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Kim JH, Hong SJ, Cha JJ, Lim S, Joo HJ, Park JH, Yu CW, Ahn TH, Jeong YH, Kim BK, Chang K, Park Y, Song YB, Ahn SG, Suh JW, Lee SY, Cho JR, Her AY, Kim HS, Kim MH, Shin ES, Lim DS. Impact of proton pump inhibitor use on clinical outcomes in East Asian patients receiving clopidogrel following drug-eluting stent implantation. BMC Med 2024; 22:335. [PMID: 39148087 PMCID: PMC11328459 DOI: 10.1186/s12916-024-03549-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/29/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Concomitant use of clopidogrel and proton pump inhibitor (PPI) is common, but PPI may reduce the antiplatelet effects of clopidogrel in patients undergoing percutaneous coronary intervention (PCI). We evaluated the impact of PPI use on clinical outcomes in post-PCI patients, by incorporating P2Y12 reaction unit (PRU) and CYP2C19 genotyping results. METHODS From a multicenter registry of patients who underwent PCI with drug-eluting stent implantation and received clopidogrel-based dual antiplatelet therapy (DAPT), patients who were prescribed a PPI at the time of PCI (PPI users) were compared to those who were not (non-users). The primary outcome included all-cause death, myocardial infarction, stent thrombosis, or cerebrovascular accident at 12 months. Major bleeding (Bleeding Academic Research Consortium [BARC] types 3-5) and gastrointestinal (GI) bleeding (BARC types 3-5) were important secondary outcomes. The adjusted outcomes were compared using a 1:1 propensity-score (PS) matching and competing risk analysis. RESULTS Of 13,160 patients, 2,235 (17.0%) were prescribed PPI, with an average age of 65.4 years. PPI users had higher on-treatment PRU levels than non-users. After PS matching, the primary outcome occurred in 51 patients who were PPI users (cumulative incidence, 4.7%) and 41 patients who were non-users (cumulative incidence, 3.7%; log-rank p = 0.27). In carriers of both CYP2C19 loss-of-function alleles, PPI use was linked to an increased risk of the primary outcome (hazard ratio, 3.22; 95% confidence interval, 1.18-8.78). The incidence of major bleeding and GI bleeding (BARC types 3-5) was comparable between PPI users and non-users in the PS-matched cohort. CONCLUSIONS In post-PCI patients receiving clopidogrel-based DAPT, PPI use was not linked to an increased risk of adverse cardiac and cerebrovascular events, but there was a small but significant increase in on-treatment PRU. Future research using a more individualized approach would further elucidate these interactions and guide evidence-based clinical practices.
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Affiliation(s)
- Ju Hyeon Kim
- Department of Cardiology, Korea University Anam Hospital, Korea University College of Medicine, Cardiovascular Center 73, Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, Republic of Korea
| | - Soon Jun Hong
- Department of Cardiology, Korea University Anam Hospital, Korea University College of Medicine, Cardiovascular Center 73, Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, Republic of Korea.
