CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. oActive pathological bleeding, such as peptic ulcer or intracranial hemorrhage (4.1)oHypersensitivity to clopidogrel or any component of the product (4.2). oActive pathological bleeding, such as peptic ulcer or intracranial hemorrhage (4.1). oHypersensitivity to clopidogrel or any component of the product (4.2). 4.1 Active Bleeding. Clopidogrel bisulfate is contraindicated in patients with active pathological bleeding such as peptic ulcer or intracranial hemorrhage.. 4.2 Hypersensitivity Clopidogrel bisulfate is contraindicated in patients with hypersensitivity (e.g., anaphylaxis) to clopidogrel or any component of the product [see Adverse Reactions (6.2)].

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following serious adverse reactions are discussed below and elsewhere in the labeling:oBleeding [see Warnings and Precautions (5.2)]oThrombotic thrombocytopenic purpura [see Warnings and Precautions (5.4)]. oBleeding [see Warnings and Precautions (5.2)]. oThrombotic thrombocytopenic purpura [see Warnings and Precautions (5.4)]. Bleeding, including life-threatening and fatal bleeding, is the most commonly reported adverse reaction. (6.1)To report SUSPECTED ADVERSE REACTIONS, contact Apotex Inc. at 1-800-706-5575 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.. 6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions and durations of follow up, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Clopidogrel bisulfate has been evaluated for safety in more than 54,000 patients, including over 21,000 patients treated for one year or more. The clinically important adverse reactions observed in trials comparing clopidogrel plus aspirin to placebo plus aspirin and trials comparing clopidogrel bisulfate alone to aspirin alone are discussed below. BleedingCUREIn CURE, clopidogrel bisulfate use with aspirin was associated with an increase in major bleeding (primarily gastrointestinal and at puncture sites) compared to placebo with aspirin (see Table 1). The incidence of intracranial hemorrhage (0.1%) and fatal bleeding (0.2%) were the same in both groups. Other bleeding events that were reported more frequently in the clopidogrel group were epistaxis, hematuria, and bruise. The overall incidence of bleeding is described in Table 1. Table 1: CURE Incidence of Bleeding Complications (% patients) EventClopidogrel Bisulfate (+aspirin) (n=6259)Placebo (+ aspirin) (n=6303)Major bleeding3.7 2.7 Life-threatening bleeding2.21.8Fatal0.20.25 g/dL hemoglobin drop0.90.9Requiring surgical intervention0.70.7Hemorrhagic strokes0.10.1Requiring inotropes0.50.5Requiring transfusion (>=4 units)1.21.0Other major bleeding1.61.0Significantly disabling0.40.3Intraocular bleeding with significant loss of vision0.050.03Requiring to units of blood1.30.9Minor bleeding+ 5.12.4 Life-threatening and other major bleeding.+Led to interruption of study medication.COMMIT In COMMIT, similar rates of major bleeding were observed in the clopidogrel bisulfate and placebo groups, both of which also received aspirin (see Table 2). Table 2: Incidence of Bleeding Events in COMMIT (% patients)Type of Bleeding Clopidogrel bisulfate (+ aspirin) (n=22961)Placebo (+ aspirin) (n=22891)p-valueMajor noncerebral or cerebral bleeding0.60.50.59Major noncerebral0.40.30.48Fatal0.20.20.90Hemorrhagic stroke0.20.20.91Fatal0.20.20.81Other noncerebral bleeding (non-major)3.63.10.005Any noncerebral bleeding3.93.40.004 Major bleeds were cerebral bleeds or noncerebral bleeds thought to have caused death or that required transfusion. CAPRIE (Clopidogrel bisulfate vs Aspirin) In CAPRIE, gastrointestinal hemorrhage occurred at rate of 2.0% in those taking clopidogrel bisulfate versus 2.7% in those taking aspirin; bleeding requiring hospitalization occurred in 0.7% and 1.1%, respectively. The incidence of intracranial hemorrhage was 0.4% for clopidogrel bisulfate compared to 0.5% for aspirin. Other bleeding events that were reported more frequently in the clopidogrel bisulfate group were epistaxis and hematoma. Other Adverse Events In CURE and CHARISMA, which compared clopidogrel bisulfate plus aspirin to aspirin alone, there was no difference in the rate of adverse events (other than bleeding) between clopidogrel bisulfate and placebo. In CAPRIE, which compared clopidogrel bisulfate to aspirin, pruritus was more frequently reported in those taking clopidogrel bisulfate. No other difference in the rate of adverse events (other than bleeding) was reported.. 6.2 Postmarketing Experience. The following adverse reactions have been identified during postapproval use of clopidogrel bisulfate. Because these reactions are reported voluntarily from population of an unknown size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure. Hemorrhages, including those with fatal outcome, have been reported in patients treated with clopidogrel.oBlood and lymphatic system disorders: Agranulocytosis, aplastic anemia/pancytopenia, thrombotic thrombocytopenic purpura (TTP), acquired hemophilia oGastrointestinal disorders: Colitis (including ulcerative or lymphocytic colitis), pancreatitis, stomatitis, gastric/duodenal ulcer, diarrheaoGeneral disorders and administration site condition: FeveroHepatobiliary disorders: Acute liver failure, hepatitis (noninfectious), abnormal liver function testoImmune system disorders: Hypersensitivity reactions, anaphylactoid reactions, serum sickness, insulin autoimmune syndrome, which can lead to severe hypoglycemia.oMusculoskeletal, connective tissue and bone disorders: Myalgia, arthralgia, arthritisoNervous system disorders: Taste disorders, headache, ageusiaoPsychiatric disorders: Confusion, hallucinations oRespiratory, thoracic and mediastinal disorders: Bronchospasm, interstitial pneumonitis, eosinophilic pneumoniaoRenal and urinary disorders: Increased creatinine levelsoSkin and subcutaneous tissue disorders: Maculopapular, erythematous or exfoliative rash, urticaria, bullous dermatitis, eczema, toxic epidermal necrolysis, Stevens-Johnson syndrome, acute generalized exanthematous pustulosis (AGEP), angioedema, drug-induced hypersensitivity syndrome, drug rash with eosinophilia and systemic symptoms (DRESS), erythema multiforme, lichen planus, generalized pruritusoVascular disorders: Vasculitis, hypotension. oBlood and lymphatic system disorders: Agranulocytosis, aplastic anemia/pancytopenia, thrombotic thrombocytopenic purpura (TTP), acquired hemophilia . oGastrointestinal disorders: Colitis (including ulcerative or lymphocytic colitis), pancreatitis, stomatitis, gastric/duodenal ulcer, diarrhea. oGeneral disorders and administration site condition: Fever. oHepatobiliary disorders: Acute liver failure, hepatitis (noninfectious), abnormal liver function test. oImmune system disorders: Hypersensitivity reactions, anaphylactoid reactions, serum sickness, insulin autoimmune syndrome, which can lead to severe hypoglycemia.. oMusculoskeletal, connective tissue and bone disorders: Myalgia, arthralgia, arthritis. oNervous system disorders: Taste disorders, headache, ageusia. oPsychiatric disorders: Confusion, hallucinations oRespiratory, thoracic and mediastinal disorders: Bronchospasm, interstitial pneumonitis, eosinophilic pneumonia. oRenal and urinary disorders: Increased creatinine levels. oSkin and subcutaneous tissue disorders: Maculopapular, erythematous or exfoliative rash, urticaria, bullous dermatitis, eczema, toxic epidermal necrolysis, Stevens-Johnson syndrome, acute generalized exanthematous pustulosis (AGEP), angioedema, drug-induced hypersensitivity syndrome, drug rash with eosinophilia and systemic symptoms (DRESS), erythema multiforme, lichen planus, generalized pruritus. oVascular disorders: Vasculitis, hypotension.

