Plavix
FDA Label NDC 16590-288

Structure Image (Plavix 75mg Structure)

Clopidogrel bisulfate is a white to off-white powder. It is practically insoluble in water at neutral pH but freely soluble at pH 1. It also dissolves freely in methanol, dissolves sparingly in methylene chloride, and is practically insoluble in ethyl ether. It has a specific optical rotation of about +56°.

PLAVIX for oral administration is provided as either pink, round, biconvex, debossed, film-coated tablets containing 97.875 mg of clopidogrel bisulfate which is the molar equivalent of 75 mg of clopidogrel base or pink, oblong, debossed film-coated tablets containing 391.5 mg of clopidogrel bisulfate which is the molar equivalent of 300 mg of clopidogrel base.

Each tablet contains hydrogenated castor oil, hydroxypropylcellulose, mannitol, microcrystalline cellulose and polyethylene glycol 6000 as inactive ingredients. The pink film coating contains ferric oxide, hypromellose 2910, lactose monohydrate, titanium dioxide and triacetin. The tablets are polished with Carnauba wax.

The association between CYP2C19 genotype and clopidogrel treatment outcome was evaluated in 2 post-hoc clinical trial analyses (substudies of CLARITY-TIMI 281 [n=465] and TRITON-TIMI 382 [n=1,477]) and 5 cohort studies (total n=6,489). In CLARITY-TIMI 28 and one of the cohort studies (n=765; Trenk3), cardiovascular event rates did not differ significantly by genotype. In TRITON-TIMI 38 and 3 of the cohort studies (n= 3,516; Collet,4 Sibbing,5 Giusti6), patients with an impaired metabolizer status (intermediate and poor combined) had a higher rate of cardiovascular events (death, myocardial infarction, and stroke) or stent thrombosis compared to extensive metabolizers. In the fifth cohort study (n=2,208; Simon7), the increased event rate was observed only in poor metabolizers.

Pharmacogenetic testing can identify genotypes associated with variability in CYP2C19 activity.

There may be genetic variants of other CYP450 enzymes with effects on the ability to form clopidogrel's active metabolite.

The pharmacokinetics of clopidogrel's active metabolite is not known in these special populations.

In elderly (≥75 years) volunteers compared to young healthy volunteers, there were no differences in platelet aggregation and bleeding time. No dosage adjustment is needed for the elderly.

After repeated doses of 75 mg PLAVIX per day in patients with severe renal impairment (creatinine clearance from 5 to 15 mL/min), inhibition of ADP-induced platelet aggregation was lower (25%) than that observed in healthy volunteers, however, the prolongation of bleeding time was similar to healthy volunteers receiving 75 mg of PLAVIX per day.

After repeated doses of 75 mg PLAVIX per day for 10 days in patients with severe hepatic impairment, inhibition of ADP-induced platelet aggregation was similar to that observed in healthy subjects. The mean bleeding time prolongation was also similar in the two groups.

In a small study comparing men and women, less inhibition of ADP-induced platelet aggregation was observed in women, but there was no difference in prolongation of bleeding time. In the large, controlled clinical study (Clopidogrel vs. Aspirin in Patients at Risk of Ischemic Events; CAPRIE), the incidence of clinical outcome events, other adverse clinical events, and abnormal clinical laboratory parameters was similar in men and women.

The prevalence of CYP2C19 alleles that result in intermediate and poor CYP2C19 metabolism differs according to race/ethnicity (see CLINICAL PHARMACOLOGY: Pharmacogenetics).

Chart Image (Plavix 75mg Chart)

Although the statistical significance favoring PLAVIX over aspirin was marginal (P=0.045), and represents the result of a single trial that has not been replicated, the comparator drug, aspirin, is itself effective (vs. placebo) in reducing cardiovascular events in patients with recent myocardial infarction or stroke. Thus, the difference between PLAVIX and placebo, although not measured directly, is substantial.

