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Australian Journal of Pharmacy : March 2005
ucation in patients with prosthetic heart valves. It is also marketed for secondary prevention of stroke in combination with aspirin. Fur- ther data are needed to confirm the superiority of this combina- tion over aspirin alone. Clopidogrel and ticlopidine block the platelet ADP recep- tor, which prevents activation of the platelet glycoprotein IIb/IIIa complex, preventing platelet aggregation and thrombus forma- tion and its activity persists for as long as seven days. Clopidogrel is approved for acute coronary syndromes with- out ST-segment elevation in combination with aspirin. It decreases risk of cardiovascular events but increases risk of major bleeding. It is also approved for prevention of thromboembolism in patients with symptomatic atherosclerosis (recent ischaemic stroke, recent myocardial infarction or intermittent claudica- tion). It is slightly more effective than aspirin, especially in patients with intermittent claudication;4–8 its use is limited by high cost. Clopidogrel rather than ticlopidine should be used as it has less risk of serious adverse effects. Clopidogrel may also be used in combination with aspirin in patients who have a cardiovascular event on aspirin, and for acute coronary symptoms without ST-segment elevation. The combination of aspirin and clopidogrel is also used to prevent thromboembolism after insertion of a coronary stent, usually for four weeks. The risk of myelotoxicity appears to be low, and unlike ticlopidine no specific haematological monitoring is rec- ommended.4–8 The Pharmaceutical Benefits Schedule subsidises clopidogrel under the following conditions (PBS Schedule 1/11/04). Authority required Prevention of recurrence of ischaemic stroke or transient cere- bral ischaemic events in patients: (1)with a history of symptomatic cerebrovascular ischaemic episodes while on therapy with low-dose aspirin; or (2)where low-dose aspirin poses an unacceptable risk of gas- trointestinal bleeding; or (3)where there is a history of anaphylaxis, urticaria or asthma within four hours of ingestion of aspirin, other salicylates, or NSAIDs. Prevention of recurrence of myocardial infarction or unstable angina in patients: (1)with a history of symptomatic cardiac ischaemic events while on therapy with low-dose aspirin; or (2)where low-dose aspirin poses an unacceptable risk of gas- trointestinal bleeding; or (3)where there is a history of anaphylaxis, urticaria or asthma within four hours of ingestion of aspirin, other salicylates, or NSAIDs. Ticlopidine is marketed for the prevention of thromboem- bolism in cerebrovascular disease in patients unable to tolerate aspirin, in peripheral arterial disease, and after intracoronary stenting; it should be avoided because of its severe haematolog- ical adverse effects (1 per cent severe neutropenia). Similar to other antiplatelet agents, clopidogrel and ticlopidine prolong bleeding time and should be used with caution in patients at risk of increased bleeding. Clopidogrel has a similar adverse effect profile to aspirin. Ticlopidine may be used as an alternative drug in patients allergic to clopidogrel, but has more significant adverse reactions including agranulocytosis and neu- tropenia. If a patient is commenced on ticlopidine specific haematological monitoring is required, at baseline and then at regular intervals.4–8 Abciximab (Reopro Injection) eptifibatide (Integrilin injection) and tirofiban (Aggastat injection) are platelet glycoprotein IIb/IIIa THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 MARCH 2005 ? 205