| | - Jung-Joon Cha
- Department of Cardiology, Korea University Anam Hospital, Korea University College of Medicine, Cardiovascular Center 73, Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, Republic of Korea
| | - Subin Lim
- Department of Cardiology, Korea University Anam Hospital, Korea University College of Medicine, Cardiovascular Center 73, Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, Republic of Korea
| | - Hyung Joon Joo
- Department of Cardiology, Korea University Anam Hospital, Korea University College of Medicine, Cardiovascular Center 73, Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, Republic of Korea
| | - Jae Hyoung Park
- Department of Cardiology, Korea University Anam Hospital, Korea University College of Medicine, Cardiovascular Center 73, Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, Republic of Korea
| | - Cheol Woong Yu
- Department of Cardiology, Korea University Anam Hospital, Korea University College of Medicine, Cardiovascular Center 73, Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, Republic of Korea
| | - Tae Hoon Ahn
- Department of Cardiology, Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong-Si, Republic of Korea
| | - Young-Hoon Jeong
- Department of Cardiology, Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong-Si, Republic of Korea
| | | | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Yongwhi Park
- Department of Internal Medicine, School of Medicine and Cardiovascular Center, Gyeongsang National University, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Gyun Ahn
- Department of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Jung-Won Suh
- Department of Internal Medicine, Department of Cardiology, Seoul National University College of Medicineand Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sang Yeub Lee
- Department of Cardiology, Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong-Si, Republic of Korea
| | - Jung Rae Cho
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Moo Hyun Kim
- Department of Cardiology, Dong-A University Hospital, Busan, Republic of Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Do-Sun Lim
- Department of Cardiology, Korea University Anam Hospital, Korea University College of Medicine, Cardiovascular Center 73, Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, Republic of Korea
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Xie J, Chen Q, He D. Pre-existing Proton Pump Inhibitor Treatment and Short-Term Prognosis of Acute Myocardial Infarction Patients. Front Cardiovasc Med 2022; 9:919716. [PMID: 35859584 PMCID: PMC9289161 DOI: 10.3389/fcvm.2022.919716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionEvidence suspects proton pump inhibitor (PPI) use is a risk factor of poor prognosis of acute myocardial infarction (AMI). We aimed to investigate the association between pre-existing PPI use before emergency department (ED) visit and short-term prognosis of AMI patients.Materials and MethodsAMI patients admitted to ED were included and categorized as cohorts with or without pre-existing PPI use. Hospital mortality, length of hospital stay, being admitted to intensive care unit (ICU), and length of (total) ICU stay were studied as prognostic outcomes. Multivariable logistic regression or linear regression were used to estimate the associations between pre-existing PPI use and the outcomes after adjusting for potential confounders.ResultsA total of 2001 AMI patients were included. No significant difference was found in hospital mortality and length of ICU stay between cohorts; patients with pre-existing PPI use showed a significantly longer length of hospital stay (median 3.81 vs. 3.20 days, P = 0.002) but lower proportion of being admitted to ICU (25.59% vs. 40.83%, P < 0.001) compared to those without pre-existing PPI use. Pre-existing PPI use was not associated with hospital mortality [odds ratio (OR) 1.08, 95% confidence interval (CI) 0.58–1.99], length of hospital stay (β = 0.23, 95% CI −0.35 to 0.82), and length of ICU stay (β = −0.18, 95% CI −1.06 to 0.69), but was statistically significantly associated with lower risk of being admitted to ICU (OR 0.69, 95% CI 0.52–0.92).ConclusionThe current study does not support newly diagnosed AMI patients with pre-existing PPI use before ED visit would experience worse short-term prognosis than those without.
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Affiliation(s)
- Juntao Xie
- Intensive Care Unit, The First People’s Hospital of Chenzhou, Chenzhou, China
- Intensive Care Unit, The Chenzhou Affiliated Hospital, Hengyang Medical School, University of South China, Chenzhou, China
| | - Qingui Chen
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dejian He
- Department of Emergency, The First People’s Hospital of Chenzhou, Chenzhou, China
- Department of Emergency, The Chenzhou Affiliated Hospital, Hengyang Medical School, University of South China, Chenzhou, China
- *Correspondence: Dejian He,
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Guo H, Ye Z, Huang R. Clinical Outcomes of Concomitant Use of Proton Pump Inhibitors and Dual Antiplatelet Therapy: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:694698. [PMID: 34408652 PMCID: PMC8366318 DOI: 10.3389/fphar.2021.694698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/23/2021] [Indexed: 11/27/2022] Open
Abstract
Background: The safety and efficacy associated with the use of proton pump inhibitors (PPIs) by patients with coronary artery disease receiving dual antiplatelet therapy (DAPT) remain unclear. Methods: The evaluated outcomes included combined major adverse cardiovascular events (MACEs), myocardial infarction (MI), all-cause mortality, and gastrointestinal (GI) bleeding. A random effects meta-analysis, stratified by study design, was performed and heterogeneity was assessed using the I2 statistic. Results: In total, 6 randomized controlled trials (RCTs) (6930 patients) and 16 observational studies (183,546 patients) were included. Analysis of RCTs showed that there were no significant differences in the incidences of MACEs (risk ratio [RR] = 0.89 [95% confidence interval (CI) = 0.75-1.05]), MI (RR = 0.93 [95% CI = 0.76-1.15]), and all-cause mortality (RR = 0.79 [95% CI = 0.50-1.23]) in the PPI groups vs. the non-PPI groups. Pooled data from observational studies revealed an inconsistent association between the use of each PPI subtype and the increased risks of MACEs during clopidogrel treatment. There was no increased risk of MACEs or all-cause mortality associated with the use of PPIs (as a class) and other P2Y12 inhibitors. Both the RCTs and observational studies revealed that the use of PPIs significantly reduced the risks of GI bleeding. Conclusion: The use of PPIs was associated with a reduced risk of GI bleeding in patients treated with DAPT after percutaneous coronary intervention or acute coronary syndrome. There was no clear evidence of an association between the use of PPIs and adverse cardiovascular events. Clinical Trial Registration: identifier [CRD42020190315].
