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Jourdi G, Hulot JS, Gaussem P. An update on oral antiplatelet drug interactions with proton pump inhibitors: what are the risks? Expert Opin Drug Metab Toxicol 2024:1-16. [PMID: 38980768 DOI: 10.1080/17425255.2024.2378888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/08/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Aspirin and anti-P2Y12 are widely prescribed in cardiovascular patients, often in combination with proton pump inhibitors (PPIs) to limit the risk of upper gastrointestinal bleedings. The potential interaction between PPIs and antiplatelet agents has been widely discussed, but doubts remain as to whether PPIs may reduce the cardiovascular protection provided by aspirin, prasugrel, ticagrelor, and clopidogrel. AREAS COVERED Many pharmacokinetic (PK) and pharmacodynamic (PD) studies have confirmed the interaction, especially between PPIs and clopidogrel, but with uncertain consequences on clinical outcomes. Therefore, we aimed to summarize the evidence for the widespread combined use of oral antiplatelet drugs and PPIs, to outline the current evidence supporting or opposing drug-drug interaction, and to discuss the clinical implications of such interactions. EXPERT OPINION A large body of evidence describes the PK/PD interaction of antiplatelet drugs with PPIs and its potential role in increasing clinical cardiovascular adverse events, but no solid clinical data have confirmed these effects. In the light of the published studies, there seems to be no restriction on the choice of PPI with aspirin, prasugrel, and/or ticagrelor. The choice of a PPI with no (or minimal) interference with the hepatic cytochrome P450 2C19 is preferred in patients receiving clopidogrel.
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Affiliation(s)
- Georges Jourdi
- Faculté de Pharmacie de Paris, Université Paris Cité, Inserm, Innovative Therapies in Haemostasis, UMR_S1140, Paris, France
- Laboratory of haematology, Lariboisière University hospital, Paris, France
| | - Jean-Sébastien Hulot
- Université Paris Cité, Inserm, Paris Cardiovascular Research center, UMR_S970, Paris, France
- Clinical investigation center (CIC1418), Hôpital Européen Georges Pompidou, Paris, France
| | - Pascale Gaussem
- Laboratory of haematology, Hôpital Européen Georges Pompidou, Paris, France
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2
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Deng CJ, Yan J, Zheng YY, Wu TT, Pan Y, Hou XG, Wang SF, Sirajidin S, Aimaitijiang M, Xie X. Effectiveness of lipid-lowering therapy on mortality and major adverse cardiovascular event outcomes in patients undergoing percutaneous coronary intervention: a network meta-analysis of randomised controlled trials. BMJ Open 2023; 13:e070827. [PMID: 37967998 PMCID: PMC10660972 DOI: 10.1136/bmjopen-2022-070827] [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: 12/07/2022] [Accepted: 10/16/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Emergency percutaneous coronary intervention (PCI) can quickly restore myocardial perfusion after acute coronary syndrome. Whether and which lipid-lowering regimens are effective in reducing major adverse cardiovascular events (MACEs) and mortality risk after PCI remain unclear. OBJECTIVE This study assessed the benefits of different lipid-lowering regimens on the risk of MACEs and mortality in the post-PCI population by network meta-analysis. METHODS Public databases, including PubMed, Embase and the Cochrane Library, were searched from inception to August 2022. Randomised controlled trials (RCTs) on lipid-lowering regimens in post-PCI populations were included and analysed. The outcomes were the incidence of all-cause mortality and MACEs, whether reported as dichotomous variables or as HRs. RESULTS Thirty-nine RCTs were included. For MACEs, alirocumab plus rosuvastatin (OR: 0.18; 95% CI: 0.07 to 0.44), evolocumab plus ezetimibe and statins (OR: 0.19; 95% CI: 0.06 to 0.59), eicosapentaenoic acid (EPA) plus pitavastatin (HR: 0.67; 95% CI: 0.49 to 0.96) and icosapent ethyl plus statins (HR: 0.73; 95% CI: 0.62 to 0.86) had significant advantages and relatively high rankings. For mortality, rosuvastatin (OR: 0.30; 95% CI: 0.11 to 0.84), ezetimibe plus statins (OR: 0.55; 95% CI: 0.43 to 0.89) and icosapent ethyl plus statins (OR: 0.66; 95% CI: 0.45 to 0.96) had significant advantages compared with the control. CONCLUSION EPA, especially icosapent ethyl, plus statins had a beneficial effect on reducing the risk of MACEs and mortality in post-PCI patients. Proprotein convertase subtilisin/kexin type-9 inhibitors plus statins were able to reduce the risk of MACEs, but the risk of mortality remained unclear. PROSPERO REGISTRATION NUMBER CRD42018099600.
