ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following serious adverse reactions are discussed below and elsewhere in the labeling:Bleeding [see Warnings and Precautions (5.2)] Thrombotic thrombocytopenic purpura [see Warnings and Precautions (5.5)] Bleeding [see Warnings and Precautions (5.2)] Thrombotic thrombocytopenic purpura [see Warnings and Precautions (5.5)] 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 Studies 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 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) Event Clopidogrel Bisulfate (+ aspirin) (n=6259) Placebo (+ aspirin (n=6303) Major bleeding 3.7 2.7 Life-threatening bleeding 2.2 1.8 Fatal 0.2 0.2 g/dL hemoglobin drop 0.9 0.9 Requiring surgical intervention 0.7 0.7 Hemorrhagic strokes 0.1 0.1 Requiring inotropes 0.5 0.5 Requiring transfusion (>4 units) 1.2 1.0 Other major bleeding 1.6 1.0 Significantly disabling 0.4 0.3 Intraocular bleeding with significant loss of vision 0.05 0.03 Requiring to units of blood 1.3 0.9 Minor bleeding 5.1 2.4 Other standard therapies were used as appropriate.+ Life-threatening and other major bleeding. Major bleeding event rate for clopidogrel bisulfate aspirin was dose-dependent on aspirin: <100 mg 2.6%; 100 to 200 mg 3.5%; >200 mg 4.9%.Major bleeding event rates for clopidogrel aspirin by age were: <65 years 2.5%, >=65 to <75 years 4.1%, >=75 years 5.9%. Major bleeding event rate for placebo aspirin was dose-dependent on aspirin: <100 mg 2.0%; 100 to 200 mg 2.3%; >200 mg 4.0%.Major bleeding event rates for placebo aspirin by age were: <65 years 2.1%, >=65 to <75 years 3.1%, >=75 years 3.6%. Led to interruption of study medication.Ninety-two percent (92%) of the patients in the CURE study received heparin or low molecular weight heparin (LMWH), and the rate of bleeding in these patients was similar to the overall results. 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-value Major noncerebral or cerebral bleeding 0.6 0.5 0.59 Major noncerebral 0.4 0.3 0.48 Fatal 0.2 0.2 0.90 Hemorrhagic stroke 0.2 0.2 0.91 Fatal 0.2 0.2 0.81 Other noncerebral bleeding (non-major) 3.6 3.1 0.005 Any noncerebral bleeding 3.9 3.4 0.004 Major bleeds were cerebral bleeds or non-cerebral bleeds thought to have caused death or that required transfusion. The relative rate of major noncerebral or cerebral bleeding was independent of age. Event rates for clopidogrel bisulfate aspirin by age were: <60 years 0.3%, >=60 to <70 years 0.7%, >=70 years 0.8%. Event rates for placebo aspirin by age were: <60 years 0.4%, >=60 to <70 years 0.6%, >=70 years 0.7%.CAPRIE (Clopidogrel bisulfate vs. Aspirin) In CAPRIE, gastrointestinal hemorrhage occurred at rate of 2.0% in those taking clopidogrel bisulfate vs. 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 post-approval 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. Blood and lymphatic system disorders: Agranulocytosis, aplastic anemia/pancytopenia, thrombotic thrombocytopenic purpura (TTP), acquired hemophilia Eye disorders: Eye (conjunctival, ocular, retinal) bleedingGastrointestinal disorders: Gastrointestinal and retroperitoneal hemorrhage with fatal outcome, colitis (including ulcerative or lymphocytic colitis), pancreatitis, stomatitis, gastric/duodenal ulcer, diarrheaGeneral disorders and administration site condition: Fever, hemorrhage of operative woundHepato-biliary disorders: Acute liver failure, hepatitis (non-infectious), abnormal liver function testImmune system disorders: Hypersensitivity reactions, anaphylactoid reactions, serum sicknessMusculoskeletal, connective tissue and bone disorders: Musculoskeletal bleeding, myalgia, arthralgia, arthritisNervous system disorders: Taste disorders, fatal intracranial bleeding, headachePsychiatric disorders: Confusion, hallucinations Respiratory, thoracic and mediastinal disorders: Bronchospasm, interstitial pneumonitis, respiratory tract bleeding, eosinophilic pneumoniaRenal and urinary disorders: Increased creatinine levelsSkin 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, skin bleeding, lichen planus, generalized pruritusVascular disorders: Vasculitis, hypotension. Blood and lymphatic system disorders: Agranulocytosis, aplastic anemia/pancytopenia, thrombotic thrombocytopenic purpura (TTP), acquired hemophilia . Eye disorders: Eye (conjunctival, ocular, retinal) bleeding. Gastrointestinal disorders: Gastrointestinal and retroperitoneal hemorrhage with fatal outcome, colitis (including ulcerative or lymphocytic colitis), pancreatitis, stomatitis, gastric/duodenal ulcer, diarrhea. General disorders and administration site condition: Fever, hemorrhage of operative wound. Hepato-biliary disorders: Acute liver failure, hepatitis (non-infectious), abnormal liver function test. Immune system disorders: Hypersensitivity reactions, anaphylactoid reactions, serum sickness. Musculoskeletal, connective tissue and bone disorders: Musculoskeletal bleeding, myalgia, arthralgia, arthritis. Nervous system disorders: Taste disorders, fatal intracranial bleeding, headache. Psychiatric disorders: Confusion, hallucinations Respiratory, thoracic and mediastinal disorders: Bronchospasm, interstitial pneumonitis, respiratory tract bleeding, eosinophilic pneumonia. Renal and urinary disorders: Increased creatinine levels. Skin 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, skin bleeding, lichen planus, generalized pruritus. Vascular disorders: Vasculitis, hypotension.

