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Clopidogrel and PPI

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.

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Clopidogrel and PPI

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  1. Clopidogrel and PPI Juliet Brown GP ST2

  2. 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

  3. Clinical Context • Antiplatelet therapy indicated in…. • Primary prevention…… ? • Secondary prevention: • Angina, STEMI, Non-STEMI, PCI • AF • Stroke, TIA • Peripheral Arterial disease

  4. Which antiplatelet and when? • Low dose aspirin • Clopidogrel • Dipyridamole MR + Aspirin • Clopidogrel + Aspirin

  5. 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)……

  6. Medicines that increase risk • Antiplatelets • Anticoagulants • NSAIDS • Nicorandil • Corticosteroids • Antidepressants - SSRIs

  7. Reducing risk • After food • Manage comorbidities • Alcohol and smoking • Review other medication • H2 receptor antagonist • PPI

  8. 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

  9. The theory is…. • Clopidogrel is a pro-drug • Metabolised to active form by CYP450 enzymes including CYP2C19 • PPIs inhibit CYP2C19…. so clopidogrel doesn’t work as well

  10. 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

  11. Management of antiplatelet induced dyspepsia • General measures • PPI and aspirin • Ranitidine and clopidogrel • Refer

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