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Affiliation(s)
- Chang-Jiang Deng
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Ju Yan
- cardiovascular medicine department, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Ying-Ying Zheng
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Ting-Ting Wu
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Ying Pan
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Xian-Geng Hou
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Si-Fan Wang
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Subinur Sirajidin
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Mikereyi Aimaitijiang
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
| | - Xiang Xie
- Department of Cardiology, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, China
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Suarez Ferreira SP, Hall RP, Majumdar M, Goudot G, Jessula S, Bellomo T, Lee I, Kukreja N, Parmar G, Boada AE, Dua A. Atorvastatin Effect on Clopidogrel Efficacy in Patients with Peripheral Artery Disease. Ann Vasc Surg 2023; 95:74-79. [PMID: 37257642 PMCID: PMC10524645 DOI: 10.1016/j.avsg.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/19/2023] [Accepted: 05/19/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Both clopidogrel and atorvastatin metabolism are rooted in hepatic cytochrome p450 activation. There are published reports of atorvastatin interfering with clopidogrel metabolism by inhibiting the activation of clopidogrel. This in turn would decrease the therapeutic effect of clopidogrel potentially resulting in an increase in thrombotic events in patients who are taking both medications. The emergence of viscoelastic assays, such as Thromboelastography with platelet mapping (TEG-PM), has been utilized to identify prothrombotic states and may provide insight into a patient's microvascular coagulation profile. The aim of this prospective, observational study was to delineate the differences in platelet function between patients on clopidogrel alone versus those on clopidogrel and atorvastatin in patients that are undergoing peripheral revascularization. METHODS All patients undergoing revascularization between December 2020 and August 2022 were prospectively evaluated. Patients on clopidogrel and atorvastatin were compared to those on clopidogrel alone. Serial perioperative TEG-PM analysis was performed up to 6 months postoperatively and the platelet function in terms of percent inhibition was evaluated in both groups. Statistical analysis was performed using unpaired t-test to identify differences in platelet function. RESULTS Over the study period, a total of 182 patients were enrolled. Of this cohort 72 patients met study criteria. 87 samples from the 72 patients were analyzed. 31 (43.05%) patients were on clopidogrel alone and 41 (56.94%) were on clopidogrel and atorvastatin. Patients on clopidogrel alone showed significantly greater platelet inhibition compared to those on clopidogrel and atorvastatin [49.01% vs. 34.54%, P = 0.03]. There was no statistical difference in platelet inhibition between groups in terms of aspirin use alone versus aspirin and atorvastatin. CONCLUSIONS Patients on clopidogrel and atorvastatin showed significantly less platelet inhibition compared to those on clopidogrel alone, supporting the concept that atorvastatin may interfere with the therapeutic effect of clopidogrel. Patients taking atorvastatin may require an alternative antiplatelet therapy regimen that does not include clopidogrel to achieve adequate thromboprophylaxis.
