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Khan Z, Yousif Y, Mohammed M, Khan A, Afghan A, Muhammad SA, Warrier V, Gupta A. A Rare Case of Clopidogrel-Induced Migratory Polyarthritis in a Patient With Recent Myocardial Infarction. Cureus 2022; 14:e22042. [PMID: 35340484 PMCID: PMC8914393 DOI: 10.7759/cureus.22042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
Clopidogrel is an antiplatelet drug used for secondary prevention of myocardial infarction, and it is also used in patients with cerebrovascular ischemia. Patients with acute myocardial infarction tend to be on dual antiplatelet therapy for 12 months followed by aspirin lifelong to prevent the risk of stent thrombosis. The most common side effects of clopidogrel are bleeding, neutropenia, and rash; however, arthritis is also one of the rare side effects. We present a case of a 53-year-old patient who had a recent myocardial infarction and was commenced on dual antiplatelet therapy in the form of aspirin and clopidogrel. He started to have severe joint pain, particularly in his knees and shoulders, and was not able to mobilize anymore only three weeks after starting the medications. His clopidogrel was stopped and the patient showed dramatic improvement within three to four days after discontinuation with complete resolution one week later.
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2
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Ford MK, Cohn JR. Clopidogrel Hypersensitivity: Pathogenesis, Presentation and Diagnosis. Curr Vasc Pharmacol 2020; 17:110-112. [PMID: 30381080 DOI: 10.2174/1570161116666181031143628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 10/10/2018] [Accepted: 10/15/2018] [Indexed: 11/22/2022]
Abstract
This paper provides an overview of the pathogenesis, presentation and diagnosis of clopidogrel hypersensitivity. The majority of clopidogrel hypersensitivity cases are due to a T cell mediated Gell and Coombs Type IV reaction. History, histology, and patch testing have shown consistency with a T cell mediated mechanism. Clopidogrel reactions most commonly present as a mild delayed maculopapular erythematous rash 5 to 10 days after introduction of the drug, and do not always require discontinuation of the drug. Severe cutaneous, systemic, and immediate adverse reactions to clopidogrel are rare. For the diagnosis of clopidogrel hypersensitivity, drug causality can be determined using patch testing, or for mild reactions, recurrence of symptoms after drug reintroduction, although neither are required for diagnosis.
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Affiliation(s)
- Megan K Ford
- Jane and Leonard Korman Respiratory Institute, Division of Pulmonary, Allergy & Critical Care Medicine, Allergy & Immunology Section, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107, United States
| | - John R Cohn
- Jane and Leonard Korman Respiratory Institute, Division of Pulmonary, Allergy & Critical Care Medicine, Allergy & Immunology Section, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107, United States
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The Inflammatory Role of Platelets: Translational Insights from Experimental Studies of Autoimmune Disorders. Int J Mol Sci 2016; 17:ijms17101723. [PMID: 27754414 PMCID: PMC5085754 DOI: 10.3390/ijms17101723] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/04/2016] [Accepted: 10/08/2016] [Indexed: 12/29/2022] Open
Abstract
Beyond their indispensable role in hemostasis, platelets have shown to affect the development of inflammatory disorders, as they have been epidemiologically and mechanistically linked to diseases featuring an inflammatory reaction in inflammatory diseases like multiple sclerosis, rheumatoid arthritis and inflammatory bowel disorders. The identification of novel molecular mechanisms linking inflammation and to platelets has highlighted them as new targets for therapeutic interventions. In particular, genetic and pharmacological studies have identified an important role for platelets in neuroinflammation. This review summarizes the main molecular links between platelets and inflammation, focusing on immune regulatory factors, receptors, cellular targets and signaling pathways by which they can amplify inflammatory reactions and that make them potential therapeutic targets.
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Calogiuri GF, Al-Sowaidi S, Nettis E, Cortellini G, Macchia L, Vacca A, Kounis NG. A joint allergist/cardiologist classification for thienopyridines hypersensitivity reactions based on their symptomatic patterns and its impact on the management strategies. Int J Cardiol 2016; 222:509-514. [PMID: 27505343 DOI: 10.1016/j.ijcard.2016.07.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/08/2016] [Indexed: 11/15/2022]
Abstract
The role and importance of thienopyridines such as ticlopidine, clopidogrel, and prasugrel is well-established for several indications, ranging from prevention of acute coronary syndromes to percutaneous coronary interventions, where the dual antiplatelet therapy represents the gold standard to avoid denovo coronary stenosis. However, there is a significant cohort of patients with coronary artery disease who may manifest hypersensitivity reactions to thienopyridines. The examination of the various case reports from medical literature leads to identify mainly four clinical patterns of hypersensitivity to thienopyridines which involves more frequently cutaneous, hematologic, and articular tissues, therefore the kind and predominance of clinical symptoms may determine a different clinical approach to overcome or neutralize thienopyridines hypersensitivity.