BOXED WARNING SECTION.

WARNING: DIMINISHED ANTIPLATELET EFFECT IN PATIENTS WITH TWO LOSS-OF-FUNCTION ALLELES OF THE CYP2C19 GENE. WARNING: DIMINISHED ANTIPLATELET EFFECT IN PATIENTS WITH TWO LOSS-OF-FUNCTION ALLELES OF THE CYP2C19 GENE See full prescribing information for complete boxed warning. oEffectiveness of clopidogrel bisulfate depends on conversion to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19. (5.1, 12.3) oTests are available to identify patients who are CYP2C19 poor metabolizers. (12.5)oConsider use of another platelet P2Y12 inhibitor in patients identified as CYP2C19 poor metabolizers. (5.1). oEffectiveness of clopidogrel bisulfate depends on conversion to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19. (5.1, 12.3) oTests are available to identify patients who are CYP2C19 poor metabolizers. (12.5). oConsider use of another platelet P2Y12 inhibitor in patients identified as CYP2C19 poor metabolizers. (5.1). The effectiveness of clopidogrel bisulfate results from its antiplatelet activity, which is dependent on its conversion to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19 [see Warnings and Precautions (5.1), Clinical Pharmacology (12.3)]. Clopidogrel bisulfate at recommended doses forms less of the active metabolite and so has reduced effect on platelet activity in patients who are homozygous for nonfunctional alleles of the CYP2C19 gene, (termed CYP2C19 poor metabolizers). Tests are available to identify patients who are CYP2C19 poor metabolizers [see Clinical Pharmacology (12.5)]. Consider use of another platelet P2Y12 inhibitor in patients identified as CYP2C19 poor metabolizers.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. There was no evidence of tumorigenicity when clopidogrel was administered for 78 weeks to mice and 104 weeks to rats at dosages up to 77 mg/kg per day, which afforded plasma exposures >25 times that in humans at the recommended daily dose of 75 mg.Clopidogrel was not genotoxic in four in vitro tests (Ames test, DNA-repair test in rat hepatocytes, gene mutation assay in Chinese hamster fibroblasts, and metaphase chromosome analysis of human lymphocytes) and in one in vivo test (micronucleus test by oral route in mice).Clopidogrel was found to have no effect on fertility of male and female rats treated prior to pairing and throughout gestation at oral doses up to 400 mg/kg per day (52 times the recommended human dose on mg/m2 basis).

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Clopidogrel is an inhibitor of platelet activation and aggregation through the irreversible binding of its active metabolite to the P2Y12 class of ADP receptors on platelets.. 12.2 Pharmacodynamics. Clopidogrel must be metabolized by CYP450 enzymes to produce the active metabolite that inhibits platelet aggregation. The active metabolite of clopidogrel selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet P2Y12 receptor and the subsequent ADP-mediated activation of the glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation. This action is irreversible. Consequently, platelets exposed to clopidogrels active metabolite are affected for the remainder of their lifespan (about to 10 days). Platelet aggregation induced by agonists other than ADP is also inhibited by blocking the amplification of platelet activation by released ADP.Dose-dependent inhibition of platelet aggregation can be seen hours after single oral doses of clopidogrel. Repeated doses of 75 mg clopidogrel per day inhibit ADP-induced platelet aggregation on the first day, and inhibition reaches steady state between Day and Day 7. At steady state, the average inhibition level observed with dose of 75 mg clopidogrel per day was between 40% and 60%. Platelet aggregation and bleeding time gradually return to baseline values after treatment is discontinued, generally in about days.Geriatric Patients Elderly (>=75 years) and young healthy subjects had similar effects on platelet aggregation. Renally Impaired Patients After repeated doses of 75 mg clopidogrel per day, patients with severe renal impairment (creatinine clearance from to 15 mL/min) and moderate renal impairment (creatinine clearance from 30 to 60 mL/min) showed low (25%) inhibition of ADP-induced platelet aggregation. Hepatically Impaired Patients After repeated doses of 75 mg clopidogrel per day for 10 days in patients with severe hepatic impairment, inhibition of ADP-induced platelet aggregation was similar to that observed in healthy subjects. Gender In small study comparing men and women, less inhibition of ADP-induced platelet aggregation was observed in women.. 12.3 Pharmacokinetics. Clopidogrel is prodrug and is metabolized to pharmacologically active metabolite and inactive metabolites. Absorption After single and repeated oral doses of 75 mg per day, clopidogrel is rapidly absorbed. Absorption is at least 50%, based on urinary excretion of clopidogrel metabolites.Effect of food Clopidogrel can be administered with or without food. In study in healthy male subjects when clopidogrel 75 mg per day was given with standard breakfast, mean inhibition of ADP-induced platelet aggregation was reduced by less than 9%. The active metabolite AUC0-24 was unchanged in the presence of food, while there was 57% decrease in active metabolite Cmax. Similar results were observed when clopidogrel 300 mg loading dose was administered with high-fat breakfast. MetabolismClopidogrel is extensively metabolized by two main metabolic pathways: one mediated by esterases and leading to hydrolysis into an inactive carboxylic acid derivative (85% of circulating metabolites) and one mediated by multiple cytochrome P450 enzymes. Cytochromes first oxidize clopidogrel to 2-oxo-clopidogrel intermediate metabolite. Subsequent metabolism of the 2-oxo-clopidogrel intermediate metabolite results in formation of the active metabolite, thiol derivative of clopidogrel. The active metabolite is formed mostly by CYP2C19 with contributions from several other CYP enzymes, including CYP1A2, CYP2B6 and CYP3A. The active thiol metabolite binds rapidly and irreversibly to platelet receptors, thus inhibiting platelet aggregation for the lifespan of the platelet. The Cmax of the active metabolite is twice as high following single 300 mg clopidogrel loading dose as it is after four days of 75 mg maintenance dose. Cmax occurs approximately 30 to 60 minutes after dosing. In the 75 to 300 mg dose range, the pharmacokinetics of the active metabolite deviates from dose proportionality: 4-fold the dose results in 2.0-fold and 2.7-fold the Cmax and AUC, respectively.Elimination Following an oral dose of 14C-labeled clopidogrel in humans, approximately 50% of total radioactivity was excreted in urine and approximately 46% in feces over the days post-dosing. After single, oral dose of 75 mg, clopidogrel has half-life of approximately hours. The half-life of the active metabolite is about 30 minutes. Drug Interactions Effect of other drugs on Clopidogrel Clopidogrel is metabolized to its active metabolite in part by CYP2C19. Concomitant use of certain inhibitors of this enzyme results in reduced plasma concentrations of the active metabolite of clopidogrel and reduction in platelet inhibition. Proton pump inhibitors (PPI)The effect of proton pump inhibitors (PPI) on the systemic exposure to the clopidogrel active metabolite following multiple doses of clopidogrel 75 mg evaluated in dedicated drug interaction studies is presented in Figure 1.Pharmacodynamic and pharmacokinetic parameters measured in these studies showed that the interaction was highest with omeprazole and least with dexlansoprazole.Opioids Coadministration of mg intravenous morphine with 600 mg loading dose of clopidogrel in healthy adults decreased the AUC and Cmax of clopidogrels thiol metabolites by 34%. Mean platelet aggregation was higher up to to hours with morphine coadministration.Effect of clopidogrel on other drugsIn vitro studies have shown that the glucuronide metabolite of clopidogrel is strong inhibitor of CYP2C8. Concomitant administration of repaglinide with clopidogrel increased the systemic exposure to repaglinide (AUC0-) by 5.1-fold following the loading dose (300 mg) and by 3.9-fold on day of the maintenance dose (75 mg) of clopidogrel [see Drug Interactions (7.6)]. figure-01.jpg. 12.5 Pharmacogenomics. CYP2C19 is involved in the formation of both the active metabolite and the 2-oxo-clopidogrel intermediate metabolite. Clopidogrel active metabolite pharmacokinetics and antiplatelet effects, as measured by ex vivo platelet aggregation assays, differ according to CYP2C19 genotype. Patients who are homozygous for nonfunctional alleles of the CYP2C19 gene are termed CYP2C19 poor metabolizers. Approximately 2% of White and 4% of Black patients are poor metabolizers; the prevalence of poor metabolism is higher in Asian patients (e.g., 14% of Chinese). Tests are available to identify patients who are CYP2C19 poor metabolizers.A crossover study in 40 healthy subjects, 10 each in the four CYP2C19 metabolizer groups, evaluated pharmacokinetic and antiplatelet responses using 300 mg followed by 75 mg per day and 600 mg followed by 150 mg per day, each for total of days. Decreased active metabolite exposure and diminished inhibition of platelet aggregation were observed in the poor metabolizers as compared to the other groups. Table 3: Active Metabolite Pharmacokinetics and Antiplatelet Responses by CYP2C19 Metabolizer StatusDosePoor (n=10)Intermediate(n=10)Normal (n=10)Ultrarapid+ (n=10)Cmax (ng/mL)300 mg (24 h) 600 mg (24 h) 75 mg (Day 5) 150 mg (Day 5)11 (4) 17 (6) (1) (2)23 (11) 39 (23) 12 (5) 18 (7)32 (21) 44 (27) 13 (7) 19 (5)24 (10) 36 (13) 12 (6) 16 (9)IPA (%) 300 mg (24 h) 600 mg (24 h) 75 mg (Day 5) 150 mg (Day 5)24 (26) 32 (25) 37 (23) 61 (14)37 (21) 56 (22) 60 (18) 74 (14)39 (28) 49 (23) 58 (19) 73 (9)40 (21) 51 (28) 56 (13) 68 (18)VASP-PRI (%) 300 mg (24 h) 600 mg (24 h) 75 mg (Day 5) 150 mg (Day 5)91 (12) 85 (14) 83 (13) 61 (18)78 (12) 56 (26) 50 (16) 29 (11) 68 (16) 48 (20) 39 (14) 24 (10)73 (12) 51 (20) 40 (9) 20 (10)Intermediate metabolizers have one but not two nonfunctional alleles.+Ultrarapid metabolizers have at least one gain-of-function allele. Inhibition of platelet aggregation with 5mcM ADP; larger value indicates greater platelet inhibition.Vasodilator-stimulated phosphoprotein platelet reactivity index; smaller value indicates greater platelet inhibition. Values are mean (SD).