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Affiliation(s)
| | - Ryan P Hall
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Monica Majumdar
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Guillaume Goudot
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Samuel Jessula
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Tiffany Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Ivy Lee
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Gaurav Parmar
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Ana E Boada
- Universidad de Oriente, Anzoategui, Venezuela
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
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Naeem A, Alwadie AF, Alshehri AM, Alharbi LM, Nawaz MU, AlHadidi RA, Alshammari RS, Alsufyani MA, Babsail LO, Alshamrani SA, Alkatheeri AA, Alshehri NF, Alzahrani AM, Alzahrani YA. The Overriding of Computerized Physician Order Entry (CPOE) Drug Safety Alerts Fired by the Clinical Decision Support (CDS) Tool: Evaluation of Appropriate Responses and Alert Fatigue Solutions. Cureus 2022; 14:e31542. [DOI: 10.7759/cureus.31542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 11/16/2022] Open
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Shang YS, Zhong PY, Ma Y, Bai N, Niu Y, Wang ZL. Efficacy and Safety of Proton Pump Inhibitors in Patients With Coronary Artery Diseases Receiving Oral Antiplatelet Agents and/or Anticoagulants: A Systematic Review and Meta-Analysis. J Cardiovasc Pharmacol 2022; 80:1-12. [PMID: 35512058 PMCID: PMC9249074 DOI: 10.1097/fjc.0000000000001284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Abstract
ABSTRACT The purpose of this meta-analysis was to evaluate the efficacy and safety of proton pump inhibitors (PPIs) plus antithrombotic strategy in patients with coronary artery diseases compared with antithrombotic strategy alone. We searched PubMed, EMBASE, Cochrane Library, and Chinese Biomedical Medical Literature databases to retrieve randomized controlled trials investigating PPIs combined with antithrombotic strategy in coronary artery diseases. The primary efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE). The primary safety outcome was gastrointestinal events. Secondary outcomes included all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, significant bleeding from gastroduodenal lesions, and gastroduodenal ulcer. Overall, 43,943 patients were enrolled from 19 trials. The incidence of MACCE [relative risk (RR) 1.05; 95% confidence interval (CI) 0.96-1.15], all-cause death (RR 0.84; 95% CI 0.69-1.01), cardiovascular death (RR 0.88; 95% CI 0.69-1.12), myocardial infarction (RR 0.98; 95% CI 0.88-1.09), stent thrombosis (RR 1.01; 95% CI 0.76-1.34), and gastroduodenal ulcer (RR 0.40; 95% CI 0.13-1.29) did not increase significantly in patients receiving PPIs compared with patients without those. There were significant differences in the risk of gastrointestinal events (RR 0.34; 95% CI 0.21-0.54) and significant bleeding from gastroduodenal lesions (RR 0.09; 95% CI 0.03-0.28) between the 2 groups. In patients with coronary artery diseases, PPIs plus antithrombotic strategy could reduce the risk of gastrointestinal events and significant bleeding from gastroduodenal lesions but may not affect the incidence of MACCE, all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, and gastroduodenal ulcer (PROSPERO: CRD42021277899, date of registration October 10, 2021).