BOXED WARNING SECTION.

WARNING: DIMINISHED EFFECTIVENESS IN POOR METABOLIZERS. WARNING: DIMINISHED EFFECTIVENESS IN POOR METABOLIZERSSee full prescribing information for complete boxed warning. Effectiveness of clopidogrel bisulfate depends on activation to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19. (5.1) Poor metabolizers treated with clopidogrel bisulfate at recommended doses exhibit higher cardiovascular event rates following acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) than patients with normal CYP2C19 function. (12.5)Tests are available to identify patients CYP2C19 genotype and can be used as an aid in determining therapeutic strategy. (12.5)Consider alternative treatment or treatment strategies in patients identified as CYP2C19 poor metabolizers. (2.3, 5.1). Effectiveness of clopidogrel bisulfate depends on activation to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19. (5.1) Poor metabolizers treated with clopidogrel bisulfate at recommended doses exhibit higher cardiovascular event rates following acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) than patients with normal CYP2C19 function. (12.5). Tests are available to identify patients CYP2C19 genotype and can be used as an aid in determining therapeutic strategy. (12.5). Consider alternative treatment or treatment strategies in patients identified as CYP2C19 poor metabolizers. (2.3, 5.1). The effectiveness of clopidogrel bisulfate is dependent on its activation to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19 [see Warnings and Precautions (5.1)]. Clopidogrel bisulfate at recommended doses forms less of that metabolite and has smaller effect on platelet function in patients who are CYP2C19 poor metabolizers. Poor metabolizers with acute coronary syndrome or undergoing percutaneous coronary intervention treated with clopidogrel bisulfate at recommended doses exhibit higher cardiovascular event rates than do patients with normal CYP2C19 function. Tests are available to identify patients CYP2C19 genotype; these tests can be used as an aid in determining therapeutic strategy [see Clinical Pharmacology (12.5)]. Consider alternative treatment or treatment strategies in patients identified as CYP2C19 poor metabolizers [see Dosage and Administration (2.3)].

