Morphine Decreases Clopidogrel Concentrations and Effects A Randomized, Double-Blind, Placebo-Controlled Trial

Objectives This study sought to examine the possible drug-drug interactions between clopidogrel and morphine. Background Because morphinedthe recommended treatment for pain of myocardial infarctiondis associated with poor clinical outcome, we hypothesized that morphine lowers the plasma levels of clopidogrel active metabolite as well as its effects on platelets. Methods Twenty-four healthy subjects received a loading dose of 600 mg clopidogrel together with placebo or 5 mg morphine intravenously in a randomized, double-blind, placebo-controlled, cross-over trial. Pharmacokinetics was determined by liquid chromatography tandem mass spectrometry, and clopidogrel effects were measured by platelet function tests. Results Morphine injection delayed clopidogrel absorption (p 0.025) and reduced the area under the curve levels of its active metabolite by 34% (p 0.001). Morphine delayed the maximal inhibition of platelet aggregation on average by 2 h (n 24; p < 0.001). Residual platelet aggregation was higher 1 to 4 h after morphine injection (n 24; p < 0.005). Furthermore, morphine delayed the inhibition of platelet plug formation under high shear rates (P2Y-Innovance; n 21; p < 0.004) and abolished the 3-fold prolongation in collagen adenosine diphosphateinduced closure times seen in extensive and rapid metabolizers (n 16; p 0.001). Conclusions Morphine delays clopidogrel absorption, decreases plasma levels of clopidogrel active metabolite, and retards and diminishes its effects, which can lead to treatment failure in susceptible individuals. (Drug Drug Interactions of Aspirin and P2Y12-inhibitors; NCT01369186) (C) 2014 by the American College of Cardiology Foundation