The CAPRIE trial included a population that was randomized on the basis of 3 entry criteria. The efficacy of PLAVIX relative to aspirin was heterogeneous across these randomized subgroups (P=0.043). It is not clear whether this difference is real or a chance occurrence. Although the CAPRIE trial was not designed to evaluate the relative benefit of PLAVIX over aspirin in the individual patient subgroups, the benefit appeared to be strongest in patients who were enrolled because of peripheral vascular disease (especially those who also had a history of myocardial infarction) and weaker in stroke patients. In patients who were enrolled in the trial on the sole basis of a recent myocardial infarction, PLAVIX was not numerically superior to aspirin.

In the meta-analyses of studies of aspirin vs. placebo in patients similar to those in CAPRIE, aspirin was associated with a reduced incidence of thrombotic events. There was a suggestion of heterogeneity in these studies too, with the effect strongest in patients with a history of myocardial infarction, weaker in patients with a history of stroke, and not discernible in patients with a history of peripheral vascular disease. With respect to the inferred comparison of PLAVIX to placebo, there is no indication of heterogeneity.

The number of patients experiencing the primary outcome (CV death, MI, or stroke) was 582 (9.30%) in the PLAVIX-treated group and 719 (11.41%) in the placebo-treated group, a 20% relative risk reduction (95% CI of 10%–28%; p=0.00009) for the PLAVIX-treated group (see Table 3).

At the end of 12 months, the number of patients experiencing the co-primary outcome (CV death, MI, stroke or refractory ischemia) was 1035 (16.54%) in the PLAVIX-treated group and 1187 (18.83%) in the placebo-treated group, a 14% relative risk reduction (95% CI of 6%–21%, p=0.0005) for the PLAVIX-treated group (see Table 3).

In the PLAVIX-treated group, each component of the two primary endpoints (CV death, MI, stroke, refractory ischemia) occurred less frequently than in the placebo-treated group.

The benefits of PLAVIX (clopidogrel bisulfate) were maintained throughout the course of the trial (up to 12 months).

Chart Image 2 (Plavix 75mg Chart2)

In CURE, the use of PLAVIX was associated with a lower incidence of CV death, MI or stroke in patient populations with different characteristics, as shown in Figure 3. The benefits associated with PLAVIX were independent of the use of other acute and long-term cardiovascular therapies, including heparin/LMWH (low molecular weight heparin), IV glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors, lipid-lowering drugs, beta-blockers, and ACE-inhibitors. The efficacy of PLAVIX was observed independently of the dose of aspirin (75–325 mg once daily). The use of oral anticoagulants, non-study anti-platelet drugs and chronic NSAIDs was not allowed in CURE.

The use of PLAVIX in CURE was associated with a decrease in the use of thrombolytic therapy (71 patients [1.1%] in the PLAVIX group, 126 patients [2.0%] in the placebo group; relative risk reduction of 43%, P=0.0001), and GPIIb/IIIa inhibitors (369 patients [5.9%] in the PLAVIX group, 454 patients [7.2%] in the placebo group, relative risk reduction of 18%, P=0.003). The use of PLAVIX in CURE did not impact the number of patients treated with CABG or PCI (with or without stenting), (2253 patients [36.0%] in the PLAVIX group, 2324 patients [36.9%] in the placebo group; relative risk reduction of 4.0%, P=0.1658).

In patients with ST-segment elevation acute myocardial infarction, safety and efficacy of clopidogrel have been evaluated in two randomized, placebo-controlled, double-blind studies, COMMIT- a large outcome study conducted in China - and CLARITY- a supportive study of a surrogate endpoint conducted internationally.

The randomized, double-blind, placebo-controlled, 2×2 factorial design COMMIT trial included 45,852 patients presenting within 24 hours of the onset of the symptoms of suspected myocardial infarction with supporting ECG abnormalities (i.e., ST elevation, ST depression or left bundle-branch block). Patients were randomized to receive PLAVIX (75 mg/day) or placebo, in combination with aspirin (162 mg/day), for 28 days or until hospital discharge whichever came first.

The co-primary endpoints were death from any cause and the first occurrence of re-infarction, stroke or death.

The patient population included 28% women, 58% patients ≥60 years (26% patients ≥70 years) and 55% patients who received thrombolytics, 68% received ace-inhibitors, and only 3% had percutaneous coronary intervention (PCI).