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Affiliation(s)
- Yao-Sheng Shang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; and
| | - Peng-Yu Zhong
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; and
| | - Ying Ma
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; and
| | - Nan Bai
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; and
| | - Ying Niu
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; and
| | - Zhi-Lu Wang
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, China
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Lee D, Kim JS, Kim BJ, Shin SY, Kim DB, Ahn HS. Influence of individual proton pump inhibitors on clinical outcomes in patients receiving clopidogrel following percutaneous coronary intervention. Medicine (Baltimore) 2021; 100:e27411. [PMID: 34967346 PMCID: PMC8718184 DOI: 10.1097/md.0000000000027411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 09/17/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Data are conflicting on whether proton pump inhibitors (PPIs) diminish the efficacy of clopidogrel. We investigated individual PPIs and adverse cardiovascular events in postpercutaneous coronary intervention (PCI) patients on dual antiplatelet therapy with clopidogrel. METHODS We searched Ovid-MEDLINE, EMBASE, and Cochrane from inception to March 2020 to identify studies that evaluated the efficacy and safety of clopidogrel added PPIs versus clopidogrel only in post-PCI patient. We extracted data from 28 studies for major adverse cardiovascular endpoints (MACE), myocardial infarction (MI), cardiovascular death, and gastrointestinal bleeding. Risk ratios (RR) and hazard ratios (HR) were pooled separately. RESULTS Data were extracted on 131,412 patients from the 28 studies included. Concomitant use of PPI with clopidogrel was associated with increased risk of MACE (RR 1.30; 95% confidence interval [CI] 1.15-1.48; P < .001) and MI (RR 1.43; 95% CI 1.25-1.64; P < .001). Random-effects meta-analyses with individual PPIs demonstrated an increased risk of MACE in those taking pantoprazole (RR 1.31; 95% CI 1.07-1.61, P = .01) or lansoprazole (RR 1.35; 95% CI 1.19-1.54, P < .0001) compared with patients not on PPIs. Likewise, in adjusted analyses, the pooled HR of adjusted events for MACEs showed that the increased risk of MACEs was similar for 4 classes of PPIs but not for rabeprazole (HR: 1.32; 95% CI 0.69-2.53, P = .40). CONCLUSION The post-PCI patients on dual antiplatelet therapy with clopidogrel in the PPI group were associated with higher risk of MACE and MI. Although the results for rabeprazole were not robust, it was the only PPI that did not yield a significantly increased risk of MACE.
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Affiliation(s)
- Dongyoung Lee
- Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea
| | - Je Sang Kim
- Cardiovascular Center, Dongguk University College of Medicine and Ilsan Hospital, Goyang, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Seung Yong Shin
- Cardiovascular and Arrhythmia Center, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Dong Bin Kim
- Department of Internal Medicine, Bucheon St. Mary's Hospital, Catholic University College of Medicine, Seoul, Korea
| | - Hyung Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
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Systematic Review and Meta-analysis: The Effects of Prophylactic Proton Pump Inhibitor Treatment in Patients With Coronary Heart Disease Receiving Dual Antiplatelet Therapy. J Cardiovasc Pharmacol 2021; 77:835-861. [PMID: 34057160 DOI: 10.1097/fjc.0000000000001014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 02/28/2021] [Indexed: 12/24/2022]
Abstract
Dual antiplatelet therapy (DAPT) and proton pump inhibitors (PPIs) are widely used in clinical treatment. However, the pharmacokinetic interaction between PPIs and DAPT is still unclear in patients with cardiovascular disease. This systematic review and meta-analysis aimed to evaluate the risks and benefits of the combination of PPI and DAPT in patients with coronary heart disease. The PubMed, EMBASE, Cochrane, and Web of Science databases were systematically searched from inception to April 1, 2020, for eligible studies. The outcomes investigated in this study included major adverse cardiovascular events, myocardial infarction, all-cause death, gastrointestinal complications, and platelet function testing. Studies were excluded from the review if other gastrointestinal medication or aspirin or P2Y12 receptor inhibitor monotherapy was administered. The review included 52 studies, and data from 40 studies were extracted for meta-analysis. No association was found between the risk of adverse clinical outcomes and the combination of PPI and DAPT based on the randomized controlled trial data (risk ratio: 0.98; 95% confidence interval: 0.87-1.09; P = 0.877; I2 = 0%). However, an increased risk of adverse clinical outcomes due to the use of PPIs was observed in patients treated with DAPT based on the data from observational studies (risk ratio: 1.259; 95% confidence interval: 1.079-1.468; P = 0.003; I2 = 67.8%), although the heterogeneity of these studies was high. In conclusion, this systematic review and meta-analysis demonstrated that pharmacokinetic interactions between PPI and DAPT do not lead to adverse clinical outcomes.