CLINICAL STUDIES SECTION.

6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions and durations of follow up, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Clopidogrel bisulfate has been evaluated for safety in more than 54,000 patients, including over 21,000 patients treated for one year or more. The clinically important adverse reactions observed in trials comparing clopidogrel plus aspirin to placebo plus aspirin and trials comparing clopidogrel bisulfate alone to aspirin alone are discussed below. BleedingCUREIn CURE, clopidogrel bisulfate use with aspirin was associated with an increase in major bleeding (primarily gastrointestinal and at puncture sites) compared to placebo with aspirin (see Table 1). The incidence of intracranial hemorrhage (0.1%) and fatal bleeding (0.2%) were the same in both groups. Other bleeding events that were reported more frequently in the clopidogrel group were epistaxis, hematuria, and bruise. The overall incidence of bleeding is described in Table 1. Table 1: CURE Incidence of Bleeding Complications (% patients) EventClopidogrel Bisulfate (+aspirin) (n=6259)Placebo (+ aspirin) (n=6303)Major bleeding3.7 2.7 Life-threatening bleeding2.21.8Fatal0.20.25 g/dL hemoglobin drop0.90.9Requiring surgical intervention0.70.7Hemorrhagic strokes0.10.1Requiring inotropes0.50.5Requiring transfusion (>=4 units)1.21.0Other major bleeding1.61.0Significantly disabling0.40.3Intraocular bleeding with significant loss of vision0.050.03Requiring to units of blood1.30.9Minor bleeding+ 5.12.4 Life-threatening and other major bleeding.+Led to interruption of study medication.COMMIT In COMMIT, similar rates of major bleeding were observed in the clopidogrel bisulfate and placebo groups, both of which also received aspirin (see Table 2). Table 2: Incidence of Bleeding Events in COMMIT (% patients)Type of Bleeding Clopidogrel bisulfate (+ aspirin) (n=22961)Placebo (+ aspirin) (n=22891)p-valueMajor noncerebral or cerebral bleeding0.60.50.59Major noncerebral0.40.30.48Fatal0.20.20.90Hemorrhagic stroke0.20.20.91Fatal0.20.20.81Other noncerebral bleeding (non-major)3.63.10.005Any noncerebral bleeding3.93.40.004 Major bleeds were cerebral bleeds or noncerebral bleeds thought to have caused death or that required transfusion. CAPRIE (Clopidogrel bisulfate vs Aspirin) In CAPRIE, gastrointestinal hemorrhage occurred at rate of 2.0% in those taking clopidogrel bisulfate versus 2.7% in those taking aspirin; bleeding requiring hospitalization occurred in 0.7% and 1.1%, respectively. The incidence of intracranial hemorrhage was 0.4% for clopidogrel bisulfate compared to 0.5% for aspirin. Other bleeding events that were reported more frequently in the clopidogrel bisulfate group were epistaxis and hematoma. Other Adverse Events In CURE and CHARISMA, which compared clopidogrel bisulfate plus aspirin to aspirin alone, there was no difference in the rate of adverse events (other than bleeding) between clopidogrel bisulfate and placebo. In CAPRIE, which compared clopidogrel bisulfate to aspirin, pruritus was more frequently reported in those taking clopidogrel bisulfate. No other difference in the rate of adverse events (other than bleeding) was reported.

DESCRIPTION SECTION.

11 DESCRIPTION. Clopidogrel bisulfate is thienopyridine class inhibitor of P2Y12 ADP platelet receptors. Chemically it is methyl (+)-(S)--(2-chlorophenyl)-6,7-dihydrothieno[3,2-c]pyridine-5(4H)-acetate sulfate (1:1). The empirical formula of clopidogrel bisulfate is C16H16ClNO2SoH2SO4 and its molecular weight is 419.9 g/mol.The structural formula is as follows:Clopidogrel bisulfate is white to off-white powder. It is practically insoluble in water at neutral pH but freely soluble at pH 1. It also dissolves freely in methanol, dissolves sparingly in methylene chloride, and is practically insoluble in ethyl ether. It has specific optical rotation of about +56. Clopidogrel tablets, USP 75 mg for oral administration are provided as pink, round, biconvex, film coated tablets, engraved APO on one side, CL over 75 on the other side. The tablets contain 97.875 mg of clopidogrel bisulfate, which is the molar equivalent of 75 mg of clopidogrel base.Clopidogrel tablets, USP 300 mg for oral administration are provided as pink, oblong, biconvex, film coated tablets engraved APO on one side and CL 300 on the other side. The tablets contain 392.0 mg of clopidogrel bisulfate, which is the molar equivalent of 300 mg of clopidogrel base.Each tablet contains anhydrous lactose, colloidal silicon dioxide, crospovidone, methylcellulose and zinc stearate as inactive ingredients. The pink film coating contains ferric oxide red, hydroxypropyl cellulose, hypromellose, polyethylene glycol and titanium dioxide.. clopiodgrel-01.jpg.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. oAcute coronary syndrome (2.1)3.Initiate clopidogrel with single 300-mg oral loading dose and then continue at 75 mg once daily.4.Initiating clopidogrel without loading dose will delay establishment of an antiplatelet effect by several days. oRecent MI, recent stroke, or established peripheral arterial disease: 75 mg once daily orally without loading dose (2.2). oAcute coronary syndrome (2.1)3.Initiate clopidogrel with single 300-mg oral loading dose and then continue at 75 mg once daily.4.Initiating clopidogrel without loading dose will delay establishment of an antiplatelet effect by several days. 3.Initiate clopidogrel with single 300-mg oral loading dose and then continue at 75 mg once daily.. 4.Initiating clopidogrel without loading dose will delay establishment of an antiplatelet effect by several days. oRecent MI, recent stroke, or established peripheral arterial disease: 75 mg once daily orally without loading dose (2.2). 2.1Acute Coronary Syndrome. In patients who need an antiplatelet effect within hours, initiate clopidogrel tablets with single 300 mg oral loading dose and then continue at 75 mg once daily. Initiating clopidogrel without loading dose will delay establishment of an antiplatelet effect by several days [see Clinical Pharmacology (12.3) and Clinical Studies (14.1)]. 2.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease. 75 mg once daily orally without loading dose [see Clinical Pharmacology (12.3) and Clinical Studies (14.2)].