As shown in Table 4 and Figures 4 and 5 below, PLAVIX significantly reduced the relative risk of death from any cause by 7% (p = 0.029), and the relative risk of the combination of re-infarction, stroke or death by 9% (p = 0.002).

Chart Image3 (Plavix 75mg Chart3)

The effect of PLAVIX did not differ significantly in various pre-specified subgroups as shown in Figure 6. Additionally, the effect was similar in non-prespecified subgroups including those based on infarct location, Killip class or prior MI history (see Figure 7). Such subgroup analyses should be interpreted very cautiously.

The randomized, double-blind, placebo-controlled CLARITY trial included 3,491 patients, 5% U.S., presenting within 12 hours of the onset of a ST elevation myocardial infarction and planned for thrombolytic therapy. Patients were randomized to receive PLAVIX (300-mg loading dose, followed by 75 mg/day) or placebo until angiography, discharge, or Day 8. Patients also received aspirin (150 to 325 mg as a loading dose, followed by 75 to 162 mg/day), a fibrinolytic agent and, when appropriate, heparin for 48 hours. The patients were followed for 30 days.

The primary endpoint was the occurrence of the composite of an occluded infarct-related artery (defined as TIMI Flow Grade 0 or 1) on the predischarge angiogram, or death or recurrent myocardial infarction by the time of the start of coronary angiography.

The patient population was mostly Caucasian (89.5%) and included 19.7% women and 29.2% patients ≥65 years. A total of 99.7% of patients received fibrinolytics (fibrin specific: 68.7%, non-fibrin specific: 31.1%), 89.5% heparin, 78.7% beta-blockers, 54.7% ACE inhibitors and 63% statins.

The number of patients who reached the primary endpoint was 262 (15.0%) in the PLAVIX-treated group and 377 (21.7%) in the placebo group, but most of the events related to the surrogate endpoint of vessel patency.

PLAVIX (clopidogrel bisulfate) is indicated for the reduction of atherothrombotic events as follows:

• Recent MI, Recent Stroke or Established Peripheral Arterial Disease
  For patients with a history of recent myocardial infarction (MI), recent stroke, or established peripheral arterial disease, PLAVIX has been shown to reduce the rate of a combined endpoint of new ischemic stroke (fatal or not), new MI (fatal or not), and other vascular death.
• Acute Coronary Syndrome- For patients with non-ST-segment elevation acute coronary syndrome (unstable angina/non-Q-wave MI) including patients who are to be managed medically and those who are to be managed with percutaneous coronary intervention (with or without stent) or CABG, PLAVIX has been shown to decrease the rate of a combined endpoint of cardiovascular death, MI, or stroke as well as the rate of a combined endpoint of cardiovascular death, MI, stroke, or refractory ischemia. - For patients with ST-segment elevation acute myocardial infarction, PLAVIX has been shown to reduce the rate of death from any cause and the rate of a combined endpoint of death, re-infarction or stroke. This benefit is not known to pertain to patients who receive primary angioplasty

The use of PLAVIX is contraindicated in the following conditions:

Patients with genetically reduced CYP2C19 function have diminished antiplatelet responses and generally exhibit higher cardiovascular event rates following myocardial infarction than do patients with normal CYP2C19 function (see CLINICAL PHARMACOLOGY: Pharmacogenetics).

Co-administration of PLAVIX with omeprazole, a proton pump inhibitor that is an inhibitor of CYP2C19, reduces the pharmacological activity of PLAVIX if given concomitantly or if given 12 hours apart. There is no evidence that other drugs that reduce stomach acid, such as most H2 blockers (except cimetidine, which is a CYP2C19 inhibitor) or antacids interfere with the antiplatelet activity of clopidogrel (see PRECAUTIONS: Drug Interactions).

TTP has been reported rarely following use of PLAVIX, sometimes after a short exposure (less than 2 weeks). TTP is a serious condition that can be fatal and requires urgent treatment including plasmapheresis (plasma exchange). It is characterized by thrombocytopenia, microangiopathic hemolytic anemia (schistocytes [fragmented RBCs] seen on peripheral smear), neurological findings, renal dysfunction, and fever. (See ADVERSE REACTIONS.)