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Affiliation(s)
| | | | - Rongchong Huang
- Cardiac Center/Division of Cardiovascular Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Marker S, Barbateskovic M, Perner A, Wetterslev J, Jakobsen JC, Krag M, Granholm A, Anthon CT, Møller MH. Prophylactic use of acid suppressants in adult acutely ill hospitalised patients: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2020; 64:714-728. [PMID: 32060905 DOI: 10.1111/aas.13568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/31/2020] [Accepted: 02/12/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Acutely ill patients are at risk of stress-related gastrointestinal (GI) bleeding and prophylactic acid suppressants are frequently used. In this systematic review, we assessed the effects of stress ulcer prophylaxis (SUP) with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) versus placebo or no prophylaxis in acutely ill hospitalised patients. METHODS We conducted the review according to the PRISMA statement, the Cochrane Handbook and GRADE, using conventional meta-analysis and trial sequential analysis (TSA). The primary outcomes were all-cause mortality, clinically important GI bleeding and serious adverse events (SAEs). The primary analyses included overall low risk of bias trials. RESULTS We included 65 comparisons from 62 trials (n = 9713); 43 comparisons were from intensive care units. Only three trials (n = 3596) had overall low risk of bias. We did not find an effect on all-cause mortality (RR 1.03, 95% CI 0.94 to 1.14; TSA-adjusted CI 0.90 to 1.18; high certainty). The rate of clinically important GI bleeding was lower with SUP (RR 0.62, 95% CI 0.43 to 0.89; TSA-adjusted CI 0.14 to 2.81; moderate certainty). We did not find a difference in pneumonia rates (moderate certainty). Effects on SAEs, Clostridium difficile enteritis, myocardial ischaemia and health-related quality of life (HRQoL) were inconclusive due to sparse data. Analyses of all trials regardless of risk of bias were consistent with the primary analyses. CONCLUSIONS We did not observe a difference in all-cause mortality or pneumonia with SUP. The incidence of clinically important GI bleeding was reduced with SUP, whereas any effects on SAEs, myocardial ischaemia, Clostridium difficile enteritis and HRQoL were inconclusive. STUDY REGISTRATION PROSPERO registration number CRD42017055676; published study protocol: Marker, et al 2017 in Systematic Reviews.
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Affiliation(s)
- Søren Marker
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Marija Barbateskovic
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Janus C. Jakobsen
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Department of Cardiology Holbaek Hospital Holbaek Denmark
- Department of Regional Health Research The Faculty of Heath Sciences University of Southern Denmark Odense Denmark
| | - Mette Krag
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Anders Granholm
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Carl T. Anthon
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Morten H. Møller
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
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Drug-Drug Interactions in Acute Coronary Syndrome Patients: Systematic Review. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2019-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Drug-drug interaction (DDI) is defined as a clinically significant change in the exposure and/or response to a drug caused by co-administration of another drug which may result in a precipitation of an adverse event or alteration of its therapeutic effects. The aim of this systematic review was to provide an overview of DDIs that were actually observed or evaluated in acute coronary syndrome (ACS) patients with particular focus on DDIs with clinical relevance. Electronic searches of the literature were conducted in the following databases: MEDLINE, EBSCO, Scopus, Google Scholar and SCIndeks. A total of 117 articles were included in the review. This review showed that ACS patients can be exposed to a variety of DDIs with diverse outcomes which include decreased efficacy of antiplatelet drugs, thrombolytics or anticoagulants, increased risk of bleeding, rhabdomyolysis, hepatotoxicity, adverse effects on cardiovascular system (e.g. QT interval prolongation, arrhythmias, excessive bradycardia, severe hypotension), serotonin syndrome and drug-induced fever. Majority of the DDIs involved antiplatelet drugs (e.g. aspirin, clopidogrel and ticagrelor). Evidence of some of the reported DDIs is inconclusive as some of the studies have shown conflicting results. There is a need for additional post-marketing and population-based studies to evaluate the true effects of disease states and other factors on the clinical outcomes of DDIs. Clinicians should be attentive to the potential for DDIs and their associated harm in order to minimize or, if possible, avoid medication-related adverse events in ACS patients.
