It seems almost automatic that someone on Plavix/aspirin (after Drug coated stent), will be at risk for bruising. My questions have to do with severity and trends (getting worse over time, for example). Other than the obvious connection I already stated, I have not found lots of specifics, so I am wondering about peoples' experience here with bruising. I have had some real "good" ones lately, and they have just started appearing. One I have had took a long time to go away (actually it is still slightly visible). Maybe I am just now starting to get careless (actually never thought about it), but the several I have had look ugly and large. I have put ice packs on them.

Any comments? Obviously also there is a catch 22, as one does not want to stop the Rxs to improve the bruising potential.

Thanks,

Ken

My Mom is on Coumadin (warfarin) and bruises very easily. One little bang, and she has a bruise. Her skin has become very thin, and she has many marks on it. She hates what coumadin is doing to her skin, but she has no choice. Like yourself, some bruises take longer to fade than others.

I've been on both Plavix and aspirin since having a stent placed in early Oct '04. At first, I was on a regular 325 mg aspirin, but in June '05 that was changed to two 81 mg (or 1/2 regular) because of excessive bruising...my ears started to bleed occasionally and I had a huge bruise all over one foot from a slight bump.

I've bruised easily all my life but it really increased with these meds. It's just something I live with. I'm colorful these days;)

Being various shades of yellow, green and purple (and rarely knowing how I got that way since all it takes is a very minor bump) is my new normal.

Sure beats the alternative....

Thanks for all the comments....yes, the bruising is much better than the alternative. Guess one just better be as careful as possible. I picked up a heavy computer monitor and the edge pressed into my biceps and later (I didn't really notice), I had a "nice one" over my entire lower bicep. Yes, the colors are sort of pretty as it ages.....

Again, thanks for the comments.

Ken,

I got a bloody nose every day of the two months that I took that godforsaken drug (Plavix)...I'd NEVER take it again.

Isn't it reasonable that for every bruise you see, or every case of a bloody nose or bloody ears, and there's probably an internal bleed or two that you NEVER see. Of course the worst of these internal bleed is in the brain, aka hemorrhagic stroke.

Plavix is the modern day equivalent of "bleeding" therapy!

I predict the drug will eventually be removed from the market but not before it has killed a mighty multitude.

Yikes! You are probably right on target but what is so scary is the statistics that seem uncontrovertable showing tragic thrombosis in the DES if one stops taking these. Aspirin alone does not seem to work.

I take fish oil in addition to the plavix and aspirin. I can not chance running the experiment to see if aspirin and fish oil act as effective as aspirin and plavix.

Re: bleeding in the brain. That's why it's always good to know the symptoms of stroke, even if all we take is aspirin. But the good thing is that my skull is pretty hard (unlike my thinning skin as I age) and cushions against the minor bumps that seem to be the cause of most of my bruising. And since I've had no GI discomfort or bleeding, I ain't too worried.

Each of us has to make the decision that is best for us, based upon whatever research and personal experience we have. Once we are no longer disease free, it usually boils down to a choice of weighing the risks of various treatments or treatment vs. no treatment.

Me, I'll risk the slightly increased risk I have of a stroke over another 99% blockage in my LAD.

BTW, my cardiologist won't let me take fish oil along with my aspirin and Plavix as he says that fish oil could increase the risk of a bleed. He says it's just better to eat a lot of fish.

Ken,
I dispute there is convincing evidence showing the efficacy of Plavix over aspirin alone and evidence only for showing additional benefit for combining aspirin and Plavix (clopidogrel) for 2 months...and then no more.

And there is just too much of this kind of stuff:
Dr. Charles Bennett, a Northwestern University researcher, has developed a proactive method for detecting adverse drug effects by examinning adverse drug reports submitted to FDA’s database and reports from reports by phamaceutical companies and independent groups of researchers thoughout the US and Canada. The project is called the Research on Adverse Drug Events and Reports (RADAR).

