Prescribing Proton Pump Inhibitor and Clopidogrel Together

Current State of Recommendations

Neena S. Abraham

Disclosures

Curr Opin Gastroenterol. 2011;27(6):558-564. 

In This Article

Current State of Recommendations

To reduce the risk of gastrointestinal bleeding among patients who are prescribed mono-antiplatelet or dual-antiplatelet therapy, clinicians should embrace risk stratification and modification principles. These include always prescribing the lowest dose of ASA possible (i.e., 75 or 81 mg daily), as ASA is an independent risk factor for gastrointestinal bleeding, and carefully assessing individual risk for antiplatelet-associated gastrointestinal bleeding. A history of ulcer disease or gastrointestinal bleeding is the greatest risk factor to predict recurrent gastrointestinal bleeding with an antiplatelet strategy. However, as the risk of gastrointestinal bleeding increases as risk factors accumulate, any patient who has more than one risk factor, such as advanced age; H. pylori infection; or concomitant use of steroids, anticoagulants, nonsteroidal anti-inflammatory drugs, ASA or SSRIs, should also be considered a high-risk individual; and gastroprotection with a PPI is still the best strategy to minimize gastrointestinal bleeding in high-risk individuals. A 66% reduction in gastrointestinal bleeding has been demonstrated in an RCT,[39••] supporting the benefit of PPI gastroprotection over alternatives such as histamine blockers.[17,67,68] If a concern exists that the patient may be a poor metabolizer of clopidogrel, future studies may support the prescription of an omeprazole alternative such as pantoprazole (which is least dependent on CYP metabolism) or rabeprazole, which is non-CYP metabolized. However, the current state of science does not strongly support altering the choice of PPI among cardiovascular patients on antiplatelet therapy who require PPI gastroprotection. Finally, the role of pharmacogenomics and point-of-care testing is being aggressively studied. Results from these studies will likely challenge the current paradigm for gastroprotection of cardiovascular patients who require dual-antiplatelet therapy.

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