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. Clopidogrel tablets, USP 75 mg are pink, round, biconvex, film coated tablets, engraved APO on one side and CL over 75 on the other side.Clopidogrel tablets, USP 300 mg are pink, oblong, biconvex, film coated tablets engraved APO on one side and CL 300 on the other side.. Tablets: 75 mg, 300 mg (3).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. oOpioids: Decreased exposure to clopidogrel. Consider use of parenteral antiplatelet agent. (7.2) oNonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, selective serotonin and serotonin norepinephrine reuptake inhibitors (SSRIs, SNRIs): Increases risk of bleeding. (7.3, 7.4, 7.5)oRepaglinide (CYP2C8 substrates): Increases substrate plasma concentrations. (7.6) oOpioids: Decreased exposure to clopidogrel. Consider use of parenteral antiplatelet agent. (7.2) oNonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, selective serotonin and serotonin norepinephrine reuptake inhibitors (SSRIs, SNRIs): Increases risk of bleeding. (7.3, 7.4, 7.5). oRepaglinide (CYP2C8 substrates): Increases substrate plasma concentrations. (7.6) 7.1 CYP2C19 Inhibitors. Clopidogrel is metabolized to its active metabolite in part by CYP2C19. Concomitant use of drugs that inhibit the activity of this enzyme results in reduced plasma concentrations of the active metabolite of clopidogrel and reduction in platelet inhibition [see Warnings and Precautions (5.1)]. Omeprazole or EsomeprazoleAvoid concomitant use of clopidogrel bisulfate with omeprazole or esomeprazole. In clinical studies, omeprazole was shown to reduce significantly the antiplatelet activity of clopidogrel bisulfate when given concomitantly or 12 hours apart. similar reduction in antiplatelet activity was observed with esomeprazole when given concomitantly with clopidogrel bisulfate. Dexlansoprazole, lansoprazole and pantoprazole had less effect on the antiplatelet activity of clopidogrel bisulfate than did omeprazole or esomeprazole [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)]. 7.2 Opioids. As with other oral P2Y12 inhibitors, coadministration of opioid agonists delay and reduce the absorption of clopidogrel, presumably because of slowed gastric emptying, resulting in reduced exposure to its metabolites [see Clinical Pharmacology (12.3)]. Consider the use of parenteral antiplatelet agent in acute coronary syndrome patients requiring coadministration of morphine or other opioid agonists.. 7.3 Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Coadministration of clopidogrel bisulfate and NSAIDs increases the risk of gastrointestinal bleeding.. 7.4 Warfarin (CYP2C9 Substrates). Although the administration of clopidogrel 75 mg per day did not modify the pharmacokinetics of S-warfarin (a CYP2C9 substrate) or INR in patients receiving long-term warfarin therapy, coadministration of clopidogrel bisulfate with warfarin increases the risk of bleeding because of independent effects on hemostasis.However, at high concentrations in vitro, clopidogrel inhibits CYP2C9.. 7.5 SSRIs and SNRIs. Since selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) affect platelet activation, the concomitant administration of SSRIs and SNRIs with clopidogrel may increase the risk of bleeding.. 7.6 Repaglinide (CYP2C8 Substrates). The acyl--glucuronide metabolite of clopidogrel is strong inhibitor of CYP2C8. Clopidogrel can increase the systemic exposure to drugs that are primarily cleared by CYP2C8, thereby needing dose-adjustment and appropriate monitoring.Clopidogrel increased repaglinide exposures by 3.9-fold to 5.1-fold [see Clinical Pharmacology (12.3)]. Avoid concomitant use of repaglinide with clopidogrel. If concomitant use cannot be avoided, initiate repaglinide at 0.5 mg before each meal and do not exceed total daily dose of mg. Increased frequency of glucose monitoring may be required during concomitant use.

GERIATRIC USE SECTION.

8.5 Geriatric Use. Of the total number of subjects in the CAPRIE and CURE controlled clinical studies, approximately 50% of patients treated with clopidogrel bisulfate were 65 years of age and older, and 15% were 75 years and older. In COMMIT, approximately 58% of the patients treated with clopidogrel bisulfate were 60 years and older, 26% of whom were 70 years and older.The observed risk of bleeding events with clopidogrel plus aspirin versus placebo plus aspirin by age category is provided in Table and Table for the CURE and COMMIT trials, respectively [see Adverse Reactions (6.1)]. No dosage adjustment is necessary in elderly patients.

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. Clopidogrel tablets USP, 300 mg are pink, oblong, biconvex, film-coated tablets, engraved APO on one side and CL 300 on the other side. They are supplied as follows:Carton of 20 tablets (10 tablets per blister pack 2), NDC 0904-6467-10Carton of 30 tablets (10 tablets per blister pack 3), NDC 0904-6467-07Store at 25C(77F); excursions permitted from 15C to 30C (59F to 86F) [See USP Controlled Room Temperature]. Protect from moisture.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. Clopidogrel bisulfate is P2Y12 platelet inhibitor indicated for: 2.Acute coronary syndrome For patients with non-ST-segment elevation ACS (unstable angina [UA]/non-ST-elevation myocardial infarction [NSTEMI]), clopidogrel bisulfate has been shown to reduce the rate of myocardial infarction (MI) and stroke. (1.1) For patients with ST-elevation myocardial infarction (STEMI), clopidogrel bisulfate has been shown to reduce the rate of MI and stroke. (1.1) 2.Recent MI, recent stroke, or established peripheral arterial disease. Clopidogrel bisulfate has been shown to reduce the rate of MI and stroke. (1.2) 2.Acute coronary syndrome. 2.Recent MI, recent stroke, or established peripheral arterial disease. Clopidogrel bisulfate has been shown to reduce the rate of MI and stroke. (1.2) 1.1 Acute Coronary Syndrome (ACS). oClopidogrel tablets are indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non-ST-segment elevation ACS (unstable angina [UA]/non-ST-elevation myocardial infarction [NSTEMI]), including patients who are to be managed medically and those who are to be managed with coronary revascularization. Clopidogrel should be administered in conjunction with aspirin.oClopidogrel tablets are indicated to reduce the rate of myocardial infarction and stroke in patients with acute ST-elevation myocardial infarction (STEMI) who are to be managed medically. Clopidogrel bisulfate should be administered in conjunction with aspirin. oClopidogrel tablets are indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non-ST-segment elevation ACS (unstable angina [UA]/non-ST-elevation myocardial infarction [NSTEMI]), including patients who are to be managed medically and those who are to be managed with coronary revascularization. Clopidogrel should be administered in conjunction with aspirin.. oClopidogrel tablets are indicated to reduce the rate of myocardial infarction and stroke in patients with acute ST-elevation myocardial infarction (STEMI) who are to be managed medically. Clopidogrel bisulfate should be administered in conjunction with aspirin. 1.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease. In patients with established peripheral arterial disease or with history of recent myocardial infarction (MI) or recent stroke clopidogrel bisulfate is indicated to reduce the rate of MI and stroke.

