COMMENTARY

Game Changers in Gastroenterology: 2011

David A. Johnson, MD

Disclosures

November 23, 2011

In This Article

Game Changers for Clinical Gastroenterology Practice

The papers selected for this review contain important observations that are "game changers," defined as scientific observations that are likely to have substantial impact on clinical gastroenterology practice.

Effect of Concomitant Use of Clopidogrel and Proton Pump Inhibitors After Percutaneous Coronary Intervention

Banerjee S, Weideman RA, Weideman MW, et al.
Am J Cardiol. 2011;107:871-878.

Concerns about the combined use of clopidogrel and proton pump inhibitors (PPIs) began when physiologic studies suggested that PPIs impaired the intended antiplatelet activity of clopidogrel. Banerjee and colleagues analyzed the effect of post-discharge drug exposure on the outcomes of 23,200 patients who received uncomplicated cardiac stent placement. Using data from the Veterans Affairs Pharmacy Benefits Management database, the researchers noted gaps in clopidogrel and PPI usage and performed a daily reconciliation of medication exposures for each patient. Omeprazole was the most commonly prescribed PPI (88%); esomeprazole, lansoprazole, rabeprazole, and pantoprazole accounted for the remainder of PPI prescriptions.

Continuous exposure to clopidogrel with concomitant use of PPIs in patients after percutaneous coronary intervention was not associated with increased risk for major adverse cardiovascular events, the primary endpoint of the study. Of note, the hazard ratios of adverse cardiovascular outcomes overall replicated the concerns of increased risks associated with concomitant exposure to clopidogrel and a PPI. However, after the investigators used propensity-matched evaluations to correct for covariate cardiovascular risks, they found no significant association between major cardiovascular events and use of clopidogrel with continuous, switched, or discontinued PPIs.

Why Is This a Game Changer?

This study is the first to bring sanity to the mayhem caused by previously reported retrospective analyses that implicated simultaneous use of PPIs and clopiogrel in cardiovascular harm. The appropriate correction for potential confounding variables in this study provides welcome relief. This study also clearly identified patients receiving PPIs as having significantly more comorbid conditions, suggesting the potential for channeling bias in previous evaluations. This study also illustrates the importance of careful analysis of drug-prescription patterns before conclusive recommendations are made.

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