For example, Dr. Bennett discovered that the widely used anti-clotting drug, Plavix, can cause “a catastrophic collapse of the blood system.” He urged the FDA to issue Black Box warnings, but the FDA refused, but did add a less prominent warning.

Dr. Bennett published a paper in the journal Stroke (February) in which he compared the effectiveness of various systems for detecting adverse drug effects. The FDA system ranked at the very bottom:

“The study assessed how the FDA, Plavix's manufacturer and RADAR pursued adverse drug reports, documented the side effects and assessed patient outcomes over a four-year period. Basically it was a report card, and RADAR scored 92 to 100 percent; drug companies, 8 to 58 percent; and the FDA, 0 to 23 percent.”

And then there's the CHARISMA TRIAL:
The CHARISMA trial is an international, multicenter, double-blinded, placebo-controlled study involving 15,603 patients aged 45 years or older who were at high risk of heart attack, stroke or death from cardiovascular disease. The study was designed to assess whether adding clopidogrel (75 mg/day) to aspirin therapy (75-162 mg/day) provided any benefit over aspirin monotherapy in preventing the occurrence of those events.

The study's efficacy results showed that the addition of clopidogrel to aspirin therapy did not result in a significant lowering (p =0.22) of risk of the primary endpoint, the combined risk of heart attack, stroke or cardiovascular death (6.8 percent in the clopidogrel plus aspirin group and 7.3 in the aspirin-only group -- a difference that was not statistically significant). Additionally, the rate of moderate-to-severe bleeding was increased in the patients taking clopidogrel with aspirin compared to the rate in those taking aspirin alone.

Aspirin: The Unsurpassed Antiplatelet Gold Standard

Aspirin is the most studied antiplatelet agent, with more than a 100-year track record of efficacy and safety. As the cornerstone antiplatelet therapy for reducing the risk of cardiovascular events, time-tested aspirin is well recognized for its benefits as first-line therapy across a wide cardiovascular risk continuum because of its proven efficacy, safety and cost-effectiveness -- benefits that have been demonstrated in more than 200 trials involving over 200,000 patients, including CHARISMA.

My opinion, which is STRONGLY fact based, is that there may be a benefit/risk ratio greater than 1 for anyone getting a stent and taking the COMBINATION aspirin + clopidgogrel that persists for 60 days. Any other use exposes the user to a huge dangerous risk of fatal bleeds (death or a loss of more than 4 units of blood) with very little benefit. THe number usually given for this potentially fatal bleed is 1% of users...this is NOT a bruise or a bloody nose I'm talking about.

My prediction: keep your eyes and ears open and you will soon see more and more damning evidence for this GARGANTUAN money maker...and the WARNINGS will become more strident.

Ken,
I dispute there is convincing evidence showing the efficacy of Plavix over aspirin alone and evidence only for showing additional benefit for combining aspirin and Plavix (clopidogrel) for 2 months...and then no more.


Lenin: I do not dispute what you say. I wonder however, that you do not mention the flip side---stopping taking the plavix/aspirin combination. There are facts (I do not have the citation readily available) about the demonstrated increase in risk for those who stop taking the combo, even for a short time. The recos go out to 12 months, I think because no data exists for longer than this. I have posted somewhere else, a quote from a cardiologist about this.

So...risks of taking and risks from stopping. I admit and am thinking seriously, based in part on your comments, about how much fish oil I should continue taking. I have already cut back, but not to zero and doubt I will.

Great discussion...good learning from these messages.

Thanks.

Lenin,

I'm surprised that you did not quote the complete results of the CHARISMA study. While it did find that there was not a significant difference in prevention of cardiovascular events in people who are AT RISK of these events, when they analyzed the subgroups (people who were AT RISK vs. those KNOWN to have disease) there was, in fact, a statistically significant benefit of taking Plavix plus aspirin for those who have heart disease.