Due to the risk of bleeding and undesirable hematological effects, blood cell count determination and/or other appropriate testing should be promptly considered, whenever such suspected clinical symptoms arise during the course of treatment (see ADVERSE REACTIONS).

In patients with recent TIA or stroke who are at high risk of recurrent ischemic events, the combination of aspirin and PLAVIX has not been shown to be more effective than PLAVIX alone, but the combination has been shown to increase major bleeding.

In CURE, PLAVIX use with aspirin was associated with an increase in bleeding compared to placebo with aspirin (see Table 6). There was an excess in major bleeding in patients receiving PLAVIX plus aspirin compared with placebo plus aspirin, primarily gastrointestinal and at puncture sites. The incidence of intracranial hemorrhage (0.1%), and fatal bleeding (0.2%), were the same in both groups.

The overall incidence of bleeding is described in Table 6 for patients receiving both PLAVIX and aspirin in CURE.

Ninety-two percent (92%) of the patients in the CURE study received heparin/LMWH, and the rate of bleeding in these patients was similar to the overall results.

There was no excess in major bleeds within seven days after coronary bypass graft surgery in patients who stopped therapy more than five days prior to surgery (event rate 4.4% PLAVIX + aspirin; 5.3% placebo + aspirin). In patients who remained on therapy within five days of bypass graft surgery, the event rate was 9.6% for PLAVIX + aspirin, and 6.3% for placebo + aspirin.

In CLARITY, the incidence of major bleeding (defined as intracranial bleeding or bleeding associated with a fall in hemoglobin great than 5 g/dL) was similar between groups (1.3% versus 1.1% in the PLAVIX + aspirin and in the placebo + aspirin groups, respectively). This was consistent across subgroups of patients defined by baseline characteristics, and type of fibrinolytics or heparin therapy. The incidence of fatal bleeding (0.8% versus 0.6% in the PLAVIX + aspirin and in the placebo + aspirin groups, respectively) and intracranial hemorrhage (0.5% versus 0.7%, respectively) was low and similar in both groups.

The overall rate of noncerebral major bleeding or cerebral bleeding in COMMIT was low and similar in both groups as shown in Table 7 below

Adverse events occurring in greater than or equal to 2.5% of patients on PLAVIX in the CAPRIE controlled clinical trial are shown below regardless of relationship to PLAVIX. The median duration of therapy was 20 months, with a maximum of 3 years

No additional clinically relevant events to those observed in CAPRIE with a frequency greater than or equal to 2.5%, have been reported during the CURE and CLARITY controlled studies. COMMIT collected only limited safety data.

Other adverse experiences of potential importance occurring in 1% to 2.5% of patients receiving PLAVIX (clopidogrel bisulfate) in the controlled clinical trials are listed below regardless of relationship to PLAVIX. In general, the incidence of these events was similar to that in patients receiving aspirin (in CAPRIE) or placebo + aspirin (in the other clinical trials).

Autonomic Nervous System Disorders: Syncope, Palpitation. Body as a Whole-general disorders: Asthenia, Fever, Hernia. Cardiovascular disorders: Cardiac failure. Central and peripheral nervous system disorders: Cramps legs, Hypoaesthesia, Neuralgia, Paraesthesia, Vertigo. Gastrointestinal system disorders: Constipation, Vomiting. Heart rate and rhythm disorders: Fibrillation atrial. Liver and biliary system disorders: Hepatic enzymes increased. Metabolic and nutritional disorders: Gout, hyperuricemia, non-protein nitrogen (NPN) increased. Musculo-skeletal system disorders: Arthritis, Arthrosis. Platelet, bleeding and clotting disorders: GI hemorrhage, hematoma, platelets decreased. Psychiatric disorders: Anxiety, Insomnia. Red blood cell disorders: Anemia. Respiratory system disorders: Pneumonia, Sinusitis. Skin and appendage disorders: Eczema, Skin ulceration. Urinary system disorders: Cystitis. Vision disorders: Cataract, Conjunctivitis.

