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Drug Insight: clopidogrel nonresponsiveness

Nature Clinical Practice Cardiovascular Medicine volume 3, pages 387–395 (2006)Cite this article

Abstract

Platelet reactivity to agonists and subsequent activation are important factors that affect the development of atherothrombosis and resultant ischemic events. Pharmacologic intervention with clopidogrel and aspirin during acute coronary syndromes and percutaneous coronary intervention is considered the gold standard for attenuating platelet activation and aggregation. Despite significant benefits reported with dual antiplatelet treatment in major clinical trials, the occurrence of adverse ischemic events, including stent thrombosis, remains a serious clinical problem. Nonresponsiveness, also called resistance, to current clopidogrel regimens might play a part in the occurrence of ischemic events. Various mechanisms have been implicated in nonresponsiveness to clopidogrel, including variability in intestinal absorption and hepatic conversion to the active metabolite, drug–drug interactions and receptor polymorphisms. Increased loading and maintenance doses and the use of new and more-potent P2Y12-receptor blockers might overcome the phenomenon of clopidogrel nonresponsiveness. The aim of this article is to provide a comprehensive and current review of clopidogrel response variability and nonresponsiveness.

Key Points

  • Marked response variability and nonresponsiveness to clopidogrel have been consistently observed in many research studies

  • Data from small studies suggest that patients with high ex vivo platelet reactivity to ADP during and after percutaneous coronary intervention are at the greatest risk of subsequent ischemic events

  • Inadequate production of the active metabolite to sufficiently block the P2Y12 receptor might lead to clopidogrel nonresponsiveness

  • No uniformly established method is currently available to quantify ex vivo platelet reactivity after clopidogrel treatment; neither are treatment recommendations available for patients exhibiting high platelet reactivity during therapy

  • Increases in loading and maintenance doses of clopidogrel or new P2Y12-receptor blockers might overcome the limitations associated with use of this drug

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Figure 1: Mechanism of action of clopidogrel.

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Authors and Affiliations

  1. PA Gurbel is Director and US Tantry is Laboratory Director at the Sinai Center for Thrombosis Research, Baltimore, MD, USA

    Paul A Gurbel & Udaya S Tantry

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  1. Paul A Gurbel
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  2. Udaya S Tantry
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Corresponding author

Correspondence to Paul A Gurbel.

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Competing interests

Paul A Gurbel has received research grants from Shering-Plough and Millennium, Astra Zeneca, Bayer, and Haemoscope and NIH in the past 2 years to conduct, respectively, the following studies: the antiplatelet effects of clopidogrel and eptifibatide in elective stenting; the antiplatelet effects of clopidogrel in relation to stent thrombosis and of AZD6140 in elective stenting; the antiplatelet effects of aspirin in outpatients; and the physical properties of clotting to recurrent events after elective stenting. He was a co-investigator in the past 2 years for Medtronic and Boston Scientific studying new drug-eluting stents. Finally, he was a scientific office for a start-up company called Thromboscience, which is no longer in existence.

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Gurbel, P., Tantry, U. Drug Insight: clopidogrel nonresponsiveness. Nat Rev Cardiol 3, 387–395 (2006). https://doi.org/10.1038/ncpcardio0602

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