Clopidogrel and PPI

Juliet Brown GP ST2

Learning objectives

To review the indications for antiplatelet therapy Identify the interactions of antiplatelet therapies with other drugs, particularly clopidogrel and proton pump inhibitors Review the management of antiplatelet induced dyspepsia

Clinical Context

Antiplatelet therapy indicated in.

Primary prevention ? Secondary prevention:

Angina, STEMI, Non-STEMI, PCI AF Stroke, TIA Peripheral Arterial disease

Which antiplatelet and when?

Low dose aspirin Clopidogrel Dipyridamole MR + Aspirin Clopidogrel + Aspirin

Problems with antiplatelets

GI Bleeding

Higher risk in:

High dose aspirin Older age History of GI bleed or ulcer Serious co-morbidity H-pylori Concomitant use of medications that increase risk (aspirin+clopidogrel)

Medicines that increase risk

Antiplatelets Anticoagulants NSAIDS Nicorandil Corticosteroids Antidepressants - SSRIs

Reducing risk

After food Manage comorbidities Alcohol and smoking Review other medication H2 receptor antagonist PPI

Why the fuss?

8205 patients taking clopidogrel 5244 also prescribed PPI either at discharge and/or during follow up PPI+Clopi

1561 cases of death or rehospitalisation for ACS = 29.8%

Clopidogrel

615 cases of death or rehospitalisation for ACS = 20.8%

NNH = 11 in PPI+clopidogrel group

The theory is.

Clopidogrel is a pro-drug Metabolised to active form by CYP450 enzymes including CYP2C19 PPIs inhibit CYP2C19. so clopidogrel doesnt work as well

MHRA Advice

The need for PPI in patients on clopidogrel should be reviewed at their next appointment Prescribe PPIs strictly in line with licensed indications Check that patients who are taking clopidogrel are not buying OTC PPI

Management of antiplatelet induced dyspepsia

General measures PPI and aspirin Ranitidine and clopidogrel Refer