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. Advise patients to read FDA approved patient labeling (Medication Guide). DiscontinuationAdvise patients not to discontinue clopidogrel without first discussing it with the healthcare provider who prescribed it [see Warnings and Precautions (5.3)].Bleeding Advise patients that they: 1.will bruise and bleed more easily 2.will take longer than usual to stop bleeding 3.must report any unanticipated, prolonged, or excessive bleeding, or blood in their stool or urine [see Warnings and Precautions (5.2)] Thrombotic Thrombocytopenic PurpuraInstruct patients to get prompt medical attention if they experience symptoms of TTP that cannot otherwise be explained [see Warnings and Precautions (5.4)].Invasive ProceduresAdvise patients to inform physicians and dentists that they are taking clopidogrel before any surgery or dental procedure [see Warnings and Precautions (5.2, 5.3)]. Proton Pump InhibitorsAdvise patients not to take omeprazole or esomeprazole while taking clopidogrel. Dexlansoprazole, lansoprazole and pantoprazole had less pronounced effects on the antiplatelet activity of clopidogrel than did omeprazole or esomeprazole [see Drug Interactions (7.1)].APOTEX INC.CLOPIDOGREL TABLETS, USP 75 mg and 300 mgManufactured byManufactured forApotex Inc.Apotex Corp.Toronto, OntarioWeston, FloridaCanada M9L 1T933326Distributed By:MAJOR(R) PHARMACEUTICALS17177 Laurel Park Dr., Suite 233Livonia, MI 48152Revised: June 2019Rev. 26. 1.will bruise and bleed more easily 2.will take longer than usual to stop bleeding 3.must report any unanticipated, prolonged, or excessive bleeding, or blood in their stool or urine [see Warnings and Precautions (5.2)].

LACTATION SECTION.

8.2 Lactation. Risk SummaryThere are no data on the presence of clopidogrel in human milk or the effects on milk production. No adverse effects on breastfed infants have been observed with maternal clopidogrel use during lactation in small number of postmarketing cases. Studies in rats have shown that clopidogrel and/or its metabolites are present in the milk. When drug is present in animal milk, it is likely that the drug will be present in human milk. The developmental and health benefits of breastfeeding should be considered along with mothers clinical need for clopidogrel and any potential adverse effects on the breastfed infant from clopidogrel or from underlying maternal condition.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. Clopidogrel is an inhibitor of platelet activation and aggregation through the irreversible binding of its active metabolite to the P2Y12 class of ADP receptors on platelets.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. There was no evidence of tumorigenicity when clopidogrel was administered for 78 weeks to mice and 104 weeks to rats at dosages up to 77 mg/kg per day, which afforded plasma exposures >25 times that in humans at the recommended daily dose of 75 mg.Clopidogrel was not genotoxic in four in vitro tests (Ames test, DNA-repair test in rat hepatocytes, gene mutation assay in Chinese hamster fibroblasts, and metaphase chromosome analysis of human lymphocytes) and in one in vivo test (micronucleus test by oral route in mice).Clopidogrel was found to have no effect on fertility of male and female rats treated prior to pairing and throughout gestation at oral doses up to 400 mg/kg per day (52 times the recommended human dose on mg/m2 basis).

OVERDOSAGE SECTION.

10 OVERDOSAGE. Platelet inhibition by clopidogrel is irreversible and will last for the life of the platelet. Overdose following clopidogrel administration may result in bleeding complications. single oral dose of clopidogrel at 1,500 or 2,000 mg/kg was lethal to mice and to rats and at 3,000 mg/kg to baboons. Symptoms of acute toxicity were vomiting, prostration, difficult breathing, and gastrointestinal hemorrhage in animals.Based on biological plausibility, platelet transfusion may restore clotting ability.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

Package/Label Display Panel Clopidogrel Tablets, USP300 mg30 Tablets. carton label.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. Safety and effectiveness in pediatric populations have not been established.A randomized, placebo-controlled trial (CLARINET) did not demonstrate clinical benefit of clopidogrel in neonates and infants with cyanotic congenital heart disease palliated with systemic-to-pulmonary arterial shunt. Possible factors contributing to this outcome were the dose of clopidogrel, the concomitant administration of aspirin, and the late initiation of therapy following shunt palliation. It cannot be ruled out that trial with different design would demonstrate clinical benefit in this patient population.

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. Clopidogrel must be metabolized by CYP450 enzymes to produce the active metabolite that inhibits platelet aggregation. The active metabolite of clopidogrel selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet P2Y12 receptor and the subsequent ADP-mediated activation of the glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation. This action is irreversible. Consequently, platelets exposed to clopidogrels active metabolite are affected for the remainder of their lifespan (about to 10 days). Platelet aggregation induced by agonists other than ADP is also inhibited by blocking the amplification of platelet activation by released ADP.Dose-dependent inhibition of platelet aggregation can be seen hours after single oral doses of clopidogrel. Repeated doses of 75 mg clopidogrel per day inhibit ADP-induced platelet aggregation on the first day, and inhibition reaches steady state between Day and Day 7. At steady state, the average inhibition level observed with dose of 75 mg clopidogrel per day was between 40% and 60%. Platelet aggregation and bleeding time gradually return to baseline values after treatment is discontinued, generally in about days.Geriatric Patients Elderly (>=75 years) and young healthy subjects had similar effects on platelet aggregation. Renally Impaired Patients After repeated doses of 75 mg clopidogrel per day, patients with severe renal impairment (creatinine clearance from to 15 mL/min) and moderate renal impairment (creatinine clearance from 30 to 60 mL/min) showed low (25%) inhibition of ADP-induced platelet aggregation. Hepatically Impaired Patients After repeated doses of 75 mg clopidogrel per day for 10 days in patients with severe hepatic impairment, inhibition of ADP-induced platelet aggregation was similar to that observed in healthy subjects. Gender In small study comparing men and women, less inhibition of ADP-induced platelet aggregation was observed in women.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. Clopidogrel is prodrug and is metabolized to pharmacologically active metabolite and inactive metabolites. Absorption After single and repeated oral doses of 75 mg per day, clopidogrel is rapidly absorbed. Absorption is at least 50%, based on urinary excretion of clopidogrel metabolites.Effect of food Clopidogrel can be administered with or without food. In study in healthy male subjects when clopidogrel 75 mg per day was given with standard breakfast, mean inhibition of ADP-induced platelet aggregation was reduced by less than 9%. The active metabolite AUC0-24 was unchanged in the presence of food, while there was 57% decrease in active metabolite Cmax. Similar results were observed when clopidogrel 300 mg loading dose was administered with high-fat breakfast. MetabolismClopidogrel is extensively metabolized by two main metabolic pathways: one mediated by esterases and leading to hydrolysis into an inactive carboxylic acid derivative (85% of circulating metabolites) and one mediated by multiple cytochrome P450 enzymes. Cytochromes first oxidize clopidogrel to 2-oxo-clopidogrel intermediate metabolite. Subsequent metabolism of the 2-oxo-clopidogrel intermediate metabolite results in formation of the active metabolite, thiol derivative of clopidogrel. The active metabolite is formed mostly by CYP2C19 with contributions from several other CYP enzymes, including CYP1A2, CYP2B6 and CYP3A. The active thiol metabolite binds rapidly and irreversibly to platelet receptors, thus inhibiting platelet aggregation for the lifespan of the platelet. The Cmax of the active metabolite is twice as high following single 300 mg clopidogrel loading dose as it is after four days of 75 mg maintenance dose. Cmax occurs approximately 30 to 60 minutes after dosing. In the 75 to 300 mg dose range, the pharmacokinetics of the active metabolite deviates from dose proportionality: 4-fold the dose results in 2.0-fold and 2.7-fold the Cmax and AUC, respectively.Elimination Following an oral dose of 14C-labeled clopidogrel in humans, approximately 50% of total radioactivity was excreted in urine and approximately 46% in feces over the days post-dosing. After single, oral dose of 75 mg, clopidogrel has half-life of approximately hours. The half-life of the active metabolite is about 30 minutes. Drug Interactions Effect of other drugs on Clopidogrel Clopidogrel is metabolized to its active metabolite in part by CYP2C19. Concomitant use of certain inhibitors of this enzyme results in reduced plasma concentrations of the active metabolite of clopidogrel and reduction in platelet inhibition. Proton pump inhibitors (PPI)The effect of proton pump inhibitors (PPI) on the systemic exposure to the clopidogrel active metabolite following multiple doses of clopidogrel 75 mg evaluated in dedicated drug interaction studies is presented in Figure 1.Pharmacodynamic and pharmacokinetic parameters measured in these studies showed that the interaction was highest with omeprazole and least with dexlansoprazole.Opioids Coadministration of mg intravenous morphine with 600 mg loading dose of clopidogrel in healthy adults decreased the AUC and Cmax of clopidogrels thiol metabolites by 34%. Mean platelet aggregation was higher up to to hours with morphine coadministration.Effect of clopidogrel on other drugsIn vitro studies have shown that the glucuronide metabolite of clopidogrel is strong inhibitor of CYP2C8. Concomitant administration of repaglinide with clopidogrel increased the systemic exposure to repaglinide (AUC0-) by 5.1-fold following the loading dose (300 mg) and by 3.9-fold on day of the maintenance dose (75 mg) of clopidogrel [see Drug Interactions (7.6)]. figure-01.jpg.