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 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 PatientsAfter 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 PatientsAfter 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. GenderIn 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 FoodClopidogrel 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. This metabolic pathway is mediated by CYP2C19, CYP3A, CYP2B6 and CYP1A2. 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: increasing the dose by factor of four results in 2.0- and 2.7-fold increases in Cmax and AUC, respectively.EliminationFollowing 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 InteractionsClopidogrel 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.. figure-01. 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. Genetic variants of other CYP450 enzymes may also affect the formation of clopidogrels active metabolite.The CYP2C191 allele corresponds to fully functional metabolism while the CYP2C192 and alleles are nonfunctional. CYP2C192 and account for the majority of reduced function alleles in white (85%) and Asian (99%) poor metabolizers. Other alleles associated with absent or reduced metabolism are less frequent, and include, but are not limited to, CYP2C194, 5, 6, 7, and 8. patient with poor metabolizer status will possess two loss-of-function alleles as defined above. Published frequencies for poor CYP2C19 metabolizer genotypes are approximately 2% for whites, 4% for blacks and 14% for Chinese. Tests are available to determine patients CYP2C19 genotype. 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. When poor metabolizers received the 600 mg/150 mg regimen, active metabolite exposure and antiplatelet response were greater than with the 300 mg/75 mg regimen (see Table 3). An appropriate dose regimen for this patient population has not been established in clinical outcome trials.Table 3: Active Metabolite Pharmacokinetics and Antiplatelet Responses by CYP2C19 Metabolizer Status Dose Ultrarapid (n=10) Extensive (n=10) Intermediate (n=10) Poor (n=10) Values are mean (SD) Cmax (ng/mL) 300 mg (24 h) 24 (10) 32 (21) 23 (11) 11 (4) 600 mg (24 h) 36 (13) 44 (27) 39 (23) 17 (6) 75 mg (Day 5) 12 (6) 13 (7) 12 (5) (1) 150 mg (Day 5) 16 (9) 19 (5) 18 (7) (2) IPA (%)Inhibition of platelet aggregation with 5mcM ADP; larger value indicates greater platelet inhibition 300 mg (24 h) 40 (21) 39 (28) 37 (21) 24 (26) 600 mg (24 h) 51 (28) 49 (23) 56 (22) 32 (25) 75 mg (Day 5) 56 (13) 58 (19) 60 (18) 37 (23) 150 mg (Day 5) 68 (18) 73 (9) 74 (14) 61 (14) VASP-PRI (%) Vasodilator-stimulated phosphoprotein platelet reactivity index; smaller value indicates greater platelet inhibition 300 mg (24 h) 73 (12) 68 (16) 78 (12) 91 (12) 600 mg (24 h) 51 (20) 48 (20) 56 (26) 85 (14) 75 mg (Day 5) 40 (9) 39 (14) 50 (16) 83 (13) 150 mg (Day 5) 20 (10) 24 (10) 29 (11) 61 (18)Some published studies suggest that intermediate metabolizers have decreased active metabolite exposure and diminished antiplatelet effects.The relationship between CYP2C19 genotype and clopidogrel treatment outcome was evaluated in retrospective analyses of clopidogrel-treated subjects in CHARISMA (n=2428) and TRITON-TIMI 38 (n=1477), and in several published cohort studies. In TRITON-TIMI 38 and the majority of the cohort studies, the combined group of patients with either intermediate or poor metabolizer status had higher rate of cardiovascular events (death, myocardial infarction, and stroke) or stent thrombosis compared to extensive metabolizers. In CHARISMA and one cohort study, the increased event rate was observed only in poor metabolizers.

CLINICAL STUDIES SECTION.

6.1 Clinical Studies 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 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) Event Clopidogrel Bisulfate (+ aspirin) (n=6259) Placebo (+ aspirin (n=6303) Major bleeding 3.7 2.7 Life-threatening bleeding 2.2 1.8 Fatal 0.2 0.2 g/dL hemoglobin drop 0.9 0.9 Requiring surgical intervention 0.7 0.7 Hemorrhagic strokes 0.1 0.1 Requiring inotropes 0.5 0.5 Requiring transfusion (>4 units) 1.2 1.0 Other major bleeding 1.6 1.0 Significantly disabling 0.4 0.3 Intraocular bleeding with significant loss of vision 0.05 0.03 Requiring to units of blood 1.3 0.9 Minor bleeding 5.1 2.4 Other standard therapies were used as appropriate.+ Life-threatening and other major bleeding. Major bleeding event rate for clopidogrel bisulfate aspirin was dose-dependent on aspirin: <100 mg 2.6%; 100 to 200 mg 3.5%; >200 mg 4.9%.Major bleeding event rates for clopidogrel aspirin by age were: <65 years 2.5%, >=65 to <75 years 4.1%, >=75 years 5.9%. Major bleeding event rate for placebo aspirin was dose-dependent on aspirin: <100 mg 2.0%; 100 to 200 mg 2.3%; >200 mg 4.0%.Major bleeding event rates for placebo aspirin by age were: <65 years 2.1%, >=65 to <75 years 3.1%, >=75 years 3.6%. Led to interruption of study medication.Ninety-two percent (92%) of the patients in the CURE study received heparin or low molecular weight heparin (LMWH), and the rate of bleeding in these patients was similar to the overall results. 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-value Major noncerebral or cerebral bleeding 0.6 0.5 0.59 Major noncerebral 0.4 0.3 0.48 Fatal 0.2 0.2 0.90 Hemorrhagic stroke 0.2 0.2 0.91 Fatal 0.2 0.2 0.81 Other noncerebral bleeding (non-major) 3.6 3.1 0.005 Any noncerebral bleeding 3.9 3.4 0.004 Major bleeds were cerebral bleeds or non-cerebral bleeds thought to have caused death or that required transfusion. The relative rate of major noncerebral or cerebral bleeding was independent of age. Event rates for clopidogrel bisulfate aspirin by age were: <60 years 0.3%, >=60 to <70 years 0.7%, >=70 years 0.8%. Event rates for placebo aspirin by age were: <60 years 0.4%, >=60 to <70 years 0.6%, >=70 years 0.7%.CAPRIE (Clopidogrel bisulfate vs. Aspirin) In CAPRIE, gastrointestinal hemorrhage occurred at rate of 2.0% in those taking clopidogrel bisulfate vs. 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.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. Active pathological bleeding, such as peptic ulcer or intracranial hemorrhage (4.1)Hypersensitivity to clopidogrel or any component of the product (4.2). Active pathological bleeding, such as peptic ulcer or intracranial hemorrhage (4.1). Hypersensitivity 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)].