The jury is still out, in my opinion, about how long we should be taking this medication. But the evidence is pretty clear that it is helpful for at least the first year in people who have stents. Of course it can cause bleeding. So can aspirin and any number of other things. It is common sense that taking both further increases the risk of bleeding. But anti-coagulants of various types have been used for decades in people with a history of heart attack and stroke. (And it is a risk I'm willing to take, when compared to my risk of death from a heart attack. My decision might be different if I had a nose bleed everyday, or less serious CAD, or any number of other individual variables).

Anyone interested in reading about this study can Google "CHARISMA Plavix" and get any number of articles summarizing the study. You can also go to the source (New England Journal of Medicine) and read the abstract for free, or pay to read the entire study article. As an example, here is the Reuter's news article:

ATLANTA (Reuters Health) Mar 13 - Adding clopidogrel (Plavix) to a daily dose of aspirin does not lower the risk of death, myocardial infarction or stroke in high-risk patients, researchers reported at the 55th annual meeting of the American College of Cardiology on Sunday.

"The overall findings were negative, but a benefit was seen in patients with established cardiovascular disease," said lead investigator Dr. Deepak Bhatt, of the Cleveland Clinic Cardiovascular Coordinating Center in Ohio.

A study of more than 15,000 patients showed that combining clopidogrel with aspirin may do more harm than good for patients at risk of heart disease, but it may help those who have already had an MI or stroke.

The results confirm aspirin as "the gold standard" for treating patients at risk of heart disease, according to Dr. Charles Hennekens, of the University of Miami School of Medicine. The study findings "redouble the message that aspirin has the best benefit-to-risk and the best benefit-to-cost ratios of any heart drug out there," he added.

The study included patients who had a previous MI, stroke, or impaired circulation (stable heart disease group), along with patients with cardiovascular risk factors, such as diabetes, hypertension or hyperlipidemia.

At 28-month follow-up, the researchers found a 7.3% risk of mortality, MI or stroke in patients assigned to placebo plus aspirin, compared with 6.8% for those patients on clopidogrel plus aspirin - a nonsignificant difference. The addition of clopidogrel did reduce hospitalization rate from 17.9% to 16.7%.

When the analysis was limited to the 12,153 patients with established heart disease, clopidogrel reduced the combined risk of mortality, MI or stroke from 7.9% to 6.9%.

"There is no reason to use the combination therapy for primary prevention, whereas it might be useful in patients who have already had a heart attack or stroke," Dr. Bhatt said.

The trial showed no significant increase in severe bleeding in patients with cardiovascular disease. But the addition of clopidogrel may have increased the risk of severe bleeding and death in patients with risk factors for heart disease, the researchers said.

"Aspirin is tough to beat, but it too has bleeding risk," Dr. Bhatt added.

Just wanted to add that I appreciate this discussion...it's always good to see different points of view, and it prompted me to update my own research on Plavix...had been awhile since Iwent to PubMed, Medscape etc. specifically on this med.

I have trouble any time I read anything like "so can aspirin" as in "Plavix can cause serious bleeds but then SO CAN ASPIRIN."
It really is akin to saying that slicing your throat with a 12 inch chef's knife can cause bleeding but the so can shaving.
Yes that's true but DEGREE is important.

I have taken rather high dose aspirin all my life and NEVER saw any bleeding, or untimely clotting from it but after two weeks of Plavix I was a veritable GEYSER of blood.

There is no comparison to the dangerous bleeding risk of the two drugs.

p.s. Now that the courts have just found that Bristol Meyers Squibb- Sanofi Aventis improperly acted to keep the generic clopidogrel off the market (by paying HUGE bucks to it's manufacturer,) the generic wll likely be available this year. After the BILLIONS stop going into the patent holders hands, lets watch and see if we start getting some less favorable horror stories about the drug...and how truly awful the bleeding situation is. And maybe even how very much moolah was given to doctors to prescribe it.
I'd like to see someone go to jail...to Hell with a fine.

Put ONE CEO and ONE doctor in the slammer for 5 years with LOTS of publicity and the whole medical profession will clean up it's smarmy little drug act overnight.

I have been taking plavix daily along with bp meds for over a year and a half, when I had a stroke. I was taking an aspirin daily but my doctor told me to stop. I have had some bruising but not all that much. I will bump myself and say oops! that will leave a mark and it usually does.