PREGNANCY SECTION.

8.1 Pregnancy. Risk SummaryAvailable data from cases reported in published literature and postmarketing surveillance with clopidogrel use in pregnant women have not identified any drug-associated risks for major birth defects or miscarriage [see Data]. There are risks to the pregnant woman and fetus associated with myocardial infarction and stroke [see Clinical Considerations]. No evidence of fetotoxicity was observed when clopidogrel was administered to pregnant rats and rabbits during organogenesis at doses corresponding to 65 and 78 times the recommended daily human dose [see Data]. The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. All pregnancies have background risk of birth defects, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.Clinical ConsiderationsDisease-associated maternal and/or embryo/fetal riskMyocardial infarction and stroke are medical emergencies. Therapy for the pregnant woman should not be withheld because of potential concerns regarding the effects of clopidogrel on the fetus.Labor or deliveryClopidogrel use during labor or delivery will increase the risk of maternal bleeding and hemorrhage. Avoid neuraxial blockade during clopidogrel use because of the risk of spinal hematoma. When possible, discontinue clopidogrel to days prior to labor, delivery, or neuraxial blockade.DataHuman dataThe available data from published case reports over two decades of postmarketing use have not identified an association with clopidogrel use in pregnancy and major birth defects, miscarriage, or adverse fetal outcomes.Animal dataEmbryo-fetal developmental toxicology studies were performed in pregnant rats and rabbits with doses up to 500 and 300 mg/kg/day, respectively, administered during organogenesis. These doses, corresponding to 65 and 78 times the recommended daily human dose, respectively, on mg/m2 basis, revealed no evidence of impaired fertility or fetotoxicity due to clopidogrel.

SPL MEDGUIDE SECTION.