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Proton-pump Inhibitor Use and Myocardial Infarction: A Nested Case-Control Study in the UK Clinical Practice Research Datalink. Epidemiology 2019; 31:423-431. [PMID: 31809341 DOI: 10.1097/ede.0000000000001152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Use of proton-pump inhibitors (PPIs) is suggested to be associated with adverse cardiovascular (CV) events via. endothelial dysfunction. Studies show that PPIs are associated with increased risk of myocardial infarction (MI) among patients with preexisting CV disease. However, little is known about their risk among people without known CV disease. METHODS We conducted a nested case-control study in the UK Clinical Practice Research Datalink (CPRD) GOLD to evaluate the association between PPI use and risk of MI in patients without known CV disease. From among PPIs users age 25 to 65 between 1988 and 2017, we identified 32,793 MI cases and 127,291 controls matched 4:1 on age, sex, general practice setting, and calendar time. Using logistic regression, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) for MI comparing PPI users to nonusers, adjusting for body mass index, smoking, alcohol abuse, drug abuse, type 2 diabetes, hyperlipidemia, hypertension, and peripheral artery disease. We repeated this analysis in users of histamine 2 receptor antagonists (H2RA), a drug with a similar indication, to assess protopathic bias. RESULTS The risk of MI was elevated in new users of PPIs with one to five prescriptions (adjusted OR = 2.8; 95% CI = 2.6, 3.0), but not in any other exposure category. The results among H2RA users were similar across all exposure categories, suggesting that protopathic bias likely explains the results. CONCLUSIONS Our study results were not consistent with the hypothesis that PPI use increases MI risk among people without known heart disease.
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Khan SU, Lone AN, Asad ZUA, Rahman H, Khan MS, Saleem MA, Arshad A, Nawaz N, Sattur S, Kaluski E. Meta-Analysis of Efficacy and Safety of Proton Pump Inhibitors with Dual Antiplatelet Therapy for Coronary Artery Disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:1125-1133. [PMID: 30773427 PMCID: PMC7489463 DOI: 10.1016/j.carrev.2019.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/16/2019] [Accepted: 02/05/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is inconsistency in the literature regarding the clinical effects of proton pump inhibitors (PPI) when added to dual antiplatelet therapy (DAPT) in subjects with coronary artery disease (CAD). We performed meta-analysis stratified by study design to explore these differences. METHODS AND RESULTS 39 studies [4 randomized controlled trials (RCTs) and 35 observational studies) were selected using MEDLINE, EMBASE and CENTRAL (Inception-January 2018). In 221,204 patients (PPI = 77,731 patients, no PPI =143,473 patients), RCTs restricted analysis showed that PPI did not increase the risk of all-cause mortality (Risk Ratio (RR): 1.35, 95% Confidence Interval (CI), 0.56-3.23, P = 0.50, I2 = 0), cardiovascular mortality (RR: 0.94, 95% CI, 0.25-3.54, P = 0.92, I2 = 56), myocardial infarction (MI) (RR: 0.97, 95% CI, 0.62-1.51, P = 0.88, I2 = 0) or stroke (RR: 1.11, 95% CI, 0.25-5.04, P = 0.89, I2 = 26). However, PPI significantly reduced the risk of gastrointestinal (GI) bleeding (RR: 0.32, 95% CI, 0.20-0.52, P < 0.001, I2 = 0). Conversely, analysis of observational studies showed that PPI significantly increased the risk of all-cause mortality (RR: 1.25, 95% CI, 1.11-1.41, P < 0.001, I2 = 82), cardiovascular mortality (RR: 1.25, 95% CI, 1.03-1.52, P = 0.02, I2 = 71), MI (RR: 1.30, 95% CI, 1.16-1.47, P < 0.001, I2 = 82) and stroke (RR: 1.60, 95% CI, 1.43-1.78, P < 0.001, I2 = 0), without reducing GI bleeding (RR: 0.74, 95% CI, 0.45-1.22, P = 0.24, I2 = 79). CONCLUSION Meta-analysis of RCTs endorsed the use of PPI with DAPT for reducing GI bleeding without worsening cardiovascular outcomes. These findings oppose the negative observational data regarding effects of PPI with DAPT.