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Affiliation(s)
- G F Calogiuri
- Pneumology Department Civil Hospital "NinettoMelli"S. Pietro Vernotico, Brindisi, Italy; Section of Allergology and Clinical Immunology, Department of Internal Medicine, Immunology and Infectious Diseases, University of Bari Medical School, Bari, Italy.
| | - S Al-Sowaidi
- Department of Internal Medicine, UAE University, Al-Ain, United Arab Emirates
| | - E Nettis
- Section of Allergology and Clinical Immunology, Department of Internal Medicine, Immunology and Infectious Diseases, University of Bari Medical School, Bari, Italy
| | - G Cortellini
- Internal Medicine Allergy and Rheumatology Unit, Rimini Hospital, Rimini, Italy
| | - L Macchia
- Section of Allergology and Clinical Immunology, Department of Internal Medicine, Immunology and Infectious Diseases, University of Bari Medical School, Bari, Italy
| | - A Vacca
- Department of Biomedical Science and Human Oncology, Section of Internal Medicine and Clinical Oncology University of Bari Medical School, Bari, Italy
| | - N G Kounis
- Department of Cardiology, University of Patras Medical School, Patras, Achaia, Greece
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Williams MF, Maloof JA. Resolution of clopidogrel-associated polyarthritis after conversion to prasugrel. Am J Health Syst Pharm 2014; 71:1097-100. [DOI: 10.2146/ajhp130518] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - John A. Maloof
- Department of Cardiology, Williamson Medical Center, Franklin, TN
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Agrawal S, Harburger J, Stallings G, Agrawal N, Garg J. Clopidogrel-Induced Recurrent Polyarthritis. J Investig Med High Impact Case Rep 2013; 1:2324709613500239. [PMID: 26425581 PMCID: PMC4586816 DOI: 10.1177/2324709613500239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Clopidogrel is an oral thienopyridine and together with aspirin is a component of dual antiplatelet therapy for the prevention of stent thrombosis after intracoronary stent placement. The common adverse effects from its use are an increased risk of bleeding, neutropenia, and rash. Arthralgia and backache are also known to occur with its use. There have been case reports linking arthritis with the use of clopidogrel. We describe the case of a 64-year-old man who reported symptoms of fever and joint pains following initiation of therapy with clopidogrel. Acute-phase reactants were elevated. Laboratory and radiologic testing were unremarkable. Incidentally, he reported experiencing a similar arthritis after he received a loading dose of clopidogrel prior to a diagnostic coronary angiography in the past. The symptoms improved dramatically on discontinuation of clopidogrel. There was no recurrence of symptoms with prasugrel. This describes possibly the second incidence of recurrent arthritis with clopidogrel therapy.
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Affiliation(s)
- Sahil Agrawal
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Joseph Harburger
- Division of Cardiology, Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Gary Stallings
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Nikhil Agrawal
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jalaj Garg
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Garcia AE, Rico MC, Liverani E, DeLa Cadena RA, Bray PF, Kunapuli SP. Erosive arthritis and hepatic granuloma formation induced by peptidoglycan polysaccharide in rats is aggravated by prasugrel treatment. PLoS One 2013; 8:e69093. [PMID: 23861957 PMCID: PMC3701687 DOI: 10.1371/journal.pone.0069093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 06/04/2013] [Indexed: 11/24/2022] Open
Abstract
Administration of the thienopyridine P2Y12 receptor antagonist, clopidogrel, increased the erosive arthritis induced by peptidoglycan polysaccharide (PG-PS) in rats or by injection of the arthritogenic K/BxN serum in mice. To determine if the detrimental effects are caused exclusively by clopidogrel, we evaluated prasugrel, a third-generation thienopyridine pro-drug, that contrary to clopidogrel is mostly metabolized into its active metabolite in the intestine. Prasugrel effects were examined on the PG-PS-induced arthritis rat model. Erosive arthritis was induced in Lewis rats followed by treatment with prasugrel for 21 days. Prasugrel treated arthritic animals showed a significant increase in the inflammatory response, compared with untreated arthritic rats, in terms of augmented macroscopic joint diameter associated with significant signs of inflammation, histomorphometric measurements of the hind joints and elevated platelet number. Moreover, fibrosis at the pannus, assessed by immunofluorescence of connective tissue growth factor, was increased in arthritic rats treated with prasugrel. In addition to the arthritic manifestations, hepatomegaly, liver granulomas and giant cell formation were observed after PG-PS induction and even more after prasugrel exposure. Cytokine plasma levels of IL-1 beta, IL-6, MIP1 alpha, MCP1, IL-17 and RANTES were increased in arthritis-induced animals. IL-10 plasma levels were significantly decreased in animals treated with prasugrel. Overall, prasugrel enhances inflammation in joints and liver of this animal model. Since prasugrel metabolites inhibit neutrophil function ex-vivo and the effects of both clopidogrel and prasugrel metabolites on platelets are identical, we conclude that the thienopyridines metabolites might exert non-platelet effects on other immune cells to aggravate inflammation.
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Affiliation(s)
- Analia E Garcia
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, United States of America.