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Deodhar M, Al Rihani SB, Arwood MJ, Darakjian L, Dow P, Turgeon J, Michaud V. Mechanisms of CYP450 Inhibition: Understanding Drug-Drug Interactions Due to Mechanism-Based Inhibition in Clinical Practice. Pharmaceutics 2020; 12:pharmaceutics12090846. [PMID: 32899642 PMCID: PMC7557591 DOI: 10.3390/pharmaceutics12090846] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 12/11/2022] Open
Abstract
In an ageing society, polypharmacy has become a major public health and economic issue. Overuse of medications, especially in patients with chronic diseases, carries major health risks. One common consequence of polypharmacy is the increased emergence of adverse drug events, mainly from drug–drug interactions. The majority of currently available drugs are metabolized by CYP450 enzymes. Interactions due to shared CYP450-mediated metabolic pathways for two or more drugs are frequent, especially through reversible or irreversible CYP450 inhibition. The magnitude of these interactions depends on several factors, including varying affinity and concentration of substrates, time delay between the administration of the drugs, and mechanisms of CYP450 inhibition. Various types of CYP450 inhibition (competitive, non-competitive, mechanism-based) have been observed clinically, and interactions of these types require a distinct clinical management strategy. This review focuses on mechanism-based inhibition, which occurs when a substrate forms a reactive intermediate, creating a stable enzyme–intermediate complex that irreversibly reduces enzyme activity. This type of inhibition can cause interactions with drugs such as omeprazole, paroxetine, macrolide antibiotics, or mirabegron. A good understanding of mechanism-based inhibition and proper clinical management is needed by clinicians when such drugs are prescribed. It is important to recognize mechanism-based inhibition since it cannot be prevented by separating the time of administration of the interacting drugs. Here, we provide a comprehensive overview of the different types of mechanism-based inhibition, along with illustrative examples of how mechanism-based inhibition might affect prescribing and clinical behaviors.
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Affiliation(s)
- Malavika Deodhar
- Tabula Rasa HealthCare Precision Pharmacotherapy Research and Development Institute, Orlando, FL 32827, USA; (M.D.); (S.B.A.R.); (M.J.A.); (L.D.); (P.D.); (J.T.)
| | - Sweilem B Al Rihani
- Tabula Rasa HealthCare Precision Pharmacotherapy Research and Development Institute, Orlando, FL 32827, USA; (M.D.); (S.B.A.R.); (M.J.A.); (L.D.); (P.D.); (J.T.)
| | - Meghan J. Arwood
- Tabula Rasa HealthCare Precision Pharmacotherapy Research and Development Institute, Orlando, FL 32827, USA; (M.D.); (S.B.A.R.); (M.J.A.); (L.D.); (P.D.); (J.T.)
| | - Lucy Darakjian
- Tabula Rasa HealthCare Precision Pharmacotherapy Research and Development Institute, Orlando, FL 32827, USA; (M.D.); (S.B.A.R.); (M.J.A.); (L.D.); (P.D.); (J.T.)
| | - Pamela Dow
- Tabula Rasa HealthCare Precision Pharmacotherapy Research and Development Institute, Orlando, FL 32827, USA; (M.D.); (S.B.A.R.); (M.J.A.); (L.D.); (P.D.); (J.T.)
| | - Jacques Turgeon
- Tabula Rasa HealthCare Precision Pharmacotherapy Research and Development Institute, Orlando, FL 32827, USA; (M.D.); (S.B.A.R.); (M.J.A.); (L.D.); (P.D.); (J.T.)
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3C 3J7, Canada
| | - Veronique Michaud
- Tabula Rasa HealthCare Precision Pharmacotherapy Research and Development Institute, Orlando, FL 32827, USA; (M.D.); (S.B.A.R.); (M.J.A.); (L.D.); (P.D.); (J.T.)