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Affiliation(s)
- Safi U Khan
- West Virginia University, Morgantown, WV, USA.
| | | | | | - Hammad Rahman
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA
| | | | | | - Adeel Arshad
- Unity Hospital/Rochester Regional Health System, Rochester, NY, USA
| | | | - Sudhakar Sattur
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA
| | - Edo Kaluski
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA
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Farhat N, Fortin Y, Haddad N, Birkett N, Mattison DR, Momoli F, Wu Wen S, Krewski D. Systematic review and meta-analysis of adverse cardiovascular events associated with proton pump inhibitors used alone or in combination with antiplatelet agents. Crit Rev Toxicol 2019; 49:215-261. [DOI: 10.1080/10408444.2019.1583167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Nawal Farhat
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Yannick Fortin
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Nisrine Haddad
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Nicholas Birkett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Donald R. Mattison
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Risk Sciences International, Ottawa, Canada
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Shi Wu Wen
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Daniel Krewski
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Risk Sciences International, Ottawa, Canada
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Reduction in postpercutaneous coronary intervention angina in addition to gastrointestinal events in patients on combined proton pump inhibitors and dual antiplatelet therapy: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2018; 30:847-853. [PMID: 29596078 DOI: 10.1097/meg.0000000000001125] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary percutaneous coronary intervention (PCI) is a standard treatment in patients with acute coronary syndrome. Studies have shown that proton pump inhibitors (PPIs) can potentially attenuate the antiplatelet effects of P2Y12 inhibitors with associated adverse cardiovascular outcomes. MATERIALS AND METHODS Medline was searched using Pubmed from inception to 8 November 2017 for randomized control trials studying the effect of PPIs on coronary artery disease with concomitant use of dual antiplatelet therapy (DAPT). Overall, 692 studies were identified of which five randomized control trials were included. Statistical analysis was done using RevMan, version 5.3. RESULTS Five studies with 6239 patients (3113 on PPI with DAPT and 3126 with only DAPT) were included. Our analysis showed that PPI significantly reduced the incidence of gastrointestinal (GI) bleed [22 vs. 66, odds ratio (OR)=0.37, confidence interval (CI)=0.23-0.61, P≤0.0001, I=0%], GI ulcers and GI erosions (7 vs. 18, OR=0.39, CI=0.16-0.94, P=0.04, I=0%), and the incidence of post-PCI unstable angina in patients treated with PPI and P2Y12 agents (46 vs. 67, OR=0.67, CI=0.45-0.99, P=0.05, I=0%). There was an insignificant difference in myocardial infarction, stroke, and cardiovascular cause of mortality. A trend toward decreased all-cause mortality with PPIs was noted. Heterogeneity was calculated using I. CONCLUSION Concomitantly administered PPIs with P2Y12 inhibitors have a protective effect on the GI events. It also decreases the post-PCI angina without increased adverse cardiovascular outcomes.
