Even in high-risk patients with a recent history of a gastrointestinal bleed, “there needs to be an individualized physician and patient decision, weighing the risks and benefits” of taking clopidogrel and a PPI concurrently, Dr. Ho said.
“No one disputes the benefit of a PPI in a patient who has had a bleeding ulcer,” Dr. Bhatt noted.
Of the four studies in the past 4 months that examined the interaction between clopidogrel and PPIs, three found a dangerous interaction. The first suggestion of a clinical consequence from concurrent clopidogrel and PPI treatment came in the report at the AHA's scientific sessions last November. Results from a second study reported at the meeting by researchers from the University of Kentucky failed to find evidence of an interaction between clopidogrel and PPIs.
A second report suggesting a dangerous interaction was published online (CMAJ 2009 Jan. 28 [doi:10.1503/cmaj.082001]). The CMAJ report also showed that the increased risk was specific for PPIs that inhibit the p450 2C19 enzyme. Treatment with pantoprazole showed no link with an increased risk for MI rehospitalization.
“If you need to use a PPI, then pantoprazole seems to be a very reasonable strategy,” based on both the pharmacology evidence and the “limited but real” clinical evidence in the CMAJ study, Dr. Peterson said.
Dr. Ho and most of his coauthors reported having no financial disclosures. Dr. Peterson reported receiving honoraria and research support from Bristol-Myers Squibb and Sanofi Aventis, the companies that market clopidogrel.