Clopidogrel-Induced Recurrent Polyarthritis

The Mystery of Clopidogrel-Associated Inflammatory Arthritis

Clopidogrel is an antiplatelet medication that plays an important role in the management and prevention of thrombotic vascular events in patients with acute coronary syndrome (ACS) and ischemic stroke. We report a case of a male patient who received a maintenance dose of clopidogrel as part of stroke treatment and developed inflammatory arthritis after five days of starting the medication. He underwent extensive evaluation and testing to explore other common causes of inflammatory arthritis, including autoimmune etiologies. None of the test results were helpful, and we hypothesized that his arthritis was induced by clopidogrel. Discontinuing this agent resulted in the complete resolution of the patient's symptoms. Since medication-induced arthritis is a diagnosis of exclusion, these patients should undergo a complete workup for inflammatory arthritis. If possible, a risk-benefit analysis of dual antiplatelet therapy (DAPT) in ischemic stroke patients with a prior history of rheumatoid arthritis (RA) should be done in collaboration with neurology.

Analysis of the clinical characteristics of acute arthritis induced by clopidogrel

WHAT IS KNOWN AND OBJECTIVE

Knowledge regarding the association between clopidogrel exposure and acute arthritis is based mainly on case reports. The purpose of this article was to assess the clinical characteristics of clopidogrel-induced acute arthritis.

METHODS

We collected literature from 1998 to 2020 in Chinese and English on acute arthritis induced by clopidogrel for retrospective analysis.

RESULTS AND DISCUSSION

The median age of 21 patients (6 females and 15 males) was 63 years (range 34-77). The median time of symptom onset was 10 days (range 0.21-21) overall. The median onset time of symptoms of clopidogrel-induced arthritis was 14 days (range 3-21) and 3 days (range 0.21-7) in patients with and without a loading dose of clopidogrel, respectively. Arthralgias (100%), joint swelling (61.9%), fever (57.1%), rash (33.3%) and pruritus (28.6%) were the most common accompanying symptoms. Most cases were accompanied by different degrees of acute inflammation markers: the median ESR was 68 mm/h (range 10-120), and the median CRP was 142.4 mg/L (range 2.3-408). X-ray films were unremarkable. Symptoms disappeared completely in all patients at a median time of 4 days (range 0.17-30) after the discontinuation of clopidogrel. Prasugrel, ticagrelor and ticlopidine can be used as safe alternatives to clopidogrel in patients with clopidogrel-induced acute arthritis with no recurrence of arthritis.

WHAT IS NEW AND CONCLUSION

Clopidogrel-induced arthritis is a rare adverse reaction and should be suspected in patients with arthralgia and fever during clopidogrel use.

Clopidogrel-Associated Migratory Inflammatory Polyarthritis

BACKGROUND Clopidogrel is an antiplatelet medication that plays an important role in primary management and secondary prevention of thrombotic vascular events in patients with acute coronary syndrome. It is generally well tolerated by most patients, but rare adverse effects such as inflammatory arthritis has been noted. A very few cases of migratory polyarthritis secondary to clopidogrel have been reported in the literature. CASE REPORT We describe 2 cases of acute migratory polyarthritis associated with clopidogrel that resolved with discontinuation of clopidogrel and did not recur after prasugrel initiation. In the first case, the patient presented with migratory polyarthritis approximately 2-3 days after initiating clopidogrel, and the symptoms lasted in each joint for 1-2 days. In the second case, the migratory polyarthritis started 1 week after initiating clopidogrel, and the symptoms lasted in each joint for approximately 2-3 days. The symptoms completely resolved after discontinuing clopidogrel in both the cases, which is typical of an immune-mediated drug reaction. A diagnosis of acute migratory inflammatory polyarthritis related to clopidogrel was determined in both cases by excluding other conditions causing inflammatory arthritis. In both cases, the eosinophil count was within normal limits, thereby differentiating the disease process from an acute allergic reaction. CONCLUSIONS Identifying the etiology of inflammatory arthritis in a patient on clopidogrel needs extensive evaluation. The diagnosis of clopidogrel-related inflammatory arthritis is often missed due to lack of awareness. Early diagnosis and timely intervention are essential, as the symptoms completely resolve after discontinuing clopidogrel.

Bicalutamide-Associated Acute Liver Injury and Migratory Arthralgia: A Rare but Clinically Important Adverse Effect

We describe a case of acute liver injury and migratory arthralgia in a patient receiving bicalutamide treatment for prostate cancer. A 67-year-old male with metastatic prostate cancer presented with a 6-day history of migratory arthralgia. He had been undergoing treatment with bicalutamide for 4 months; 3 weeks prior to symptom appearance the bicalutamide dose had been increased. He had no other symptoms. Liver tests and inflammatory markers were markedly elevated. Serology for hepatitis viruses A, B, and C, CMV, and EBV and autoimmune causes were all negative, and an ultrasound of the upper abdomen was normal. There was no history of blood transfusion, intravenous drug abuse, or alcohol abuse. Due to the suspicion of a drug-induced symptomatology, bicalutamide was discontinued and the patient started on 30 mg prednisolone daily. Three weeks later he was symptom free and after 6 weeks his liver tests were almost normal. The Roussel Uclaf Causality Assessment Method (RUCAM) suggested a high probability of liver injury. Bicalutamide has very rarely been reported as a causative agent for liver injury and to our knowledge never for migratory polyarthralgia. The migratory polyarthralgia was attributed to bicalutamide due to the absence of other etiological factors and the disappearance of symptoms after discontinuation of the drug. To our knowledge, this is the first published case report of migratory arthralgia and concomitant liver injury attributed to bicalutamide.

Ticagrelor as an Alternative for Clopidogrel-Associated Acute Arthritis

A 65-year-old Caucasian man was hospitalized for a non-ST-elevation myocardial infarction. On discharge, the patient was started on multiple new medications, including clopidogrel and atorvastatin. Twenty-six days after discharge, he presented to the Emergency Department (ED) with polyarthralgias. He was instructed to stop atorvastatin and to follow up with rheumatology and cardiology clinic. At cardiology clinic follow-up 43 days after ED discharge, clopidogrel was discontinued and patient was switched to ticagrelor. On follow-up one month later, his symptoms had completely resolved. During the next 4 months, patient had routine follow-up due to participation in Cardiopulmonary Rehab and he had no cardiac events or recurrence of joint symptoms. Our patient had no history of arthritis. Because he initially presented with 2 medication classes associated with arthritis, each was withdrawn separately. The temporal association of patient's symptomatic improvement strongly suggests that the arthritis was caused by clopidogrel. Our patient was able to tolerate ticagrelor with complete resolution of his arthritis and no cardiac events. Clopidogrel-induced arthritis is a rare adverse drug event. For patients with a recent drug-eluting stent, alternative antiplatelet therapy with ticagrelor may provide positive cardiac outcomes without similar adverse effects.