrial fibrillation
    • Treatment of VTE following 5 to 10 days of initial therapy with a parenteral anticoagulant

NON-FDA APPROVED USES

  • Aspirin: primary prevention of cardiovascular events in patients with diabetes (see Routine Preventive Care), primary prophylaxis in coronarty arteriosclerosis, peripheral artery disease
  • Clopidogrel (Plavix): primary prevention not established.
  • Warfarin: primary prevention not established.
  • Pradaxa, Rivaroxaban, Apixaban: primary prevention not established. Note FDA warnings re: mechanical heart valves.

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Last updated: November 1, 2020