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Kinoshita Y, Ishimura N, Ishihara S. Advantages and Disadvantages of Long-term Proton Pump Inhibitor Use. J Neurogastroenterol Motil 2018; 24:182-196. [PMID: 29605975 PMCID: PMC5885718 DOI: 10.5056/jnm18001] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 01/28/2018] [Accepted: 02/09/2018] [Indexed: 12/13/2022] Open
Abstract
Proton pump inhibitors (PPIs) potently inhibit gastric acid secretion and are widely used for treatment of acid-related diseases including gastroesophageal reflux disease and secondary prevention of aspirin/NSAID-induced ulcers. Although clinically important adverse effects of PPIs can occur, just as with other drugs, those are not frequently observed during or after administration. Thus, PPIs are regarded as relatively safe and considered to be clinically beneficial. Recently, PPIs have become frequently administered to patients with functional gastrointestinal diseases or primary prevention of drug-related gastroduodenal damage, even though their beneficial effects for those conditions have not been fully confirmed. PPIs tend to be given for conditions in which the necessity of the drug has not been clarified, thus otherwise rare adverse effects are presented as clinically relevant. Although several PPI-related adverse effects have been reported, their clinical relevance is not yet clear, since the evidence reported in those studies is not at a high enough level, as the majority are based on retrospective observational studies and the reported hazard ratios are low. It is important to administer PPIs only for patients who will gain a substantial clinical benefit and to continue to investigate their adverse effects with high quality prospective studies.
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Affiliation(s)
- Yoshikazu Kinoshita
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Shimane,
Japan
| | - Norihisa Ishimura
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Shimane,
Japan
| | - Shunji Ishihara
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Shimane,
Japan
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11
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Abstract
Proton-pump inhibitors (PPIs) are the most effective therapy for the full spectrum of gastric-acid-related diseases. However, in the past decade, a steadily increasing list of complications following long-term use of PPIs has been reported. Their potent acid-suppressive action induces several structural and functional changes within the gastric mucosa, including fundic gland polyps, enterochromaffin-like cell hyperplasia and hypergastrinaemia, which can be exaggerated in the presence of Helicobacter pylori infection. As discussed in this Review, most associations of PPIs with severe adverse events are not based on sufficient evidence because of confounding factors and a lack of plausible mechanisms. Thus, a causal relationship remains unproven in most associations, and further studies are needed. Awareness of PPI-associated risks should not lead to anxiety in patients but rather should induce the physician to consider the appropriate dosing and duration of PPI therapy, including long-term monitoring strategies in selected groups of patients because of their individual comorbidities and risk factors.
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Zou D, Goh KL. East Asian perspective on the interaction between proton pump inhibitors and clopidogrel. J Gastroenterol Hepatol 2017; 32:1152-1159. [PMID: 28024166 DOI: 10.1111/jgh.13712] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/06/2016] [Accepted: 12/22/2016] [Indexed: 01/30/2023]
Abstract
Both proton pump inhibitors (PPIs) and clopidogrel are widely prescribed in the Asia-Pacific population. PPIs are the mainstay therapeutic agents for prophylaxis against aspirin gastropathy and for acid-related disorders including gastroesophageal reflux disease. They are also co-prescribed with oral anticoagulant agents and with dual-antiplatelet therapy for the treatment and prevention of gastrointestinal bleeding. Clopidogrel belongs to the drug class of thienopyridines and is currently the most widely prescribed oral anticoagulant agent either alone or in combination with aspirin. Platelet inhibition by clopidogrel is prone to significant inter-individual variability and is believed to be affected by several factors such as genetics and drug-drug interactions. Since it was first reported in 2009, the potential for drug-drug interactions between PPIs and clopidogrel has remained headline news, and its significance in clinical practice is the subject of an ongoing debate. For East Asian patients in particular, the clinical relevance of the interaction between PPIs and clopidogrel remains unclear because of conflicting data, as well as underrepresentation of East Asian subjects in landmark trials. Increased CYP2C19 genetic polymorphisms in individuals from Asia-Pacific countries only fuel the confusion. Recent studies in East Asian cohorts suggests that the potential of PPIs to attenuate the efficacy of clopidogrel could be minimized by the use of newer PPIs with weaker affinity for the CYP2C19 isoenzyme, namely, pantoprazole, dexlansoprazole, and rabeprazole. This review aims to help clinicians choose the most appropriate PPI for co-prescription with clopidogrel in patients from Asia-Pacific countries.
