The effect of clopidogrel on platelet activity in patients with and without type-2 diabetes mellitus: a comparative study

Abstract

Background: Although antiplatelet therapy involving clopidogrel is a standard treatment for preventing cardiovascular events after coronary stent implantation, patients can display differential responses. Here, we assessed the effectiveness of clopidogrel on platelet function inhibition in subjects with and without type-2 diabetes and stable coronary artery disease. In addition, we investigated the correlation between platelet function and routine clinical parameters.

Methods: A total of 64 patients with stable coronary heart disease were enrolled in the study. Among these, 32 had known type-2 diabetes, whereas the remaining 32 subjects were non-diabetics (control group). A loading dose of 300 mg clopidogrel was given to clopidogrel-naïve patients (13 patients in the diabetes group and 14 control patients). All patients were given a daily maintenance dose of 75 mg clopidogrel. In addition, all patients received 100 mg ASA per day. Agonist-induced platelet aggregation measurements were performed on hirudin-anticoagulated blood using an impedance aggregometer (Multiple Platelet Function Analyzer, Dynabyte, Munich, Germany). Blood samples were drawn from the antecubital vein 24 h after coronary angiography with percutaneous coronary intervention. The platelets were then stimulated with ADP alone or ADP and prostaglandin-E (ADP and ADP-PGE tests, respectively) in order to evaluate clopidogrel-mediated inhibition of platelet function. The effectiveness of ASA was measured by stimulation with arachidonic acid (ASPI test). In addition, maximal platelet aggregation was assessed via stimulation with thrombin receptor-activating peptide (TRAP test).

Results: Patients with diabetes exhibited significantly less inhibition of platelet function than patients without diabetes (ADP-PGE test p = 0.003; ASPI test p = 0.022). Administering a clopidogrel loading dose of 300 mg did not result in a lower level of ADP-PGE-induced platelet reactivity in comparison to the use of a 75 mg maintenance dose. Moreover, we observed that ADP-PGE-induced platelet inhibition was positively correlated with fasting blood glucose and HbA1c (p < 0.01).

Conclusions: Patients with type-2 diabetes exhibited increased platelet reactivity compared to patients without diabetes despite combined treatment with clopidogrel and ASA. Using a loading dose of clopidogrel rather than small daily doses was not sufficient for adequately overcoming increased platelet reactivity in patients with type-2 diabetes, highlighting the need for more effective anti-platelet drugs for such patients.

Figure 1

Clinical study design. Legend: Schematic representation of the study design. Patients presenting stable coronary heart disease with or without type-2 diabetes were enrolled. A 300 mg loading dose of clopidogrel was given to clopidogrel-naïve patients. All other patients were given a daily maintenance dose of 75 mg clopidogrel. In addition, all patients received acetylsalicylic acid (ASA; 100 mg/day). Blood samples were drawn 24 h after coronary angiography with percutaneous coronary intervention (PCI), and agonist-induced platelet aggregation measurements were performed.

Figure 2

ADP- and ADP-PGE -induced platelet aggregation in patients with and without diabetes. Legend: Agonist-induced platelet aggregation measurements were performed on blood samples from diabetic and non-diabetic patients using an impedance aggregometer. The platelets were stimulated with adenosine diphosphate (ADP; A) alone or ADP and prostaglandin-E (ADP-PGE; B). P values were calculated using a student’s t-test for independent samples.

Figure 3

TRAP-induced platelet aggregation in patients with and without diabetes. Legend: Agonist-induced platelet aggregation measurements were performed on blood samples from diabetic and non-diabetic patients through impedance aggregometry. Maximal platelet aggregation was assessed via stimulation with thrombin receptor-activating peptide (TRAP). P values were calculated using a student’s t-test for independent samples.

Figure 4

ASPI test in patients with and without diabetes. Legend: Platelet aggregation measurements were performed on blood samples from diabetic and non-diabetic patients using an impedance aggregometer. The effectiveness of acetylsalicylic acid (ASA) was measured by stimulation with arachidonic acid (ASPI test). P values were calculated using a student’s t-test for independent samples.

Figure 5

ADP/PGE-induced platelet aggregation after clopidogrel loading and maintenance doses in diabetic and non-diabetic patients. Legend: Agonist-induced platelet aggregation measurements were performed on blood samples through impedance aggregometry. The platelets were stimulated with adenosine diphosphate and prostaglandin (ADP-PGE) in order to evaluate clopidogrel-mediated inhibition of platelet function after a 300 mg loading dose (A), and after a 75 mg maintenance dose (B) in patients with and without diabetes. P values were calculated using a student’s t-test for independent samples.