DESCRIPTION SECTION.

11 DESCRIPTION. Clopidogrel bisulfate is an inhibitor of ADP-induced platelet aggregation acting by direct inhibition of adenosine diphosphate (ADP) binding to its receptor and of the subsequent ADP-mediated activation of the glycoprotein GPIIb/IIIa complex. 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. 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 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 hydroxypropyl cellulose, hypromellose, polyethylene glycol, red ferric oxide and titanium dioxide.. clopiodgrel-01.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Acute coronary syndrome (2.1)-UA/NSTEMI: 300 mg loading dose followed by 75 mg once daily, in combination with aspirin (75 to 325 mg once daily)-STEMI: 75 mg once daily, in combination with aspirin (75 to 325 mg once daily), with or without loading dose Recent MI, recent stroke, or established peripheral arterial disease: 75 mg once daily (2.2). Acute coronary syndrome (2.1)-UA/NSTEMI: 300 mg loading dose followed by 75 mg once daily, in combination with aspirin (75 to 325 mg once daily)-STEMI: 75 mg once daily, in combination with aspirin (75 to 325 mg once daily), with or without loading dose -UA/NSTEMI: 300 mg loading dose followed by 75 mg once daily, in combination with aspirin (75 to 325 mg once daily). -STEMI: 75 mg once daily, in combination with aspirin (75 to 325 mg once daily), with or without loading dose Recent MI, recent stroke, or established peripheral arterial disease: 75 mg once daily (2.2). 2.1Acute Coronary Syndrome. Clopidogrel tablets can be administered with or without food [see Clinical Pharmacology (12.3)]. For patients with non-ST-elevation ACS (UA/NSTEMI), initiate clopidogrel tablets with single 300 mg oral loading dose and then continue at 75 mg once daily. Initiate aspirin (75 to 325 mg once daily) and continue in combination with clopidogrel tablets [see Clinical Studies (14.1)].For patients with STEMI, the recommended dose of clopidogrel is 75 mg once daily orally, administered in combination with aspirin (75 to 325 mg once daily), with or without thrombolytics. Clopidogrel may be initiated with or without loading dose [see Clinical Studies (14.1)].. For patients with non-ST-elevation ACS (UA/NSTEMI), initiate clopidogrel tablets with single 300 mg oral loading dose and then continue at 75 mg once daily. Initiate aspirin (75 to 325 mg once daily) and continue in combination with clopidogrel tablets [see Clinical Studies (14.1)].. For patients with STEMI, the recommended dose of clopidogrel is 75 mg once daily orally, administered in combination with aspirin (75 to 325 mg once daily), with or without thrombolytics. Clopidogrel may be initiated with or without loading dose [see Clinical Studies (14.1)].. 2.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease. The recommended daily dose of clopidogrel is 75 mg once daily orally, with or without food [see Clinical Pharmacology (12.3)].. 2.3 CYP2C19 Poor Metabolizers. CYP2C19 poor metabolizer status is associated with diminished antiplatelet response to clopidogrel. Although higher dose regimen in poor metabolizers increases antiplatelet response [see Clinical Pharmacology (12.5)], an appropriate dose regimen for this patient population has not been established. 2.4 Use with Proton Pump Inhibitors (PPI). Avoid using omeprazole or esomeprazole with clopidogrel. Omeprazole and esomeprazole significantly reduce the antiplatelet activity of clopidogrel. When concomitant administration of PPI is required, consider using another acid-reducing agent with minimal or no CYP2C19 inhibitory effect on the formation of clopidogrel active metabolite [see Warnings and Precautions (5.1), Drug Interactions (7.1) and Clinical Pharmacology (12.3)].

