Drug points: Clopidogrel associated with acute arthritis

doi:10.1136/bmj.320.7233.483/a

BMJ 2000;320:483 ( 19 February )

Papers

Drug points

Clopidogrel associated with acute arthritis

Anu Garg, Johannes Radvan, Neil Hopkinson.

Department of Cardiology, Royal Bournemouth Hospital, Bournemouth, Dorset BH8 8DH

Clopidogrel is a new ADP receptor antagonist used in the prevention of myocardial infarction, stroke, and vascular death.We report two cases of acute arthritis and tendonitis after clopidogreluse.

Case 1
A 76 year old woman was referred with a sixyear history of angina pectoris. She was stabilised on treatmentbut began to develop further symptoms at rest two months beforereferral. She had a long history of hypertension. She took atenolol100 mg once daily, diltiazem 90 mg twice daily, isosorbide mononitrate20 mg twice daily, and aspirin 75 mgdaily.

Significant two vessel coronary artery disease was found at cardiac catheterisation. She underwent percutaneous transluminalcoronary angioplasty and stent insertion of the right coronaryartery. She was prescribed diltiazem 120 mg twice daily, clopidogrel75 mg once daily, and aspirin 150 mg oncedaily.

Two weeks later she developed widespread pruritus, with no obvious rash, and intense pain and swelling of the metacarpophalangealjoints. The joints were red and hot, and there was synovitis.Other joints were unaffected. Her erythrocyte sedimentation rateand C reactive protein concentration were increased to 86 mm inthe first hour and 81 mg/l respectively. Uric acid concentrationwas normal and x ray films showed soft tissue swelling only withno chondrocalcinosis. Clopidogrel wasstopped.

One week later the pruritus had settled and the joint pain had improved. Repeat testing of inflammatory markers confirmedtheimprovement.

Case 2
A 63 year old man was referred with threeepisodes of chest discomfort on exertion. He was an ex-smokerand had a six year history of mild type 2 diabetes mellitus. In1984 he had an uncomplicated subarachnoid haemorrhage. He tooklisinopril 20 mg once daily and long acting diltiazem 200 mg oncedaily.

Severe coronary artery disease in a left dominant system was found at cardiac catheterisation. He underwent coronary arterybypass grafting. He was allergic to aspirin so was prescribedclopidogrel 75 mg once daily in addition tolisinopril.

Three weeks later he presented to his doctor with severe pain of his right knee. The knee was tender, and he was unable tobear weight on the leg. There was tenderness, heat, and swellingover the quadriceps tendon proximal to the patella. His erythrocytesedimentation rate was mildly increased to 47 mm in the firsthour. His serum urate concentration was normal. Clopidogrel wasdiscontinued, and the symptomsresolved.

To our knowledge arthritis has not been described as a side effect of clopidogrel, and the manufacturer knows of only onecase. The two cases we describe had acute musculoskeletal inflammationand increased concentrations of inflammatory markers. We recommendthat clopidogrel be considered as a potential cause ofarthritis.

© BMJ 2000

CiteULike

Complore

Connotea

Del.icio.us Add to Digg

Digg

StumbleUpon Add to Technorati

Technorati What's this?

Rapid Responses:

Read all Rapid Responses

Clopidogrel associated arthritis needs to be confirmed: Albert J Kirshen
bmj.com, 18 Feb 2000 [Full text]
Clopidogrel: safety studies wanted: Tom Oommen
bmj.com, 22 Feb 2000 [Full text]
Clopidogrel associated with acute arthritis: Klaus-Heinrich Bruendel
bmj.com, 5 Apr 2000 [Full text]
Careless talk may cost lives: Michael Green, et al.
bmj.com, 10 Oct 2001 [Full text]
Authors' reply: A Garg, et al.
bmj.com, 10 Oct 2001 [Full text]