Medication Guide Clopidogrel Bisulfate Tablets, USP 75 mg and 300 mg (kloe pid oh grel bye sul fate)Read this Medication Guide before you start taking clopidogrel tablets and each time you get refill. There may be new information. This Medication Guide does not take the place of talking with your doctor about your medical condition or your treatment.What is the most important information should know about clopidogrel tablets1. Clopidogrel tablets may not work as well in people who: 1.have certain genetic factors that affect how the body breaks down clopidogrel. Your doctor may do genetic tests to make sure clopidogrel is right for you. 2.take certain medicines, especially omeprazole (Prilosec(R)) or esomeprazole (Nexium(R)). Your doctor may change the medicine you take for stomach acid problems while you take clopidogrel tablets.2. Clopidogrel tablets can cause bleeding which can be serious and can sometimes lead to death. Clopidogrel is blood thinner medicine that lowers the chance of blood clots forming in your body. While you take clopidogrel tablets: 1.you may bruise and bleed more easily 2.you are more likely to have nose bleeds 3.it will take longer for any bleeding to stop Call your doctor right away if you have any of these signs or symptoms of bleeding:ounexpected bleeding or bleeding that lasts long timeoblood in your urine (pink, red or brown urine)ored or black stools (looks like tar)obruises that happen without known cause or get largerocough up blood or blood clotsovomit blood or your vomit looks like coffee groundsDo not stop taking clopidogrel tablets without talking to the doctor who prescribes it for you. People who stop taking clopidogrel tablets too soon have higher risk of having heart attack or dying. If you must stop clopidogrel tablets because of bleeding, your risk of heart attack may be higher.What are clopidogrel tabletsClopidogrel bisulfate tablets are prescription medicine used to treat people who have any of the following:ochest pain due to heart problemsopoor circulation in their legs (peripheral arterial disease)oa heart attackoa strokeClopidogrel is used alone or with aspirin to lower your chance of having another serious problem with your heart or blood vessels such as heart attack, stroke, or blood clot that can lead to death.Platelets are blood cells that help your blood clot normally. Clopidogrel helps to prevent platelets from sticking together and forming clot that can block an artery.It is not known if clopidogrel tablets are safe and effective in children.Who should not take clopidogrel tabletsDo not take clopidogrel tablets if you:ocurrently have condition that causes bleeding, such as stomach ulceroare allergic to clopidogrel or other ingredients in clopidogrel tablets. See the end of this leaflet for complete list of ingredients in clopidogrel tablets.What should tell my doctor before taking clopidogrel tabletsBefore you take clopidogrel tablets, tell your doctor if you:ohave history of bowel (gastrointestinal) or stomach ulcersohave history of bleeding problemsoplan to have surgery or dental procedure. See How should take clopidogrel tabletsoare pregnant or plan to become pregnant. It is not known if clopidogrel will harm your unborn babyoare breastfeeding or plan to breastfeed. It is not known if clopidogrel passes into your breast milk. decision should be made with your healthcare provider to avoid or discontinue breastfeeding when continuing clopidogrel is needed.ohave had an allergy or reaction to any medicine used to treat your disease.Tell all of your doctors and your dentist that you are taking clopidogrel tablets. They should talk to the doctor who prescribed clopidogrel tablets for you before you have any surgery or invasive procedure.Tell your doctor about all the medicines you take, including prescription, non-prescription medicines, vitamins and herbal supplements.Clopidogrel tablets may affect the way other medicines work, and other medicines may affect how clopidogrel tablets work. See What is the most important information should know about clopidogrel tabletsClopidogrel may increase blood levels of other medicines such as repaglinide (Prandin(R)).Taking clopidogrel tablets with certain other medicines may increase your risk of bleeding. Especially tell your doctor if you take:oaspirin, especially if you have had stroke. Always talk to your doctor about whether you should take aspirin along with clopidogrel to treat your condition.oNon-steroidal anti-inflammatory drugs (NSAIDs). Ask your doctor or pharmacist for list of NSAID medicines if you are not sure.owarfarin (Coumadin(R), Jantoven(R)).oselective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). Ask your doctor or pharmacist for list of SSRI or SNRI medicines if you are not sure.Know the medicines you take. Keep list of them to show your doctor or pharmacist when you get new medicine.How should take clopidogrel tabletsoTake clopidogrel tablets exactly as your doctor tells you.oDo not change your dose or stop taking clopidogrel tablets without talking to your doctor first. Stopping clopidogrel tablets may increase your risk of heart attack or stroke.oTake clopidogrel tablets with aspirin as instructed by your doctor.oIf you miss dose, take clopidogrel tablets as soon as you remember. If it is almost time for your next dose, skip the missed dose. Take the next dose at your regular time. Do not take doses of clopidogrel tablets at the same time unless your doctor tells you to.oIf you take too much clopidogrel, call your doctor or go to the nearest emergency room right away.oTalk with your doctor about stopping your clopidogrel tablets before you have surgery. Your doctor may tell you to stop taking clopidogrel tablets at least days before you have surgery to avoid excessive bleeding during surgery.What are the possible side effects of clopidogrel tabletsClopidogrel tablets can cause serious side effects including:oSee What is the most important information should know about clopidogrel tabletsoA blood clotting problem called Thrombotic Thrombocytopenic Purpura (TTP). TTP can happen with clopidogrel, sometimes after short time (less than weeks). TTP is blood clotting problem where blood clots form in blood vessels; and can happen anywhere in the body. TTP needs to be treated in hospital right away, because it may cause death. Get medical help right away if you have any of these symptoms and they can not be explained by another medical condition:opurplish spots (called purpura) on the skin or in the mouth (mucous membranes) due to bleeding under the skinoyour skin or the whites of your eyes are yellow (jaundice)oyou feel tired or weakoyour skin looks very paleofeverofast heart rate or feeling short of breathoheadacheospeech changesoconfusionocomaostrokeoseizureolow amount of urine, or urine that is pink or has blood in itostomach area (abdominal) painonausea, vomiting, or diarrheaovision changes 1. Persistent low blood sugar symptomsTell your doctor if you have any side effect that bothers you or that does not go away.Tell your doctor if you develop an allergic reaction including skin reactions while taking clopidogrel tablets.These are not all the possible side effects of clopidogrel tablets. For more information, ask your doctor or pharmacist.Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.How should store clopidogrel tabletsoStore clopidogrel tablets at 59F to 86F (15C to 30C). Protect from moisture.Keep clopidogrel and all medicines out of the reach of children.General information about clopidogrel tabletsMedicines are sometimes used for purposes other than those listed in Medication Guide. Do not take clopidogrel tablets for condition for which it was not prescribed. Do not give clopidogrel tablets to other people, even if they have the same symptoms that you have. It may harm them.This Medication Guide summarizes the most important information about clopidogrel tablets. If you would like more information, talk to your doctor. Ask your doctor or pharmacist for information about clopidogrel that was written for healthcare professionals.For more information, go to www.apotex.com or call 1-800-706-5575.What are the ingredients in clopidogrel tabletsActive ingredient: clopidogrel bisulfateInactive ingredients:Tablet: anhydrous lactose, colloidal silicon dioxide, crospovidone, methylcellulose and zinc stearateFilm coating: ferric oxide red, hydroxypropyl cellulose, hypromellose, polyethylene glycol and titanium dioxide. All registered trademarks in this document are the property of their respective owners.This Medication Guide has been approved by the U.S. Food and Drug Administration.APOTEX INC.CLOPIDOGREL TABLETS, USP 75 mg and 300 mgManufactured byManufactured forApotex Inc.Apotex Corp.Toronto, OntarioWeston, FloridaCanada M9L 1T933326Distributed By:MAJOR(R) PHARMACEUTICALS17177 Laurel Park Dr., Suite 233Livonia, MI 48152Revised: June 2019Rev. 26. 1.have certain genetic factors that affect how the body breaks down clopidogrel. Your doctor may do genetic tests to make sure clopidogrel is right for you. 2.take certain medicines, especially omeprazole (Prilosec(R)) or esomeprazole (Nexium(R)). Your doctor may change the medicine you take for stomach acid problems while you take clopidogrel tablets.. 1.you may bruise and bleed more easily 2.you are more likely to have nose bleeds 3.it will take longer for any bleeding to stop ounexpected bleeding or bleeding that lasts long time. oblood in your urine (pink, red or brown urine). ored or black stools (looks like tar). obruises that happen without known cause or get larger. ocough up blood or blood clots. ovomit blood or your vomit looks like coffee grounds. ochest pain due to heart problems. opoor circulation in their legs (peripheral arterial disease). oa heart attack. oa stroke. ocurrently have condition that causes bleeding, such as stomach ulcer. oare allergic to clopidogrel or other ingredients in clopidogrel tablets. See the end of this leaflet for complete list of ingredients in clopidogrel tablets.. ohave history of bowel (gastrointestinal) or stomach ulcers. ohave history of bleeding problems. oplan to have surgery or dental procedure. See How should take clopidogrel tablets. oare pregnant or plan to become pregnant. It is not known if clopidogrel will harm your unborn baby. oare breastfeeding or plan to breastfeed. It is not known if clopidogrel passes into your breast milk. decision should be made with your healthcare provider to avoid or discontinue breastfeeding when continuing clopidogrel is needed.. ohave had an allergy or reaction to any medicine used to treat your disease.. oaspirin, especially if you have had stroke. Always talk to your doctor about whether you should take aspirin along with clopidogrel to treat your condition.. oNon-steroidal anti-inflammatory drugs (NSAIDs). Ask your doctor or pharmacist for list of NSAID medicines if you are not sure.. owarfarin (Coumadin(R), Jantoven(R)).. oselective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). Ask your doctor or pharmacist for list of SSRI or SNRI medicines if you are not sure.. oTake clopidogrel tablets exactly as your doctor tells you.. oDo not change your dose or stop taking clopidogrel tablets without talking to your doctor first. Stopping clopidogrel tablets may increase your risk of heart attack or stroke.. oTake clopidogrel tablets with aspirin as instructed by your doctor.. oIf you miss dose, take clopidogrel tablets as soon as you remember. If it is almost time for your next dose, skip the missed dose. Take the next dose at your regular time. Do not take doses of clopidogrel tablets at the same time unless your doctor tells you to.. oIf you take too much clopidogrel, call your doctor or go to the nearest emergency room right away.. oTalk with your doctor about stopping your clopidogrel tablets before you have surgery. Your doctor may tell you to stop taking clopidogrel tablets at least days before you have surgery to avoid excessive bleeding during surgery.. oSee What is the most important information should know about clopidogrel tablets. oA blood clotting problem called Thrombotic Thrombocytopenic Purpura (TTP). TTP can happen with clopidogrel, sometimes after short time (less than weeks). TTP is blood clotting problem where blood clots form in blood vessels; and can happen anywhere in the body. TTP needs to be treated in hospital right away, because it may cause death. Get medical help right away if you have any of these symptoms and they can not be explained by another medical condition:opurplish spots (called purpura) on the skin or in the mouth (mucous membranes) due to bleeding under the skinoyour skin or the whites of your eyes are yellow (jaundice)oyou feel tired or weakoyour skin looks very paleofeverofast heart rate or feeling short of breathoheadacheospeech changesoconfusionocomaostrokeoseizureolow amount of urine, or urine that is pink or has blood in itostomach area (abdominal) painonausea, vomiting, or diarrheaovision changes opurplish spots (called purpura) on the skin or in the mouth (mucous membranes) due to bleeding under the skin. oyour skin or the whites of your eyes are yellow (jaundice). oyou feel tired or weak. oyour skin looks very pale. ofever. ofast heart rate or feeling short of breath. oheadache. ospeech changes. oconfusion. ocoma. ostroke. oseizure. olow amount of urine, or urine that is pink or has blood in it. ostomach area (abdominal) pain. onausea, vomiting, or diarrhea. ovision changes. 1. Persistent low blood sugar symptoms. oStore clopidogrel tablets at 59F to 86F (15C to 30C). Protect from moisture.