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3C 3J7, Canada
- Correspondence: ; Tel.: +1-856-938-8697
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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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11
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Ostroumova OD, Kochetkov AI, Pereverzev AP, Kravchenko EV, Kazjulin AN, Andreev DN, Pavleeva EE. [The relationship between the combined use of various proton pump inhibitors with antiplatelet drugs and the risk of cardiovascular complications]. TERAPEVT ARKH 2019; 91:118-126. [PMID: 32598763 DOI: 10.26442/00403660.2019.08.000355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
In the article the problem of the combined use of clopidogrel and various proton pump inhibitors (PPIs) in terms of cardiovascular complications risk and stent thrombosis is considered. The results of meta - analyses and a systematic reviews affecting this issue are represented in detail. The inter - drug interactions mechanisms of various PPIs with clopidogrel based on the characteristics of the metabolism in the liver cytochromes system are discussed. The authors conducted a search, systematization and analysis of studies regarding the association between cardiovascular risk and combined use of individual medications from PPI class with clopidogrel, and these results are presented in the review. Currently available data do not allow to answer the question about the differences between individual PPIs in their impact on the risk of adverse cardiovascular events due to the small number of such studies, design heterogeneity, differences in the inclusion criteria and end points as well as in the rate of administration of individual PPIs.
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Affiliation(s)
- O D Ostroumova
- Pirogov Russian National Research Medical University - Russian Clinical and Research Center of Gerontology.,Sechenov First Moscow State Medical University (Sechenov University)
| | - A I Kochetkov
- Pirogov Russian National Research Medical University - Russian Clinical and Research Center of Gerontology
| | - A P Pereverzev
- Pirogov Russian National Research Medical University - Russian Clinical and Research Center of Gerontology
| | - E V Kravchenko
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - A N Kazjulin
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - D N Andreev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - E E Pavleeva
- Yevdokimov Moscow State University of Medicine and Dentistry
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12
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An K, Huang R, Tian S, Guo D, Wang J, Lin H, Wang S. Statins significantly reduce mortality in patients receiving clopidogrel without affecting platelet activation and aggregation: a systematic review and meta-analysis. Lipids Health Dis 2019; 18:121. [PMID: 31122249 PMCID: PMC6533696 DOI: 10.1186/s12944-019-1053-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/15/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Combination of statins and clopidogrel is frequently administered in patients with coronary artery disease (CAD). They are mainly activated and eliminated in the liver by cytochrome P450 isoenzyme 3A4 (CYP3A4). The aim was to clarify whether the coadministration of clopidogrel and statins attenuate respective efficacy. METHODS PubMed, Embase, the Cochrane Library, Web of Science and Clinical Trials. gov were searched for until August 2018. Randomized controlled trials (RCTs) and cohort studies were taken into quality evaluation. Data were pooled using random effect models to estimate standard mean difference (SMD) or risk ratio (RR) with 95% confidence interval (CI). RESULTS In total, 28 studies representing 25,267 participants were included. Statins reduce the mortality of patients administered clopidogrel (RR 0.54; 95% CI 0.40,0.74; p = 0.000), no differences were found in platelet aggregation (PA) (SMD 0.02; 95% CI -0.38,0.42; p = 0.920) and the expressions of P-selectin (SMD -0.04; 95% CI -0.14,0.05; p = 0.346), CD40L (SMD 0.09; 95% CI -0.29,0.48; p = 0.633), CD63 (SMD 0.09; 95% CI -0.01,0.19; p = 0.079) and PAC-1 (SMD 0.03; 95% CI -0.08,0.13; p = 0.633). Furthermore, CYP3A4 metabolized or non-CYP3A4 metabolized statins have no discrepancies in PA (SMD 0.13; 95% CI -0.31,0.58; p = 0.556), P-selectin (SMD 0.17; 95% CI -0.16,0.51; p = 0310), death (RR 0.89; 95% CI 0.38,2.07; p = 0.791), except for triglyceride (TG) (SMD -0.19; 95% CI -0.33,-0.06; p = 0.005). CONCLUSIONS This meta-analysis confirmed that statins reduce mortality in patients undergoing clopidogrel treatment without affecting platelet activation and aggregation.
