Short term palindromic rheumatism after clopidogrel use
Authors: P R J Ames
Journal: Annals of the Rheumatic Diseases (2006)

Clopidogrel belongs to a new class of adenosine diphosphate (ADP) receptor antagonists employed for the prevention of ischaemic stroke and myocardial infarction.We describe a case of palindromic rheumatism developing 3 weeks after clopidogrel treatment.A 47 year old woman underwent a stress ECG for sporting purposes that showed a 2.2 mm depression of the S-T segment.A coronary angiogram showed stenosis of the IVA in its middle portion and in the right coronary artery.The patient had never had hyperlipidaemia, diabetes or hypertension, was not menopausal, but had been smoking 10 cigarettes a day for the past 15 years.She underwent angioplasty with insertion of two stents and was given clopidogrel (75 mg/day) and aspirin (75 mg/day).Two weeks later the patient developed an urticarial rash over the skin of the forearms, arms, neck, and trunk.The lesions fully disappeared from one area within 24-36 hours but only to reappear in a different area.Antihistamines suppressed these symptoms within 3 days, but a few days later the patient experienced arthralgia and restricted motion that lasted almost 24 hours, fully disappearing from an affected joint to reappear in another.The right wrist, the left wrist, right shoulder, left shoulder, right knee, left knee were affected in this sequence and were objectively swollen, hot, and tender.At the onset of these symptoms and 2 weeks later the erythrocyte sedimentation rate (ESR) was 50 mm/1st h and 46 mm/1st h, respectively, and C reactive protein (CRP) was 20 and 9.8 mg/l, respectively.On the same occasions, complement levels, rheumatoid factor, antinuclear antibody, immunoglobulins, liver function tests, serology for hepatitis B and C, urate, kidney function tests with urinary sediment were normal or negative.Aspirin was increased to 1 g daily for 14 days with progressive disappearance of the palindromic sequence and with less joint pain and swelling.At 4 weeks from the onset of the articular symptoms the ESR was 18 mm/1st h and CRP was 4.5 mg/l.At 3 months from the onset the joint symptoms had totally subsided.So far, clopidogrel has been associated with three cases of acute arthritis. 2 3.In a 76 year old woman pain and swelling of the metacarpophalangeal joints developed 2 weeks after starting clopidogrel (75 mg/day) for coronary angioplasty.In a 63 year old man the left knee had become painful, hot, and tender 3 weeks after starting clopidogrel (75 mg/day) for coronary artery bypass grafting.In a 60 year old woman pain, swelling, and redness developed in her wrists, hands, and knees in association with myalgia, fever, and a macular rash on the trunk and back 10 days after switching from aspirin to clopidogrel.In these patient, symptoms improved within a week of stopping clopidogrel, aided by prednisolone (20 mg/ day) and celecoxib (200 mg/day) in the third patient.As far as we know, our patient is the first to experience transitory palindromic rheumatism after clopidogrel use, a drug that the patient did not want to discontinue.Given the usefulness of clopidogrel in the prevention of vascular complications of atherosclerosis, and the concern about attributing acute arthritis after clopidogrel intake to the ADP receptor antagonist itself, 4 our case shows that clopidogrel need not be discontinued and that the arthritis may be self limiting.