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 and 300 mg (3).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. Nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, selective serotonin and serotonin norepinephrine reuptake inhibitors (SSRIs, SNRIs): Increases risk of bleeding. (7.2, 7.3, 7.4) Nonsteroidal anti-inflammatory drugs (NSAIDs), warfarin, selective serotonin and serotonin norepinephrine reuptake inhibitors (SSRIs, SNRIs): Increases risk of bleeding. (7.2, 7.3, 7.4) 7.1 CYP2C19 Inhibitors. Clopidogrel is metabolized to its active metabolite in part by CYP2C19. Concomitant use of certain 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) and Dosage and Administration (2.4)].Proton Pump Inhibitors (PPI) Avoid concomitant use of clopidogrel bisulfate with omeprazole or esomeprazole. In clinical studies, omeprazole was shown to reduce the antiplatelet activity of clopidogrel bisulfate when given concomitantly or 12 hours apart. higher dose regimen of clopidogrel concomitantly administered with omeprazole increases antiplatelet response; an appropriate dose regimen has not been established. similar reduction in antiplatelet activity was observed with esomeprazole when given concomitantly with clopidogrel bisulfate. Consider using another acid-reducing agent with minimal or no CYP2C19 inhibitory effect on the formation of clopidogrel active metabolite. Dexlansoprazole, lansoprazole and pantoprazole had less effect on the antiplatelet activity of clopidogrel bisulfate than did omeprazole or esomeprazole [see Dosage and Administration (2.4), Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)]. 7.2 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). Coadministration of clopidogrel bisulfate and NSAIDs increases the risk of gastrointestinal bleeding.. 7.3 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 vitr o, clopidogrel inhibits CYP2C9.. 7.4 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.

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 75 mg are pink, round, biconvex, film coated tablets, engraved APO on one side and CL over 75 on the other side. They are supplied as follows: Blistercards of 30 NDC 0615-8014-39Blistercards of 15 NDC 0615-8014-05Unit-Dose Boxes of 30 NDC 0615-8014-30Clopidogrel tablets USP, 300 mg are pink, oblong, biconvex, film-coated tablets, engraved APO on one side and CL 300 on the other side. Store at 25C(77F); excursions permitted from 15 to 30C (59 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: 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 decrease the rate of combined endpoint of cardiovascular death, myocardial infarction (MI), or stroke as well as the rate of combined endpoint of cardiovascular death, MI, stroke, or refractory ischemia. (1.1) For patients with ST-elevation myocardial infarction (STEMI), clopidogrel bisulfate has been shown to reduce the rate of death from any cause and the rate of combined endpoint of death, re-infarction, or stroke. The benefit for patients who undergo primary PCI is unknown. (1.1) Recent MI, recent stroke, or established peripheral arterial disease. Clopidogrel bisulfate has been shown to reduce the combined endpoint of new ischemic stroke, new MI, and other vascular death. (1.2) Acute coronary syndrome. Recent MI, recent stroke, or established peripheral arterial disease. Clopidogrel bisulfate has been shown to reduce the combined endpoint of new ischemic stroke, new MI, and other vascular death. (1.2) 1.1 Acute Coronary Syndrome (ACS). For 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 bisulfate has been shown to decrease the rate of combined endpoint of cardiovascular death, myocardial infarction (MI), or stroke as well as the rate of combined endpoint of cardiovascular death, MI, stroke, or refractory ischemia.For patients with ST-elevation myocardial infarction (STEMI), clopidogrel bisulfate has been shown to reduce the rate of death from any cause and the rate of combined endpoint of death, re-infarction, or stroke. The benefit for patients who undergo primary percutaneous coronary intervention is unknown.The optimal duration of clopidogrel bisulfate therapy in ACS is unknown. For 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 bisulfate has been shown to decrease the rate of combined endpoint of cardiovascular death, myocardial infarction (MI), or stroke as well as the rate of combined endpoint of cardiovascular death, MI, stroke, or refractory ischemia.. For patients with ST-elevation myocardial infarction (STEMI), clopidogrel bisulfate has been shown to reduce the rate of death from any cause and the rate of combined endpoint of death, re-infarction, or stroke. The benefit for patients who undergo primary percutaneous coronary intervention is unknown.. 1.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease. For patients with history of recent myocardial infarction (MI), recent stroke, or established peripheral arterial disease, clopidogrel bisulfate has been shown to reduce the rate of combined endpoint of new ischemic stroke (fatal or not), new MI (fatal or not), and other vascular death.