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Affiliation(s)
- Ke An
- Department of Endocrinology, Affiliated Zhongda Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China
- Medical School of Southeast University, Nanjing, 210009, People's Republic of China
| | - Rong Huang
- Department of Endocrinology, Affiliated Zhongda Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China
| | - Sai Tian
- Department of Endocrinology, Affiliated Zhongda Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China
| | - Dan Guo
- Department of Endocrinology, Affiliated Zhongda Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China
| | - Jiaqi Wang
- Department of Endocrinology, Affiliated Zhongda Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China
| | - Hongyan Lin
- Department of Endocrinology, Affiliated Zhongda Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China
| | - Shaohua Wang
- Department of Endocrinology, Affiliated Zhongda Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China.
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13
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Kim MS, Song HJ, Lee J, Yang BR, Choi NK, Park BJ. Effectiveness and Safety of Clopidogrel Co-administered With Statins and Proton Pump Inhibitors: A Korean National Health Insurance Database Study. Clin Pharmacol Ther 2019; 106:182-194. [PMID: 30648733 DOI: 10.1002/cpt.1361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 12/16/2018] [Indexed: 12/16/2022]
Abstract
Simultaneous competition for cytochrome P450 (CYP) 2C19 and CYP3A4 might diminish clopidogrel's antiplatelet effect by impacting its metabolic activation. This pharmacoepidemiologic study investigated whether proton pump inhibitors (PPIs) and CYP3A4-metabolized statins individually and jointly increase thrombotic events by attenuating clopidogrel's effectiveness. From Korean nationwide claims data (2007-2015), we selected 59,233 patients who initiated clopidogrel and statins after coronary stenting and compared thrombotic risks by PPI or CYP3A4-metabolized statin use or both. PPIs were associated with increased thrombotic risks (hazard ratio (HR) 1.27, 95% confidence interval (CI) 1.12-1.45), unlike CYP3A4-metabolized statins (HR 1.03, 95% CI 0.98-1.07). PPIs with high CYP2C19-inhibitory potential were more relevant than those with low potential (HR 1.28, 95% CI 1.02-1.61). Joint effects of PPIs and CYP3A4-metabolized statins were nonsignificant (relative excess risk due to interaction -0.14, 95% CI -0.34 to 0.07). Concurrent PPIs were associated with increased thrombotic risks in patients receiving clopidogrel and statins; CYP3A4-metabolized statins did not exacerbate PPI-associated risks.
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Affiliation(s)
- Mi-Sook Kim
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea.,Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
| | - Hong Ji Song
- Department of Family Medicine, Health Promotion Center, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Joongyub Lee
- Department of Prevention and Management, Inha University Hospital, Incheon, Korea
| | - Bo Ram Yang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
| | - Nam-Kyong Choi
- Department of Health Convergence, College of Science & Industry Convergence, Ewha Womans University, Seoul, Korea
| | - Byung-Joo Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
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14
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Smith TJ, Johnson JL, Habtewold A, Burmeister MA. Cardiovascular Risk Reduction: A Pharmacotherapeutic Update for Antiplatelet Medications. Crit Care Nurs Clin North Am 2018; 31:15-30. [PMID: 30736932 DOI: 10.1016/j.cnc.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This update presents evidence for new antiplatelet therapies including modified P2Y12 inhibitors and a new class of thromboxane antagonists. Discussed are emerging data on established antihyperlipidemic medications that support an additional antiplatelet effect. Current information about the effectiveness of several bleeding reversal agents is discussed, and the concept of personalized antiplatelet therapy, wherein selection of an antiplatelet therapy is based on genetic factors or laboratory testing that predict response to therapy and risk of adverse effects. Finally, future drug targets are introduced and drug interactions that can be leveraged to design more effective and safe antiplatelet therapies are described.