Other potentially serious adverse events which may be of clinical interest but were rarely reported (less than 1%) in patients who received PLAVIX in the controlled clinical trials are listed below regardless of relationship to PLAVIX. In general, the incidence of these events was similar to that in patients receiving aspirin (in CAPRIE) or placebo + aspirin (in the other clinical trials).

Body as a whole: Allergic reaction, necrosis ischemic. Cardiovascular disorders: Edema generalized. Gastrointestinal system disorders: Peptic, gastric or duodenal ulcer, gastritis, gastric ulcer perforated, gastritis hemorrhagic, upper GI ulcer hemorrhagic. Liver and Biliary system disorders: Bilirubinemia, hepatitis infectious, liver fatty. Platelet, bleeding and clotting disorders: hemarthrosis, hematuria, hemoptysis, hemorrhage intracranial, hemorrhage retroperitoneal, hemorrhage of operative wound, ocular hemorrhage, pulmonary hemorrhage, purpura allergic, thrombocytopenia. Red blood cell disorders: Anemia aplastic, anemia hypochromic. Reproductive disorders, female: Menorrhagia. Respiratory system disorders: Hemothorax. Skin and appendage disorders: Bullous eruption, rash erythematous, rash maculopapular, urticaria. Urinary system disorders: Abnormal renal function, acute renal failure. White cell and reticuloendothelial system disorders: Agranulocytosis, granulocytopenia, leukemia, leukopenia, neutropenia.

The following events have been reported spontaneously from worldwide postmarketing experience:

• Body as a whole:- hypersensitivity reactions, anaphylactoid reactions, serum sickness
• Central and Peripheral Nervous System disorders:- confusion, hallucinations, taste disorders
• Hepato-biliary disorders:- abnormal liver function test, hepatitis (non-infectious), acute liver failure
• Platelet, Bleeding and Clotting disorders:- cases of bleeding with fatal outcome (especially intracranial, gastrointestinal and retroperitoneal hemorrhage) - thrombotic thrombocytopenic purpura (TTP) – some cases with fatal outcome – (see WARNINGS) - agranulocytosis, aplastic anemia/pancytopenia - conjunctival, ocular and retinal bleeding
• Respiratory, thoracic and mediastinal disorders:- bronchospasm, interstitial pneumonitis
• Skin and subcutaneous tissue disorders:- angioedema, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, lichen planus
• Renal and urinary disorders:- glomerulopathy, increased creatinine levels
• Vascular disorders:- vasculitis, hypotension
• Gastrointestinal disorders:- colitis (including ulcerative or lymphocytic colitis), pancreatitis, stomatitis
• Musculoskeletal, connective tissue and bone disorders:- myalgia

Overdose following clopidogrel administration may lead to prolonged bleeding time and subsequent bleeding complications. A single oral dose of clopidogrel at 1500 or 2000 mg/kg was lethal to mice and to rats and at 3000 mg/kg to baboons. Symptoms of acute toxicity were vomiting (in baboons), prostration, difficult breathing, and gastrointestinal hemorrhage in all species.

Based on biological plausibility, platelet transfusion may be appropriate to reverse the pharmacological effects of PLAVIX if quick reversal is required.

DOSAGE AND ADMINISTRATIONRecent MI, Recent Stroke, or Established Peripheral Arterial Disease

The recommended daily dose of PLAVIX is 75 mg once daily.

For patients with non-ST-segment elevation acute coronary syndrome (unstable angina/non-Q-wave MI), PLAVIX should be initiated with a single 300-mg loading dose and then continued at 75 mg once daily. Aspirin (75 mg-325 mg once daily) should be initiated and continued in combination with PLAVIX. In CURE, most patients with Acute Coronary Syndrome also received heparin acutely (see CLINICAL STUDIES).

For patients with ST-segment elevation acute myocardial infarction, the recommended dose of PLAVIX is 75 mg once daily, administered in combination with aspirin, with or without thrombolytics. PLAVIX may be initiated with or without a loading dose (300 mg was used in CLARITY; see CLINICAL STUDIES).

