Published 20 May 2009, doi:10.1136/bmj.b1931
Cite this as: BMJ 2009;338:b1931

Letters

Clopidogrel

More on proton pump inhibitors

The first 100% of the full text of this article appears below.

Although proton pump inhibitors reduce the rates of gastrointestinal bleeding in patients with acute coronary syndromes receiving dual antiplatelet treatment,¹ recent evidence points to sinister and potentially far more injurious side effects.^{2 3}

Co-prescription of proton pump inhibitors known to inhibit hepatic cytochrome P450 2C19 (omeprazole, lansoprazole, and rabeprazole) with clopidogrel resulted in a 40% relative increase in the risk of recurrent myocardial infarction.² The risks of rehospitalisation, revascularisation procedures, and death were higher in patients with acute coronary syndromes receiving a proton pump inhibitor and clopidogrel.³ However, pantoprazole and esomeprazole have shown no negative effects on the cardioprotective action of clopidogrel,^{2 4} probably because of their differing metabolic pathways.⁵

Not all proton pump inhibitors are born equal, and further studies are urgently required to establish the safest combination.

Cite this as: BMJ 2009;338:b1931

¹ St George’s Hospital, London SW17

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Competing interests: None declared.

1. Chua D, Ignaszewski A. Clopidogrel in acute coronary syndromes. BMJ 2009;338:b1180. (14 April.)[Free Full Text]
2. Juurlink DN, Gomes T, Ko DT, et al. A population-based study of the drug interaction between proton pump inhibitors and clopidogrel. CMAJ 2009;180:713-8.[Abstract/Free Full Text]
3. Ho PM, Maddox TM, Wang L, et al. Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome. JAMA 2009;301:937-44.[Abstract/Free Full Text]
4. Sibbing D, Morath T, Stegherr J, et al. Impact of proton pump inhibitors on the antiplatelet effects of clopidogrel. Thromb Haemost 2009;101:714-9.[Web of Science][Medline]
5. Siller-Matula JM, Spiel AO, Lang IM, Kreiner G, Christ G, Jilma B. Effects of pantoprazole and esomeprazole on platelet inhibition by clopidogrel. Am Heart J 2009;157:148.e1-5.[Web of Science][Medline]

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Authors’ reply

Doson Chua and Andrew Ignaszewski
BMJ 2009 338: b2006. [Extract] [Full Text]

Clopidogrel in acute coronary syndromes

Doson Chua and Andrew Ignaszewski
BMJ 2009 338: b1180. [Extract] [Full Text]

This article has been cited by other articles:

• Chua, D., Ignaszewski, A. (2009). Authors' reply. BMJ 338: b2006-b2006 [Full text]  

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