I consider the alternative. When I was in the hospital, they had to take my blood THREE times because it clotted before they were able to get it to the downstairs lab. While there, they gave me a bloodthinner shot in my belly twice daily. You should have seen THAT bruise!!! My whole belly was one big bruise.

I am still in danger of bloodclots, but since I have blood tests every 2 -4months (I see the doc every 2 months) I know the doc is on top of things.

I've taken plavix for approximately 3 months now and I've wondered often where the brusing came from so now I know. I hardly ever bruised before my heart attack 3 months ago. And my nutristionist said she was going to have to get me off this stuff, is that bad? Yes I bruise but if thats all I have to worry about I think I can live with it. I just hate that fact that I have to take meds to survive. I do to high blood pressure meds as well as metropolol plavix and aspirin every day. Does anyone else take the same meds and how are you functioning?

With a stent I of course want to continue a platelet "unstickifier." :D I dutifully took the Plavix/aspirin combo for 6 weeks after my stent (and then dutifully forced myself to take Plavix every SECOND day for the next two weeks.) My doctor wanted 90 days but settled for my 60 day choice <I never told him about the last two weeks:jester: > after the results of the CURE STUDY convinced me that ALL the benefits of aspirin + Plavix over aspirin alone occur in the first two months after stent placement.

Since I had read a LOT about the horrific bleeding problems with clopigogrel and experience first hand severe femoral bleeding with the loading dose, and then had daily nosebleeds for 2 months afterward I felt I HAD to get off this awful drug.

I have taken daily aspirin, 650 mg., for many years and NEVER experienced nosebleeds or easy bruising so aspirin alone will be my sole anti-platelet agglomerating agent.
The CURE study shows clearly that aspirin and Plavix work equally well...and you can buy a bottleful of generic aspirin for the price of ONE Plavix tablet.

Aspirin works but nobody can get rich off it. So $$alternatives$$ MUST be rammed down our throats.

reeddo,

I usually agree with Lenin, but we have a difference of opinion on Plavix, though perhaps he would agree with me that each individual has to do their own in-depth research, consider their own circumstances, and make the decision that is best for them. I too would probably not be taking both Plavix and aspirin if I had suffered the side effects he has.

In my case, I just bruise easier (and not nearly as bad as my friends with different types of heart problems who take Coumadin). And given the recent info that drug-coated stents appear to result in a higher rate of late blood clotting, I'm not willing to make any changes now. My stent was placed in early October, 2004, and I've been on Plavix and aspirin (along with metoprolol, Lipitor, and Niaspan) ever since. I was originally on Plavix and a standard size aspirin (325 mg) but decreased the aspirin, in consultation with my cardiologist, to 2 "baby" aspirin (81 mg) when the bruising got a bit out of hand for my tastes about 1 1/2 years ago.

I too would like to get off some of the meds, but at this point I'm satisfied that, for me, my best bet is to continue the current course at least until the current controversy on drug eluting stents is better resolved.

You don't say whether you have one or more stents, or what kind you have, but my advice would be that, at a minimum, don't quit taking any of your meds without discussing it with a cardiologist (or more than one cardiologist if you'd like to get a variety of opinions and have resouces or insurance that will cover the second and third opinions).

The study that needs to be done with Plavix is to follow people with stents, heart attack, or any other heart condition and begin the study ONE year after the procedure/event.
People should be compared in years 2 through 5 to ascertain who does better, those on Plavix-aspirin or those on aspirin. And for THIS study, fatal bleeding will be included in the results, not ignored.
I am 100% certain that if this study were run, during years 2 though 5 more people would die on Plavix-aspirin therapy than on aspirin alone.

Remember, a bruise under the skin can JUST as easily be a bruise under the skull. The only difference is you can't SEE the bleed into the brain, you recognize it by COMA or paralysis.