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. [See Medication Guide]. 17.1Benefits and Risks. Summarize the effectiveness features and potential side effects of clopidogrel.Tell patients to take clopidogrel exactly as prescribed.Remind patients not to discontinue clopidogrel without first discussing it with the physician who prescribed clopidogrel.. Summarize the effectiveness features and potential side effects of clopidogrel.. Tell patients to take clopidogrel exactly as prescribed.. Remind patients not to discontinue clopidogrel without first discussing it with the physician who prescribed clopidogrel.. 17.2Bleeding. Inform patients that they:will bruise and bleed more easily.will take longer than usual to stop bleeding.should report any unanticipated, prolonged, or excessive bleeding, or blood in their stool or urine.. will bruise and bleed more easily.. will take longer than usual to stop bleeding.. should report any unanticipated, prolonged, or excessive bleeding, or blood in their stool or urine.. 17.3Other Signs and Symptoms Requiring Medical Attention. Inform patients that TTP is rare but serious condition that has been reported with clopidogrel and other drugs in this class of drugs.Instruct patients to get prompt medical attention if they experience any of the following symptoms that cannot otherwise be explained: fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin or eyes, or neurological changes.. Inform patients that TTP is rare but serious condition that has been reported with clopidogrel and other drugs in this class of drugs.. Instruct patients to get prompt medical attention if they experience any of the following symptoms that cannot otherwise be explained: fever, weakness, extreme skin paleness, purple skin patches, yellowing of the skin or eyes, or neurological changes.. 17.4Invasive Procedures. Instruct patients to:inform physicians and dentists that they are taking clopidogrel before any invasive procedure is scheduled.tell the doctor performing the invasive procedure to talk to the prescribing health care professional before stopping clopidogrel.. inform physicians and dentists that they are taking clopidogrel before any invasive procedure is scheduled.. tell the doctor performing the invasive procedure to talk to the prescribing health care professional before stopping clopidogrel.. 17.5Concomitant Medications. Ask patients to list all prescription medications, over-the-counter medications, or dietary supplements they are taking or plan to take [see Warnings and Precautions (5) and Drug Interactions (7)]. APOTEX INC. CLOPIDOGREL TABLETS, USP 75 mg and 300 mg Manufactured by Manufactured forApotex Inc. Apotex Corp.Toronto, Ontario Weston, FloridaCanada M9L 1T9 33326 Revised: September 2015Rev. 20.

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 at oral doses up to 400 mg/kg per day (52 times the recommended human dose on mg/m2 basis).

NURSING MOTHERS SECTION.

8.3 Nursing Mothers. Studies in rats have shown that clopidogrel and/or its metabolites are excreted in the milk. It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from clopidogrel, decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

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.

Clopidogrel Tablets, USP 75mg. Clopidogrel Tebs 75mg bingo label. Clopidogrel Tabs 75mg unit-dose label.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. Safety and effectiveness in pediatric populations have not been established.Additional information describing clinical study in which efficacy was not demonstrated in neonates and infants is approved in the package insert for Bristol-Myers Squibbs clopidogrel tablets. However, due to Bristol-Myers Squibbs marketing exclusivity rights, this drug product is not labeled with that pediatric information.

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 PatientsAfter 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 PatientsAfter 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. GenderIn 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 FoodClopidogrel 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. This metabolic pathway is mediated by CYP2C19, CYP3A, CYP2B6 and CYP1A2. 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: increasing the dose by factor of four results in 2.0- and 2.7-fold increases in Cmax and AUC, respectively.EliminationFollowing 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 InteractionsClopidogrel 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.. figure-01.

PREGNANCY SECTION.

8.1 Pregnancy. Pregnancy Category Reproduction studies performed in rats and rabbits at doses up to 500 and 300 mg/kg/day, respectively (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. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, clopidogrel bisulfate should be used during pregnancy only if clearly needed.

