Active Substance: clopidogrel
Common Name: clopidogrel
ATC Code: B01AC04
Marketing Authorisation Holder: Sanofi-aventis groupe
Active Substance: clopidogrel
Authorisation Date: 1998-07-15
Therapeutic Area: Peripheral Vascular Diseases Stroke Acute Coronary Syndrome Myocardial Infarction Atrial Fibrillation
Pharmacotherapeutic Group: Antithrombotic agents
Secondary prevention of atherothrombotic events
Clopidogrel is indicated in:
• Adult patients suffering from myocardial infarction (from a few days until less than 35 days), ischaemic stroke (from 7 days until less than 6 months) or established peripheral arterial disease.
• Adult patients suffering from acute coronary syndrome:
- Non-ST segment elevation acute coronary syndrome (unstable angina or non-Q-wave myocardial infarction), including patients undergoing a stent placement following percutaneous coronary intervention, in combination with acetylsalicylic acid (ASA).
- ST segment elevation acute myocardial infarction, in combination with ASA in medically treated patients eligible for thrombolytic therapy.
Prevention of atherothrombotic and thromboembolic events in atrial fibrillation
In adult patients with atrial fibrillation who have at least one risk factor for vascular events, are not suitable for treatment with Vitamin K antagonists (VKA) and who have a low bleeding risk, clopidogrel is indicated in combination with ASA for the prevention of atherothrombotic and thromboembolic events, including stroke.
What is Iscover?
Iscover is a medicine that contains the active substance clopidogrel. It is available as pink tablets (round: 75 mg; oblong: 300 mg).
What is Iscover used for?
Iscover is used to prevent problems caused by blood clots in adults who have:
- recently had a myocardial infarction (heart attack). Iscover can be started between a few days and 35 days after the attack;
- recently had an ischaemic stroke (stroke caused by failure of the blood supply to part of the brain). Iscover can be started between seven days and six months after the stroke;
- peripheral arterial disease (problems with blood flow in the arteries);
- a condition known as ‘acute coronary syndrome’, when it should be given with aspirin (another medicine that prevents blood clots). Acute coronary syndrome is a group of heart problems that include heart attacks and unstable angina (a severe type of chest pain). Some of these patients have had a stent inserted (a short tube) placed in an artery to prevent it from closing up.
- atrial fibrillation (irregular rapid contractions of the upper chambers of the heart), when it should be given with aspirin. It is used in those patients who have at least one risk factor for vascular events such as a heart attack or stroke, cannot take vitamin-K antagonists (other medicines that prevent blood clots) and are at low risk of bleeding.
The medicine can only be obtained with a prescription.
How is Iscover used?
The standard dose of Iscover is one 75-mg tablet once a day. In acute coronary syndrome, treatment generally starts with a loading dose of one 300-mg tablet or four 75-mg tablets. This is then followed by the standard 75-mg dose once a day for at least four weeks (in ‘ST-segment elevation’ myocardial infarction) or for up to 12 months (in unstable angina or ‘non-Q-wave’ myocardial infarction). In acute coronary syndrome and atrial fibrillation, Iscover is used together with aspirin, the dose of which should not be higher than 100 mg.
Iscover is converted into its active form in the body. For genetic reasons, some patients may not be able to convert Iscover as effectively as others, which could reduce their response to the medicine. The best dose to use in these patients has not been determined.
How does Iscover work?
The active substance in Iscover, clopidogrel, is an inhibitor of platelet aggregation. This means that it helps to prevent blood clots from forming. When the blood clots, this is due to special cells in the blood called platelets aggregating (sticking together). Clopidogrel stops the platelets aggregating by blocking a substance called ADP from attaching to a special receptor on their surface. This stops the platelets becoming ‘sticky’, reducing the risk of a blood clot forming and helping to prevent another heart attack or stroke.
How has Iscover been studied?
Iscover as an anticoagulant has been compared with aspirin in a study called CAPRIE including around 19,000 patients who had recently had a heart attack or an ischaemic stroke, or who had established peripheral artery disease. The main measure of effectiveness was how many patients experienced a new ‘ischaemic event’ (heart attack, ischaemic stroke or death) over one to three years.
In acute coronary syndrome, Iscover has been compared with placebo (a dummy treatment) in one study involving over 12,000 patients with non-ST-segment elevation, 2,172 of whom had a stent inserted during the study (CURE study, lasting up to a year). Iscover has also been compared with placebo in two studies involving patients with ST segment elevation: CLARITY, which involved over 3,000 patients and lasted for up to eight days; and COMMIT, which involved almost 46,000 patients and in which the patients received Iscover with or without metoprolol (another medicine used for heart problems or high blood pressure) for up to four weeks. In the studies of acute coronary syndrome, all of the patients also took aspirin and the main measure of effectiveness was the number of patients who experienced an ‘event’ such as a blocked artery, another heart attack or death during the study.
In atrial fibrillation, Iscover has been compared with placebo (both taken together with aspirin) in one main study involving around 7,500 patients who had at least one risk factor for vascular events and who could not take vitamin-K-antagonist therapy. The patients were treated for an average of three years, and the main measure of effectiveness was the number of patients who experienced an ‘event’ such as a heart attack, ischaemic stroke or death.
What benefit has Iscover shown during the studies?
Iscover was more effective than aspirin at preventing new ischaemic events. In CAPRIE, there were 939 events in the Iscover group, and 1,020 in the aspirin group. This corresponds to a relative reduction in risk of 9% compared with aspirin. This means that fewer patients will have new ischaemic events if they receive Iscover than if they receive aspirin. In other words, about 10 patients in 1,000 will avoid having a new ischaemic event two years after starting Iscover instead of aspirin.
In non-ST-segment elevation acute coronary syndrome, the overall relative reduction in the risk of an event compared with placebo was 20%. There was also a reduction in the patients who had a stent inserted. In ST-segment elevation myocardial infarction, fewer patients on Iscover had events than patients on placebo (262 against 377 in the CLARITY study, and 2,121 against 2,310 in the COMMIT study). This showed that Iscover reduces the risk of an event.
In the study in atrial-fibrillation patients, Iscover taken together with aspirin reduced the risk of new events by 11% compared with placebo taken with aspirin, with the largest reduction (28%) seen for stroke.
What is the risk associated with Iscover?
The most common side effects with Iscover (seen in between 1 and 10 patients in 100) are haematoma (a collection of blood under the skin), epistaxis (nosebleeds), gastrointestinal haemorrhage (bleeding in the stomach or gut), diarrhoea, abdominal pain (stomach ache), dyspepsia (heartburn), bruising and bleeding where the skin is punctured. For the full list of all side effects reported with Iscover, see the package leaflet.
Iscover should not be used in people who may be hypersensitive (allergic) to clopidogrel or any of the other ingredients. It must not be used in patients who have severe liver disease or a disease that may cause bleeding such as a stomach ulcer or bleeding in the brain.
Why has Iscover been approved?
The CHMP decided that Iscover’s benefits are greater than its risks and recommended that it be given marketing authorisation.
Other information about Iscover
The European Commission granted a marketing authorisation valid throughout the European Union for Iscover on 15 July 1998.
For more information about treatment with Iscover, read the package leaflet (also part of the EPAR) or contact your doctor or pharmacist.