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Affiliation(s)
- Duowu Zou
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Khean-Lee Goh
- Department of Gastroenterology and Hepatology, University of Malaya, Kuala Lumpur, Malaysia
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Impact of proton pump inhibitors on clinical outcomes in patients treated with a 6- or 24-month dual-antiplatelet therapy duration: Insights from the PROlonging Dual-antiplatelet treatment after Grading stent-induced Intimal hyperplasia studY trial. Am Heart J 2016; 174:95-102. [PMID: 26995375 DOI: 10.1016/j.ahj.2016.01.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 01/20/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are frequently prescribed in combination with clopidogrel, but conflicting data exist as to whether PPIs diminish the efficacy of clopidogrel. We assessed the association between PPI use and clinical outcomes for patients treated with percutaneous coronary intervention (PCI) and dual-antiplatelet therapy (DAPT) with clopidogrel plus aspirin. METHODS AND RESULTS In the PRODIGY trial, 1,970 patients were randomized to 6- or 24-month DAPT at 30 days from index procedure. Among them, 738 patients (37.5%) received PPI (mainly lansoprazole; 90.1%) at the time of randomization. Proton pump inhibitor users were older, were most likely to be woman, had a lower creatinine clearance, presented more frequently with acute coronary syndrome, and had a higher CRUSADE bleeding score. After adjustment, the primary efficacy end point (composite of all-cause death, myocardial infarction, and cerebrovascular accident) was similar between no PPI and PPI users (9.2% vs 11.5%, adjusted hazard ratio [HR] 1.051, 95% CI 0.788-1.400, P = .736). Bleeding rates did not differ between the 2 groups (Bleeding Academic Research Consortium type 2, 3, or 5: adjusted HR 0.996, 95% CI 0.672-1.474, P = .980). Net clinical adverse events were also similar in no PPI and PPI patients (12.9% vs 14.9%, adjusted HR 0.99, 95% CI 0.772-1.268, P = .93). Results remained consistent at sensitivity analysis when focusing on the 548 patients who remained on PPI for the whole study duration. CONCLUSIONS The current findings suggest that the concomitant use of PPIs, when clinically indicated, in patients receiving clopidogrel is not associated with adverse clinical outcome.
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Proton Pump Inhibitors in Cardiovascular Disease: Drug Interactions with Antiplatelet Drugs. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:325-350. [PMID: 27628008 DOI: 10.1007/5584_2016_124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aspirin and P2Y12 receptor antagonists are widely used across the spectrum of cardiovascular diseases. Upper gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed.PPIs provide gastroprotection by changing the intragastric milieu, essentially by raising intragastric pH. In recent years, it has been heavily discussed whether PPIs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Pharmacodynamic and pharmacokinetic studies suggested an interaction between PPIs and clopidogrel, and subsequent clinical studies were conducted to evaluate the clinical impact of this interaction. More recently, it was reported that PPIs may also attenuate the antiplatelet effect of aspirin. This may be clinically important, because a fixed combination of aspirin and a PPI (esomeprazole) has recently been approved and because aspirin is the most widely used drug in patients with cardiovascular disease. The antiplatelet effect of the new P2Y12 receptor antagonists, ticagrelor and prasugrel, seems less influenced by PPI co-treatment.Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition potentially carries considerable clinical impact. The present book chapter summarizes the evidence regarding the widespread use of platelet inhibitors and PPIs in combination. Moreover, it outlines current evidence supporting or opposing drug interactions between these drugs and discusses clinical implications.
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Affiliation(s)
| | - Yu-Xiao Yang
- University of Pennsylvania, Philadelphia, Pennsylvania
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Melloni C, Washam JB, Jones WS, Halim SA, Hasselblad V, Mayer SB, Heidenfelder BL, Dolor RJ. Conflicting results between randomized trials and observational studies on the impact of proton pump inhibitors on cardiovascular events when coadministered with dual antiplatelet therapy: systematic review. Circ Cardiovasc Qual Outcomes 2015; 8:47-55. [PMID: 25587094 DOI: 10.1161/circoutcomes.114.001177] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Discordant results have been reported on the effects of concomitant use of proton pump inhibitors (PPIs) and dual antiplatelet therapy (DAPT) for cardiovascular outcomes. We conducted a systematic review comparing the effectiveness and safety of concomitant use of PPIs and DAPT in the postdischarge treatment of unstable angina/non-ST-segment-elevation myocardial infarction patients. METHODS AND RESULTS We searched for clinical studies in MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews, from 1995 to 2012. Reviewers screened and extracted data, assessed applicability and quality, and graded the strength of evidence. We performed meta-analyses of direct comparisons when outcomes and follow-up periods were comparable. Thirty-five studies were eligible. Five (4 randomized controlled trials and 1 observational) assessed the effect of omeprazole when added to DAPT; the other 30 (observational) assessed the effect of PPIs as a class when compared with no PPIs. Random-effects meta-analyses of the studies assessing PPIs as a class consistently reported higher event rates in patients receiving PPIs for various clinical outcomes at 1 year (composite ischemic end points, all-cause mortality, nonfatal MI, stroke, revascularization, and stent thrombosis). However, the results from randomized controlled trials evaluating omeprazole compared with placebo showed no difference in ischemic outcomes, despite a reduction in upper gastrointestinal bleeding with omeprazole. CONCLUSIONS Large, well-conducted observational studies of PPIs and randomized controlled trials of omeprazole seem to provide conflicting results for the effect of PPIs on cardiovascular outcomes when coadministered with DAPT. Prospective trials that directly compare pharmacodynamic parameters and clinical events among specific PPI agents in patients with unstable angina/non-ST-segment-elevation myocardial infarction treated with DAPT are warranted.