SPL UNCLASSIFIED SECTION.

The effectiveness of clopidogrel bisulfate results from its antiplatelet activity, which is dependent on its conversion to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19 [see Warnings and Precautions (5.1), Clinical Pharmacology (12.3)]. Clopidogrel bisulfate at recommended doses forms less of the active metabolite and so has reduced effect on platelet activity in patients who are homozygous for nonfunctional alleles of the CYP2C19 gene, (termed CYP2C19 poor metabolizers). Tests are available to identify patients who are CYP2C19 poor metabolizers [see Clinical Pharmacology (12.5)]. Consider use of another platelet P2Y12 inhibitor in patients identified as CYP2C19 poor metabolizers.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. 8.1 Pregnancy. Risk SummaryAvailable data from cases reported in published literature and postmarketing surveillance with clopidogrel use in pregnant women have not identified any drug-associated risks for major birth defects or miscarriage [see Data]. There are risks to the pregnant woman and fetus associated with myocardial infarction and stroke [see Clinical Considerations]. No evidence of fetotoxicity was observed when clopidogrel was administered to pregnant rats and rabbits during organogenesis at doses corresponding to 65 and 78 times the recommended daily human dose [see Data]. The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. All pregnancies have background risk of birth defects, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.Clinical ConsiderationsDisease-associated maternal and/or embryo/fetal riskMyocardial infarction and stroke are medical emergencies. Therapy for the pregnant woman should not be withheld because of potential concerns regarding the effects of clopidogrel on the fetus.Labor or deliveryClopidogrel use during labor or delivery will increase the risk of maternal bleeding and hemorrhage. Avoid neuraxial blockade during clopidogrel use because of the risk of spinal hematoma. When possible, discontinue clopidogrel to days prior to labor, delivery, or neuraxial blockade.DataHuman dataThe available data from published case reports over two decades of postmarketing use have not identified an association with clopidogrel use in pregnancy and major birth defects, miscarriage, or adverse fetal outcomes.Animal dataEmbryo-fetal developmental toxicology studies were performed in pregnant rats and rabbits with doses up to 500 and 300 mg/kg/day, respectively, administered during organogenesis. These doses, corresponding to 65 and 78 times the recommended daily human dose, respectively, on mg/m2 basis, revealed no evidence of impaired fertility or fetotoxicity due to clopidogrel.. 8.2 Lactation. Risk SummaryThere are no data on the presence of clopidogrel in human milk or the effects on milk production. No adverse effects on breastfed infants have been observed with maternal clopidogrel use during lactation in small number of postmarketing cases. Studies in rats have shown that clopidogrel and/or its metabolites are present in the milk. When drug is present in animal milk, it is likely that the drug will be present in human milk. The developmental and health benefits of breastfeeding should be considered along with mothers clinical need for clopidogrel and any potential adverse effects on the breastfed infant from clopidogrel or from underlying maternal condition.. 8.4 Pediatric Use. Safety and effectiveness in pediatric populations have not been established.A randomized, placebo-controlled trial (CLARINET) did not demonstrate clinical benefit of clopidogrel in neonates and infants with cyanotic congenital heart disease palliated with systemic-to-pulmonary arterial shunt. Possible factors contributing to this outcome were the dose of clopidogrel, the concomitant administration of aspirin, and the late initiation of therapy following shunt palliation. It cannot be ruled out that trial with different design would demonstrate clinical benefit in this patient population.. 8.5 Geriatric Use. Of the total number of subjects in the CAPRIE and CURE controlled clinical studies, approximately 50% of patients treated with clopidogrel bisulfate were 65 years of age and older, and 15% were 75 years and older. In COMMIT, approximately 58% of the patients treated with clopidogrel bisulfate were 60 years and older, 26% of whom were 70 years and older.The observed risk of bleeding events with clopidogrel plus aspirin versus placebo plus aspirin by age category is provided in Table and Table for the CURE and COMMIT trials, respectively [see Adverse Reactions (6.1)]. No dosage adjustment is necessary in elderly patients.. 8.6Renal Impairment. Experience is limited in patients with severe and moderate renal impairment [see Clinical Pharmacology (12.2)]. 8.7Hepatic Impairment. No dosage adjustment is necessary in patients with hepatic impairment [see Clinical Pharmacology (12.2)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. oCYP2C19 inhibitors: Avoid concomitant use of omeprazole or esomeprazole. (5.1)oBleeding: Clopidogrel bisulfate increases risk of bleeding. (5.2) oDiscontinuation: Premature discontinuation increases risk of cardiovascular events. Discontinue days prior to elective surgery that has major risk of bleeding. (5.3) oThrombotic thrombocytopenic purpura (TTP) has been reported. (5.4)oCross-reactivity among thienopyridines has been reported. (5.5). oCYP2C19 inhibitors: Avoid concomitant use of omeprazole or esomeprazole. (5.1). oBleeding: Clopidogrel bisulfate increases risk of bleeding. (5.2) oDiscontinuation: Premature discontinuation increases risk of cardiovascular events. Discontinue days prior to elective surgery that has major risk of bleeding. (5.3) oThrombotic thrombocytopenic purpura (TTP) has been reported. (5.4). oCross-reactivity among thienopyridines has been reported. (5.5). 5.1 Diminished Antiplatelet Activity in Patients with Impaired CYP2C19 Function Clopidogrel is prodrug. Inhibition of platelet aggregation by clopidogrel is achieved through an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by genetic variations in CYP2C19 [see Boxed Warning]. The metabolism of clopidogrel can also be impaired by drugs that inhibit CYP2C19, such as omeprazole or esomeprazole. Avoid concomitant use of clopidogrel with omeprazole or esomeprazole because both significantly reduce the antiplatelet activity of clopidogrel [see Drug Interactions (7.1)].. 5.2 General Risk of Bleeding. Thienopyridines, including clopidogrel bisulfate, increase the risk of bleeding. Thienopyridines inhibit platelet aggregation for the lifetime of the platelet (7 to 10 days). Because the half-life of clopidogrels active metabolite is short, it may be possible to restore hemostasis by administering exogenous platelets; however, platelet transfusions within hours of the loading dose or hours of the maintenance dose may be less effective. 5.3 Discontinuation of Clopidogrel Bisulfate. Discontinuation of clopidogrel bisulfate increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.. 5.4 Thrombotic Thrombocytopenic Purpura (TTP). TTP, sometimes fatal, has been reported following use of clopidogrel bisulfate, sometimes after short exposure (<2 weeks). TTP is serious condition that requires urgent treatment including plasmapheresis (plasma exchange). It is characterized by thrombocytopenia, microangiopathic hemolytic anemia (schistocytes [fragmented RBCs] seen on peripheral smear), neurological findings, renal dysfunction, and fever [see Adverse Reactions (6.2)]. 5.5 Cross-Reactivity among Thienopyridines. Hypersensitivity including rash, angioedema or hematologic reaction has been reported in patients receiving clopidogrel, including patients with history of hypersensitivity or hematologic reaction to other thienopyridines [see Contraindications (4.2) and Adverse Reactions (6.2)].