Premature Clopidogrel Discontinuation After Drug-Eluting Stent Placement in a Large Urban Safety-Net Hospital

Published:December 07, 2015DOI:
      Premature clopidogrel discontinuation is an important cause of stent thrombosis, myocardial infarction, and death after drug-eluting stent (DES) placement. Previous studies of clopidogrel nonadherence after DES placement have had short follow-up and have relied on self-reported adherence. All patients who underwent DES placement from January 2008 to December 2011 at a single safety-net hospital and received medications through the county-subsidized health plan were considered for inclusion; those with <1-year follow-up were excluded. We retrospectively collected 1-year refill data from a large, closed pharmacy system. Our primary outcome was time to failure to obtain a clopidogrel refill, allowing a 5-day grace period. Our study cohort (n = 369) was 34% female, 39% Hispanic, 26% white, and 26% African-American; 26% identified Spanish as their primary language. The time to failure to obtain a clopidogrel refill was 153 days. Cumulative failure to obtain at least 1 refill was 23% for the first refill, increasing to 52% at 6 months and 68% at 1 year. Examining the proportion of days covered (PDC), 21% of patients had 100% coverage, whereas 34% had PDC <80%. There were no independent predictors of nonadherence (PDC <80%). In conclusion, we identified a high rate of clopidogrel nonadherence in a multiethnic urban poor patient population where clopidogrel was provided at discharge and at nominal cost thereafter. In this cohort, prediction models of nonadherence performed poorly. Novel strategies are needed to address this important problem.
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        • Price M.J.
        • Walder J.S.
        • Baker B.A.
        • Heiselman D.E.
        • Jakubowski J.A.
        • Logan D.K.
        • Winters K.J.
        • Li W.
        • Angiolillo D.J.
        Recovery of platelet function after discontinuation of prasugrel or clopidogrel maintenance dosing in aspirin-treated patients with stable coronary disease: the recovery trial.
        J Am Coll Cardiol. 2012; 59: 2338-2343
        • Jackevicius C.A.
        • Li P.
        • Tu J.V.
        Prevalence, predictors, and outcomes of primary nonadherence after acute myocardial infarction.
        Circulation. 2008; 117: 1028-1036
        • Muntner P.
        • Mann D.M.
        • Woodward M.
        • Choi J.W.
        • Stoler R.C.
        • Shimbo D.
        • Farkouh M.E.
        • Kim M.C.
        Predictors of low clopidogrel adherence following percutaneous coronary intervention.
        Am J Cardiol. 2011; 108: 822-827
        • Quadros A.S.
        • Welter D.I.
        • Camozzatto F.O.
        • Chaves A.
        • Mehta R.H.
        • Gottschall C.A.
        • Lopes R.D.
        Identifying patients at risk for premature discontinuation of thienopyridine after coronary stent implantation.
        Am J Cardiol. 2011; 107: 685-689
        • Spertus J.A.
        • Kettelkamp R.
        • Vance C.
        • Decker C.
        • Jones P.G.
        • Rumsfeld J.S.
        • Messenger J.C.
        • Khanal S.
        • Peterson E.D.
        • Bach R.G.
        • Krumholz H.M.
        • Cohen D.J.
        Prevalence, predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent placement: results from the PREMIER registry.
        Circulation. 2006; 113: 2803-2809
        • Choudhry N.K.
        • Avorn J.
        • Glynn R.J.
        • Antman E.M.
        • Schneeweiss S.
        • Toscano M.
        • Reisman L.
        • Fernandes J.
        • Spettell C.
        • Lee J.L.
        • Levin R.
        • Brennan T.
        • Shrank W.H.
        • Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) Trial
        Full coverage for preventive medications after myocardial infarction.
        N Engl J Med. 2011; 365: 2088-2097
        • Iakovou I.
        • Schmidt T.
        • Bonizzoni E.
        • Ge L.
        • Sangiorgi G.M.
        • Stankovic G.
        • Airoldi F.
        • Chieffo A.
        • Montorfano M.
        • Carlino M.
        • Michev I.
        • Corvaja N.
        • Briguori C.
        • Gerckens U.
        • Grube E.
        • Colombo A.
        Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents.
        JAMA. 2005; 293: 2126-2130
        • David R.A.
        • Rhee M.
        The impact of language as a barrier to effective health care in an underserved urban Hispanic community.
        Mt Sinai J Med. 1998; 65: 393-397
        • Kaplan R.C.
        • Bhalodkar N.C.
        • Brown Jr., E.J.
        • White J.
        • Brown D.L.
        Race, ethnicity, and sociocultural characteristics predict noncompliance with lipid-lowering medications.
        Prev Med. 2004; 39: 1249-1255
        • Mojtabai R.
        • Olfson M.
        Medication costs, adherence, and health outcomes among Medicare beneficiaries.
        Health Aff (Millwood). 2003; 22: 220-229
        • Baroletti S.
        • Dell'Orfano H.
        Medication adherence in cardiovascular disease.
        Circulation. 2010; 121: 1455-1458
        • Shroff A.
        • Ali A.
        • Groo V.L.
        Clopidogrel adherence following percutaneous coronary intervention with a drug-eluting stent in a VA medical center.
        J Pharm Technol. 2009; 25: 164-168
        • Ho P.M.
        • Lambert-Kerzner A.
        • Carey E.P.
        • Fahdi I.E.
        • Bryson C.L.
        • Melnyk S.D.
        • Bosworth H.B.
        • Radcliff T.
        • Davis R.
        • Mun H.
        • Weaver J.
        • Barnett C.
        • Barón A.
        • Del Giacco E.J.
        Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge: a randomized clinical trial.
        JAMA Intern Med. 2014; 174: 186-193
        • Rosenbaum L.
        • Shrank W.H.
        Taking our medicine—improving adherence in the accountability era.
        N Engl J Med. 2013; 369: 694-695
        • Ho P.M.
        • Bryson C.L.
        • Rumsfeld J.S.
        Medication adherence: its importance in cardiovascular outcomes.
        Circulation. 2009; 119: 3028-3035