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9
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Coulter CJ, Montandon SV. Prasugrel as a Safe Alternative for Clopidogrel-Induced Polyarthralgias. Pharmacotherapy 2012; 32:e24-6. [DOI: 10.1002/phar.1044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Chad J. Coulter
- College of Pharmacy; Sullivan University; Louisville Kentucky
| | - Shari V. Montandon
- The Department of Internal Medicine; University of Louisville; Louisville Kentucky
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Garcia AE, Mada SR, Rico MC, Dela Cadena RA, Kunapuli SP. Clopidogrel, a P2Y12 receptor antagonist, potentiates the inflammatory response in a rat model of peptidoglycan polysaccharide-induced arthritis. PLoS One 2011; 6:e26035. [PMID: 22028806 PMCID: PMC3196585 DOI: 10.1371/journal.pone.0026035] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 09/16/2011] [Indexed: 01/28/2023] Open
Abstract
The P2Y12 receptor plays a crucial role in the regulation of platelet activation by several agonists, which is irreversibly antagonized by the active metabolite of clopidogrel, a widely used anti-thrombotic drug. In this study, we investigated whether reduction of platelet reactivity leads to reduced inflammatory responses using a rat model of erosive arthritis. We evaluated the effect of clopidogrel on inflammation in Lewis rats in a peptidoglycan polysaccharide (PG-PS)-induced arthritis model with four groups of rats: 1) untreated, 2) clopidogrel-treated, 3) PG-PS-induced, and 4) PG-PS-induced and clopidogrel-treated. There were significant differences between the PG-PS+clopidogrel group when compared to the PG-PS group including: increased joint diameter and clinical manifestations of inflammation, elevated plasma levels of pro-inflammatory cytokines (IL-1 beta, interferon (IFN) gamma, and IL-6), an elevated neutrophil blood count and an increased circulating platelet count. Plasma levels of IL-10 were significantly lower in the PG-PS+clopidogrel group compared to the PG-PS group. Plasma levels of platelet factor 4 (PF4) were elevated in both the PG-PS and the PG-PS+clopidogrel groups, however PF4 levels showed no difference upon clopidogrel treatment, suggesting that the pro- inflammatory effect of clopidogrel may be due to its action on cells other than platelets. Histology indicated an increase in leukocyte infiltration at the inflammatory area of the joint, increased pannus formation, blood vessel proliferation, subsynovial fibrosis and cartilage erosion upon treatment with clopidogrel in PG-PS-induced arthritis animals. In summary, animals treated with clopidogrel showed a pro-inflammatory effect in the PG-PS-induced arthritis animal model, which might not be mediated by platelets. Elucidation of the mechanism of clopidogrel-induced cell responses is important to understand the role of the P2Y12 receptor in inflammation.
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Affiliation(s)
- Analia E Garcia
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, United States of America.
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Kawashiri SY, Taguchi M, Kawakami A, Eguchi K. Clopidogrel-associated acute arthritis. Rheumatol Int 2009; 32:449-50. [PMID: 20024558 DOI: 10.1007/s00296-009-1267-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 11/29/2009] [Indexed: 01/08/2023]
Abstract
A 54-year-old Japanese man was urgently admitted to our hospital because of "unmovable" polyarthralgia, high fever and pruritus. He had taken clopidogrel 3 weeks before this admission to prevent ischemic cerebrovascular events. On the laboratory values, acute phase reactants and serum IgE were elevated. Although his symptoms had promptly improved with non-steroidal anti-inflammatory drugs (NSAIDs) and cessation of the drug, the same phenomena were re-induced by re-administration of the drug. According to the above manifestations, he was diagnosed as suffering from clopidogrel-associated acute arthritis.
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Affiliation(s)
- Shin-ya Kawashiri
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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Khan EAR, Blake JWH, Stamp LK. Ticlopidine as a safe alternative for clopidogrel-associated arthritis. J Rheumatol 2009; 36:855-6. [PMID: 19342727 DOI: 10.3899/jrheum.081131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Titos-Arcos J, Plaza-Aniorte J, Nájera-Pérez M, Sánchez-Quiles I. Enfermedad del suero-like asociada a clopidogrel. FARMACIA HOSPITALARIA 2008; 32:131-2. [DOI: 10.1016/s1130-6343(08)72828-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Muthusamy ASR, Vaidya A, Friend PJ. Clopidogrel-associated acute migratory arthritis following kidney-pancreas transplantation. Int J Immunopathol Pharmacol 2006; 19:443-4. [PMID: 16831311 DOI: 10.1177/039463200601900221] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Clopidogrel is a potent inhibitor of platelet aggregation and has been used as an alternative, or as an adjunct to aspirin in reducing the risk of thrombosis. A 34-year-old uremic type 1 male diabetic patient who underwent simultaneous kidney-pancreas transplantation was given clopidogrel as he was allergic to aspirin. He developed polyarthralgia one week later, followed in a few days by symmetrical migratory polyarthritis, which resolved completely on withdrawing the drug. The implications to clinical management in a transplant setting are discussed.
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Affiliation(s)
- A S R Muthusamy
- Oxford Transplant Centre, Churchill Hospital, Headington, Oxford, United Kingdom.
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