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Affiliation(s)
- Chiara Melloni
- From the Duke Clinical Research Institute, Duke University Medical Center (C.M., W.S.J., S.A.H., V.H., B.L.H., R.J.D.); Duke Heart Center (J.B.W.), Duke University Medical Center, Durham, NC; and Division of Endocrinology and Metabolism, Department of Medicine, Virginia Commonwealth University, Richmond (S.B.M.).
| | - Jeffrey B Washam
- From the Duke Clinical Research Institute, Duke University Medical Center (C.M., W.S.J., S.A.H., V.H., B.L.H., R.J.D.); Duke Heart Center (J.B.W.), Duke University Medical Center, Durham, NC; and Division of Endocrinology and Metabolism, Department of Medicine, Virginia Commonwealth University, Richmond (S.B.M.)
| | - W Schuyler Jones
- From the Duke Clinical Research Institute, Duke University Medical Center (C.M., W.S.J., S.A.H., V.H., B.L.H., R.J.D.); Duke Heart Center (J.B.W.), Duke University Medical Center, Durham, NC; and Division of Endocrinology and Metabolism, Department of Medicine, Virginia Commonwealth University, Richmond (S.B.M.)
| | - Sharif A Halim
- From the Duke Clinical Research Institute, Duke University Medical Center (C.M., W.S.J., S.A.H., V.H., B.L.H., R.J.D.); Duke Heart Center (J.B.W.), Duke University Medical Center, Durham, NC; and Division of Endocrinology and Metabolism, Department of Medicine, Virginia Commonwealth University, Richmond (S.B.M.)
| | - Victor Hasselblad
- From the Duke Clinical Research Institute, Duke University Medical Center (C.M., W.S.J., S.A.H., V.H., B.L.H., R.J.D.); Duke Heart Center (J.B.W.), Duke University Medical Center, Durham, NC; and Division of Endocrinology and Metabolism, Department of Medicine, Virginia Commonwealth University, Richmond (S.B.M.)
| | - Stephanie B Mayer
- From the Duke Clinical Research Institute, Duke University Medical Center (C.M., W.S.J., S.A.H., V.H., B.L.H., R.J.D.); Duke Heart Center (J.B.W.), Duke University Medical Center, Durham, NC; and Division of Endocrinology and Metabolism, Department of Medicine, Virginia Commonwealth University, Richmond (S.B.M.)
| | - Brooke L Heidenfelder
- From the Duke Clinical Research Institute, Duke University Medical Center (C.M., W.S.J., S.A.H., V.H., B.L.H., R.J.D.); Duke Heart Center (J.B.W.), Duke University Medical Center, Durham, NC; and Division of Endocrinology and Metabolism, Department of Medicine, Virginia Commonwealth University, Richmond (S.B.M.)
| | - Rowena J Dolor
- From the Duke Clinical Research Institute, Duke University Medical Center (C.M., W.S.J., S.A.H., V.H., B.L.H., R.J.D.); Duke Heart Center (J.B.W.), Duke University Medical Center, Durham, NC; and Division of Endocrinology and Metabolism, Department of Medicine, Virginia Commonwealth University, Richmond (S.B.M.)
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