CYP2C19 poor metabolizer status is associated with diminished response to clopidogrel. The optimal dose regimen for poor metabolizers has yet to be determined. (See CLINICAL PHARMACOLOGY: Pharmacogenetics.)

No dosage adjustment is necessary for elderly patients or patients with renal disease. (See CLINICAL PHARMACOLOGY: Special Populations.)

PLAVIX (clopidogrel bisulfate) 75-mg tablets are available as pink, round, biconvex, film-coated tablets debossed with "75" on one side and "1171" on the other. Tablets are provided as follows:

PLAVIX (clopidogrel bisulfate) 300-mg tablets are available as pink, oblong, film-coated tablets debossed with "300" on one side and "1332" on the other. Tablets are provided as follows:

NDC 63653-1332-2 unit-dose packages of 30
NDC 63653-1332-3 unit-dose packages of 100

Store at 25° C (77° F); excursions permitted to 15°–30° C (59°–86° F) [See USP Controlled Room Temperature].

Distributed by:
Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership
Bridgewater, NJ 08807

PLAVIX® is a registered trademark.

Revised October 2009

Principal Display Panel - 75 mg Carton

List No. 1171-30

NDC 63653-1171-3
100 tablets

Plavix_®
(clopidogrel bisulfate)

75 mg

Rx only

  Information for Patients

Patients should be told that while taking PLAVIX or PLAVIX
combined with aspirin:

    * it may take them longer than usual to stop bleeding;
    * they may bruise and/or bleed more easily;
    * they should report any unusual bleeding to their physician;
    * they should tell their physician about any other medications they are
      taking, including prescription or over-the-counter omeprazole;
    * they should inform physicians and dentists that they are taking PLAVIX
      and/or any other product known to affect bleeding before any surgery is
      scheduled and before any new drug is taken.

   Drug Interactions

Clopidogrel is metabolized to its active metabolite in part by
CYP2C19. Concomitant use of drugs that inhibit the activity of this enzyme
results in reduced plasma concentrations of the active metabolite of clopidogrel
and a reduction in platelet inhibition. Avoid concomitant use of drugs that
inhibit CYP2C19, including omeprazole, esomeprazole, cimetidine, fluconazole,
ketoconazole, voriconazole, etravirine, felbamate, fluoxetine, fluvoxamine, and
ticlopidine (see  WARNINGS).

Studies of specific drug interactions yielded the following results:
  Omeprazole

In a crossover clinical study, 72 healthy subjects were
administered PLAVIX (300-mg loading dose followed by 75 mg/day) alone and with
omeprazole (80 mg at the same time as PLAVIX) for 5 days. The exposure to the
active metabolite of clopidogrel was decreased by 46% (Day 1) and 42% (Day 5)
when PLAVIX and omeprazole were administered together. Mean inhibition of
platelet aggregation (IPA) was diminished by 47% (24 hours) and 30% (Day 5) when
PLAVIX and omeprazole were administered together. In another study 72 healthy
subjects were given the same doses of PLAVIX and omeprazole but the drugs were
administered 12 hours apart; the results were similar indicating that
administering PLAVIX and omeprazole at different times does not prevent their
interaction (see  WARNINGS).
  Aspirin

Aspirin did not modify the clopidogrel-mediated inhibition of
ADP-induced platelet aggregation. Concomitant administration of 500 mg of
aspirin twice a day for 1 day did not significantly increase the prolongation of
bleeding time induced by PLAVIX. PLAVIX potentiated the effect of aspirin on
collagen-induced platelet aggregation. PLAVIX and aspirin have been administered
together for up to one year.
  Heparin

In a study in healthy volunteers, PLAVIX did not necessitate
modification of the heparin dose or alter the effect of heparin on coagulation.
Coadministration of heparin had no effect on inhibition of platelet aggregation
induced by PLAVIX.
  Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

In healthy volunteers receiving naproxen, concomitant
administration of PLAVIX was associated with increased occult gastrointestinal
blood loss. NSAIDs and PLAVIX should be coadministered with caution.
  Warfarin

Because of the increased risk of bleeding, the concomitant
administration of warfarin with PLAVIX should be undertaken with caution. (See
 PRECAUTIONS: General.)
  Other Concomitant Therapy

No clinically significant pharmacodynamic interactions were
observed when PLAVIX was coadministered with atenolol,
nifedipine, or both atenolol and nifedipine. The pharmacodynamic activity
of PLAVIX was also not significantly influenced by the coadministration of phenobarbital or estrogen.