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: 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. 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: you may bruise and bleed more easily you are more likely to have nose bleeds 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:unexpected bleeding or bleeding that lasts long timeblood in your urine (pink, red or brown urine)red or black stools (looks like tar)bruises that happen without known cause or get largercough up blood or blood clotsvomit 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 is clopidogrel tabletsClopidogrel bisulfate tablets are prescription medicine used to treat people who have any of the following:chest pain due to heart problemspoor circulation in their legs (peripheral arterial disease)a heart attacka 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:currently have condition that causes bleeding, such as stomach ulcerare 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:have history of bowel (gastrointestinal) or stomach ulcershave history of bleeding problemsplan to have surgery or dental procedure. See How should take clopidogrel tabletsare pregnant or plan to become pregnant. It is not known if clopidogrel will harm your unborn babyare breastfeeding or plan to breastfeed. It is not known if clopidogrel passes into your breast milk. You and your doctor should decide if you will take clopidogrel tablets or breastfeed. You should not do both without talking to your doctorhave 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 tabletsTaking clopidogrel tablets with certain other medicines may increase your risk of bleeding. Especially tell your doctor if you take:aspirin, especially if you have had stroke. Always talk to your doctor about whether you should take aspirin along with clopidogrel to treat your condition.Non-steroidal anti-inflammatory drugs (NSAIDs). Ask your doctor or pharmacist for list of NSAID medicines if you are not sure.warfarin (Coumadin(R), Jantoven(R))selective 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 tabletsTake clopidogrel tablets exactly as your doctor tells you.Do 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.Take clopidogrel tablets with aspirin as instructed by your doctor.You can take clopidogrel tablets with or without food.If 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.If you take too much clopidogrel, call your doctor or go to the nearest emergency room right away.Talk 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:See What is the most important information should know about clopidogrel tablets 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:purplish spots (called purpura) on the skin or in the mouth (mucous membranes) due to bleeding under the skinyour skin or the whites of your eyes are yellow (jaundice)you feel tired or weakyour skin looks very palefeverfast heart rate or feeling short of breathheadachespeech changesconfusioncomastrokeseizurelow amount of urine, or urine that is pink or has blood in itstomach area (abdominal) painnausea, vomiting, or diarrheavision changes Tell 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 tabletsStore 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: hydroxypropyl cellulose, hypromellose, polyethylene glycol, red ferric oxide 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 mg Manufactured by Manufactured for Apotex Inc. Apotex Corp. Toronto, Ontario Weston, Florida Canada M9L 1T9 33326Revised: September 2015Rev. 20Coumadin(R) is registered trademark of Bristol-Myers Squibb Pharma Company.Prilosec(R) is registered trademark of AstraZeneca.Jantoven(R) is registered trademark of USL Pharma.. 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. 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.. you may bruise and bleed more easily you are more likely to have nose bleeds it will take longer for any bleeding to stop unexpected bleeding or bleeding that lasts long time. blood in your urine (pink, red or brown urine). red or black stools (looks like tar). bruises that happen without known cause or get larger. cough up blood or blood clots. vomit blood or your vomit looks like coffee grounds. chest pain due to heart problems. poor circulation in their legs (peripheral arterial disease). heart attack. stroke. currently have condition that causes bleeding, such as stomach ulcer. are allergic to clopidogrel or other ingredients in clopidogrel tablets. See the end of this leaflet for complete list of ingredients in clopidogrel tablets.. have history of bowel (gastrointestinal) or stomach ulcers. have history of bleeding problems. plan to have surgery or dental procedure. See How should take clopidogrel tablets. are pregnant or plan to become pregnant. It is not known if clopidogrel will harm your unborn baby. are breastfeeding or plan to breastfeed. It is not known if clopidogrel passes into your breast milk. You and your doctor should decide if you will take clopidogrel tablets or breastfeed. You should not do both without talking to your doctor. have had an allergy or reaction to any medicine used to treat your disease.. aspirin, especially if you have had stroke. Always talk to your doctor about whether you should take aspirin along with clopidogrel to treat your condition.. Non-steroidal anti-inflammatory drugs (NSAIDs). Ask your doctor or pharmacist for list of NSAID medicines if you are not sure.. warfarin (Coumadin(R), Jantoven(R)). selective 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.. Take clopidogrel tablets exactly as your doctor tells you.. Do 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.. Take clopidogrel tablets with aspirin as instructed by your doctor.. You can take clopidogrel tablets with or without food.. If 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.. If you take too much clopidogrel, call your doctor or go to the nearest emergency room right away.. Talk 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.. See What is the most important information should know about clopidogrel tablets A 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:purplish spots (called purpura) on the skin or in the mouth (mucous membranes) due to bleeding under the skinyour skin or the whites of your eyes are yellow (jaundice)you feel tired or weakyour skin looks very palefeverfast heart rate or feeling short of breathheadachespeech changesconfusioncomastrokeseizurelow amount of urine, or urine that is pink or has blood in itstomach area (abdominal) painnausea, vomiting, or diarrheavision changes purplish spots (called purpura) on the skin or in the mouth (mucous membranes) due to bleeding under the skin. your skin or the whites of your eyes are yellow (jaundice). you feel tired or weak. your skin looks very pale. fever. fast heart rate or feeling short of breath. headache. speech changes. confusion. coma. stroke. seizure. low amount of urine, or urine that is pink or has blood in it. stomach area (abdominal) pain. nausea, vomiting, or diarrhea. vision changes. Store clopidogrel tablets at 59F to 86F (15C to 30C). Protect from moisture.

SPL UNCLASSIFIED SECTION.