WHY would anyone take Plavix for years if NO study has ever shown it safe and effective beyond 60 days??? This AMAZES and PERPLEXES :dizzy: me.

after 3 heart attacks & 4 stents and 100% blockage in left carotid artery and 50% in right after surgery ejection faction 43%. I'm doing good not taking anymore lipitor - plavix- beta blockers etc. dec 04 was last attack and have tried all therapy's, supps., drugs, etc., since 3/99 . Doing good with quality fish oil & lots of garlic & asprin, and stuff that thins the blood, plus cut out all animal protein's seems to be working. Plavix is short term use from studies I've seen. being at high risk for stroke now I'm keeping the blood thin but cut back when nose bleeds, and seems to help prevent any more attacks. Not much help from dr.s for soft plaque (not calcium deposits) in arteries and the simple ultrasound is great for seeing if you have problems, though not profitable for hospital's. Good luck to every one.

Lenin,

Ahhhh...we've finally found something we agree on re: Plavix...the study you propose absolutely does need to be done. But who do you suppose is gonna fund it?rolleyes:

It amazes me how little long term research has been done on ANYTHING related to CAD (and I presume lots of other conditions). My theory is I'll find out whether the treatments I've gotten/am getting have any significant positive impact if I make it to age 70. My Dad was diagnosed with angina when he was about 54 (I was 53) and he died at age 64 in early 1973. His only "treatment" was coumadin, nitroglycerine, and an occasional valium. (They did do an angiogram in 1972 and he was a candidate for experimental bypass surgery, but elected not to have it done).

I realize I'm increasing my risk of stroke (and other bleeding issues) by being on Plavix, but at this point I'll take my chances. Hopefully, there will be some resolution to the current drug eluting stent controversy by the time of my next cardiologist visit and I can make a different decision. I probably put too much faith in them, but since I get all my care at Mayo Clinic I'm confident they are more than reasonably "up to date."

It is time, however, for me to put "update my Plavix research file" on my to do list as it's been at least a year or more since I've gone out hunting for the scientific articles on the subject.

Connie,

I woudn't worry so much about the medicated stent (I have the same one)...odds are so good that even if it is riskier than the uncoated one that by now both our stents are covered over with artery wall/plaque and immune to clotting, furring, or other calametous outcomes.

I REALLY think the bleed risk from Plavix is far worse than the clot risk without Plavix at this time...in fact I will go so far as to say I'M CERTAIN. Aspirin is a WONDERFUL anti-platelet agglomerator, all by it's lonesome. :D

Hmm, Mayo Clinic eh...guess you can't do better than that unless you were Dwight Eisenhower...he had all his heart attacks at Bethesda Naval.

My mom had a similar history as your father's...angina for 5 years, then angiography said 3 major blockages and the only alternative was bypass. There was a time 2 decades ago when women had trouble qualifying for angioplasty (no stents at the time)...it MIGHT have been because of smaller arteries and cruder methodology...not sure why; maybe just misogyny. Her heart continued to clog and fail using atenolol, nitroglycerine, I think channel blockers later on...and then she died in 1993 at 78.
It was 15 years with her heart getting worse and worse. last 5 years were tough, in and out of the hospital...with them really doing NOTHING for her other than billing her insurance.

I HOPE you are keeping your LDL's very low. I think that is the best way to prevent gunking up stents. Mine is a stellar 62. TA-DAAAH! :D

Yup, my last numbers in November were LDL 64, HDL 51, Total 147 and Triglycerides 157. The ones in July were similar...only the Niaspan, which was added last December, has worked to get the HDL above 35. Can't remember what my LDL was before I started the Niaspan (was pretty good, but I think it's even better now). I'm on a large Lipitor dose though (40 mg) and would like to see what happens if that's lowered at least a little. And/or see what the #s look like if I take OTC niacin rather than the Rx (though it may actually be cheaper to get it Rx).

You are probably right re: not worrying too much about the drug eluting stent...I think when the news articles talk about "late clotting" they may just be talking about clotting after 30 days (which if I remember right was the longest most of the stent studies that tracked thrombosis were originally done)...