The pharmacokinetics of digoxin or theophylline were not modified by the coadministration of
PLAVIX (clopidogrel bisulfate).

At high concentrations in vitro, clopidogrel
inhibits P450 (2C9). Accordingly, PLAVIX may interfere
with the metabolism of phenytoin, tamoxifen, tolbutamide,
warfarin, torsemide, fluvastatin, and many non-steroidal
anti-inflammatory agents, but there are no data with which to predict the
magnitude of these interactions. Caution should be used when any of these drugs
is coadministered with PLAVIX.

In addition to the above specific interaction studies, patients entered into
clinical trials with PLAVIX received a variety of concomitant medications
including diuretics, beta-blocking agents, angiotensin
converting enzyme inhibitors, calcium antagonists, cholesterol lowering agents,
coronary vasodilators, antidiabetic agents (including insulin), thrombolytics, heparins
(unfractionated and LMWH), GPIIb/IIIa antagonists,
antiepileptic agents and hormone replacement
therapy without evidence of clinically significant adverse
interactions.

There are no data on the concomitant use of oral anticoagulants, non study
oral anti-platelet drugs and chronic NSAIDs with clopidogrel.
  Drug/Laboratory Test Interactions

None known.
  Carcinogenesis, Mutagenesis, Impairment of
Fertility

There was no evidence of tumorigenicity when clopidogrel was
administered for 78 weeks to mice and 104 weeks to rats at dosages up to 77
mg/kg per day, which afforded plasma exposures >25 times that in humans at
the recommended daily dose of 75 mg.

Clopidogrel was not genotoxic in four in vitro
tests (Ames test, DNA-repair test in rat hepatocytes, gene mutation assay in
Chinese hamster fibroblasts, and metaphase chromosome analysis of human
lymphocytes) and in one in vivo test (micronucleus
test by oral route in mice).

Clopidogrel was found to have no effect on fertility of male and female rats
at oral doses up to 400 mg/kg per day (52 times the recommended human dose on a
mg/m2 basis).
  Pregnancy  Pregnancy Category B

Reproduction studies performed in rats and rabbits at doses up to
500 and 300 mg/kg/day (respectively, 65 and 78 times the recommended daily human
dose on a mg/m2 basis), revealed no evidence of impaired
fertility or fetotoxicity due to clopidogrel. There are, however, no adequate
and well-controlled studies in pregnant women. Because animal reproduction
studies are not always predictive of a human response, PLAVIX should be used
during pregnancy only if clearly needed.
  Nursing Mothers

Studies in rats have shown that clopidogrel and/or its
metabolites are excreted in the milk. It is not known whether this drug is
excreted in human milk. Because many drugs are excreted in human milk and
because of the potential for serious adverse reactions in nursing infants, a
decision should be made whether to discontinue nursing or to discontinue the
drug, taking into account the importance of the drug to the nursing woman.
  Pediatric Use

Safety and effectiveness in the pediatric population have not
been established.
  Geriatric Use

Of the total number of subjects in the CAPRIE, CURE and CLARITY
controlled clinical studies, approximately 50% of patients treated with PLAVIX
were 65 years of age and older, and 15% were 75 years and older. In COMMIT,
approximately 58% of the patients treated with PLAVIX were 60 years and older,
26% of whom were 70 years and older.

The observed risk of thrombotic events with clopidogrel plus aspirin versus
placebo plus aspirin by age category is provided in Figures 3 and 6 for the CURE
and COMMIT trials, respectively (see  CLINICAL
STUDIES). The observed risk of bleeding events with clopidogrel plus
aspirin versus placebo plus aspirin by age category is provided in Tables 6 and
7 for the CURE and COMMIT trials, respectively (see  ADVERSE REACTIONS).