The effectiveness of clopidogrel bisulfate is dependent on its activation to an active metabolite by the cytochrome P450 (CYP) system, principally CYP2C19 [see Warnings and Precautions (5.1)]. Clopidogrel bisulfate at recommended doses forms less of that metabolite and has smaller effect on platelet function in patients who are CYP2C19 poor metabolizers. Poor metabolizers with acute coronary syndrome or undergoing percutaneous coronary intervention treated with clopidogrel bisulfate at recommended doses exhibit higher cardiovascular event rates than do patients with normal CYP2C19 function. Tests are available to identify patients CYP2C19 genotype; these tests can be used as an aid in determining therapeutic strategy [see Clinical Pharmacology (12.5)]. Consider alternative treatment or treatment strategies in patients identified as CYP2C19 poor metabolizers [see Dosage and Administration (2.3)].

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. Nursing mothers: Discontinue drug or nursing. (8.3) 8.1 Pregnancy. Pregnancy Category Reproduction studies performed in rats and rabbits at doses up to 500 and 300 mg/kg/day, respectively (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. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, clopidogrel bisulfate should be used during pregnancy only if clearly needed.. 8.3 Nursing Mothers. Studies in rats have shown that clopidogrel and/or its metabolites are excreted in the milk. It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from clopidogrel, decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.. 8.4 Pediatric Use. Safety and effectiveness in pediatric populations have not been established.Additional information describing clinical study in which efficacy was not demonstrated in neonates and infants is approved in the package insert for Bristol-Myers Squibbs clopidogrel tablets. However, due to Bristol-Myers Squibbs marketing exclusivity rights, this drug product is not labeled with that pediatric information. 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. CYP2C19 inhibitors: Avoid concomitant use of omeprazole or esomeprazole. (5.1) Bleeding: clopidogrel bisulfate increases risk of bleeding. Discontinue days prior to elective surgery. (5.2) Premature discontinuation increases risk of cardiovascular events. (5.3) Recent transient ischemic attack or stroke: Combination use of clopidogrel bisulfate and aspirin is not more effective than clopidogrel bisulfate alone, but increases major bleeding. (5.4) Thrombotic thrombocytopenic purpura (TTP) has been reported. (5.5) Cross-reactivity among thienopyridines has been reported. (5.6) CYP2C19 inhibitors: Avoid concomitant use of omeprazole or esomeprazole. (5.1) Bleeding: clopidogrel bisulfate increases risk of bleeding. Discontinue days prior to elective surgery. (5.2) Premature discontinuation increases risk of cardiovascular events. (5.3) Recent transient ischemic attack or stroke: Combination use of clopidogrel bisulfate and aspirin is not more effective than clopidogrel bisulfate alone, but increases major bleeding. (5.4) Thrombotic thrombocytopenic purpura (TTP) has been reported. (5.5) Cross-reactivity among thienopyridines has been reported. (5.6) 5.1 Diminished Antiplatelet Activity Due to 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] and by concomitant medications that interfere with CYP2C19. Proton Pump InhibitorsAvoid concomitant use of clopidogrel with omeprazole or esomeprazole because both significantly reduce the antiplatelet activity of clopidogrel [see Drug Interactions (7.1) and Dosage and Administration (2.4)]. 5.2 General Risk of Bleeding. Thienopyridines, including clopidogrel bisulfate, increase the risk of bleeding. If patient is to undergo surgery and an antiplatelet effect is not desired, discontinue clopidogrel bisulfate five days prior to surgery. In patients who stopped therapy more than five days prior to CABG the rates of major bleeding were similar (event rate 4.4% clopidogrel bisulfate aspirin; 5.3% placebo aspirin). In patients who remained on therapy within five days of CABG, the major bleeding rate was 9.6% for clopidogrel bisulfate aspirin, and 6.3% for placebo aspirin. Thienopyridines inhibit platelet aggregation for the lifetime of the platelet (7 to 10 days), so withholding dose will not be useful in managing bleeding event or the risk of bleeding associated with an invasive procedure. 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. Avoid lapses in therapy, and if clopidogrel bisulfate must be temporarily discontinued, restart as soon as possible. Premature discontinuation of clopidogrel bisulfate may increase the risk of cardiovascular events. 5.4 Patients with Recent Transient Ischemic Attack (TIA) or Stroke. In patients with recent TIA or stroke who are at high risk for recurrent ischemic events, the combination of aspirin and clopidogrel bisulfate has not been shown to be more effective than clopidogrel bisulfate alone, but the combination has been shown to increase major bleeding.. 5.5 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)]. 5.6 Cross-Reactivity among Thienopyridines. Hypersensitivity including rash, angioedema or hematologic reaction have 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)].

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.