Wednesday, November 7, 2007
I felt like writing about my least favorite medicine today. It's called Plavix and it is probably the most dangerous med to have on board when dealing with surgical patients. Plavix (clopidogrel bisulfate) is an anti-platelet drug (like aspirin) that inhibits the binding of ADP to its platelet receptor, thus shutting down platelet aggegation. It's used a lot in patients who have had strokes or myocardial infarctions. After coronary angioplasty and stenting, plavix is used to prevent restenosis. Platelet aggregation leads to thrombosis; shut down platelet aggregation and, theoretically, long term patient outcomes will be better. Now the data to support Plavix, in my humble opinion, is a little suspect. The CAPRIE and CURE trials have established a "statistically significant" but atoundingly modest benefit of Plavix over aspirin. Combined Plavix/aspirin therapy seems to have a more substantial benefit. I'll leave the specifics to the professionals. All I know is that whenever someone shows up in the office for hernia/gallbladder/etc., one the first things I look for is whether the box for "Plavix use" is checked yes or no. I hate the stuff. Platelets are a surgeon's friend. During an operation, it doesn't take long to see the effects of Plavix use; skin edges that won't stop bleeding, the raw liver of the gallbladder fossa that persistently oozes like a skinned knee, taple lines that have to be oversewn. It's a royal pain in the ass. But it doesn't end there. The worst part is the long term effects. Platelets aren't just for clotting. They're actually the intial mediators of the entire inflammatory cascade. Dysfunctional platelets can impair wound healing and infection-fighting capabilities. I've had two seromas for inguinal hernias over the past 6 months. Both were in patients on Plavix. Now, I usually stop it 7 days in advance of an operation, but maybe that's not long enough; lately I keep them off it for 10 days. The other problem is when patients come in with acute surgical illnesses and are on Plavix. You can give platelet transfusions or just bite the bullet. Either way, your stress quotient gets amped up significantly. And non-surgeons won't touch these patients for any interventions. I have a lady in the hospital now with choledocholithiasis who needs an ERCP prior to her lap chole, but the GI guy wants to wait a week before doing a sphincterotomy (reasonable, as she isn't toxic). So I hope this magic pill is preventing thousands of strokes and heart attacks every year because it doesn't do me any favors.