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Affiliation(s)
- Troy J Smith
- Department of Pharmacy Practice and Administration, William Carey University School of Pharmacy, 19640 MS-67, Biloxi, MS 39532, USA.
| | - Jessica L Johnson
- Department of Pharmacy Practice and Administration, William Carey University School of Pharmacy, 19640 MS-67, Biloxi, MS 39532, USA
| | - Abiy Habtewold
- Department of Pharmaceutical Sciences, William Carey University School of Pharmacy, 19640 MS-67, Biloxi, MS 39532, USA
| | - Melissa A Burmeister
- Department of Pharmaceutical Sciences, William Carey University School of Pharmacy, 19640 MS-67, Biloxi, MS 39532, USA
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15
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Divanji P, Shunk K. Modern Antiplatelet Therapy: When Is Clopidogrel the Right Choice? CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2018. [DOI: 10.15212/cvia.2017.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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16
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Hu W, Tong J, Kuang X, Chen W, Liu Z. Influence of proton pump inhibitors on clinical outcomes in coronary heart disease patients receiving aspirin and clopidogrel: A meta-analysis. Medicine (Baltimore) 2018; 97:e9638. [PMID: 29504996 PMCID: PMC5779765 DOI: 10.1097/md.0000000000009638] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are usually prescribed to protect against gastrointestinal bleeding in patients on dual antiplatelet therapy. This meta-analysis reviewed clinical outcomes in patients taking aspirin and clopidogrel, with and without concomitant PPIs to address concerns of adverse reactions. METHODS We searched PubMed, Embase, and the Cochrane Library for articles published between January 1, 2010 and April 11, 2017. The primary end points were major adverse cardiovascular events and gastrointestinal bleeding. Secondary end points were myocardial infarction, stent thrombosis, revascularization, cardiogenic death, and all-cause mortality. RESULTS The meta-analysis included 33,492 patients in 4 randomized controlled trials and 8 controlled observational studies. Overall, patients taking PPIs had statistical differences in major adverse cardiovascular events [odds ratio (OR) 1.17 (95% confidence interval [CI] 1.07-1.28); P = .001; I = 28.3%], gastrointestinal bleeding [OR 0.58 (95% CI 0.36-0.92); P = .022; I = 80.6%], stent thrombosis [OR 1.30 (95% CI 1.01-1.68); P = .041; I = 0%], and revascularization [OR 1.20 (95% CI 1.04-1.38); P = .011; I = 5.1%], compared those not taking PPIs. There were no significant differences in myocardial infarction [OR 1.03 (95% CI 0.87-1.22); P = .742; I = 0%], cardiogenic death [OR 1.09 (95% CI 0.83-1.43); P = .526; I = 0%], or all-cause mortality [OR 1.08 (95% CI 0.93-1.25); P = .329; I = 0%). CONCLUSIONS Among the patients taking aspirin and clopidogrel, the results indicated that the combined use of PPIs increased the rates of major adverse cardiovascular events, stent thrombosis, and revascularization.
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Affiliation(s)
| | - Jin Tong
- Department of Respirology, The Second Affiliated Hospital/The Second Clinical Institute, Chongqing Medical University, Chongqing, China
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17
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Shamliyan TA, Middleton M, Borst C. Patient-centered Outcomes with Concomitant Use of Proton Pump Inhibitors and Other Drugs. Clin Ther 2017; 39:404-427.e36. [PMID: 28189362 DOI: 10.1016/j.clinthera.2017.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE We performed a systematic review of patient-centered outcomes after the concomitant use of proton pump inhibitors (PPIs) and other drugs. METHODS We searched 4 databases in July 2016 to find studies that reported mortality and morbidity after the concomitant use of PPIs and other drugs. We conducted direct meta-analyses using a random-effects model and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation working group approach. FINDINGS We included data from 17 systematic reviews and meta-analyses, 16 randomized controlled trials, and 16 observational studies that examined the concomitant use of PPIs with medications from 10 drug classes. Low-quality evidence suggests that the use of PPIs is associated with greater morbidity when administered with antiplatelet drugs, bisphosphonates, antibiotics, anticoagulants, metformin, mycophenolate mofetil, or nelfinavir. Concomitant PPIs reduce drug-induced gastrointestinal bleeding and are associated with greater docetaxel and cisplatin response rates in patients with metastatic breast cancer. For demonstrated statistically significant relative risks and benefits from concomitant PPIs, the magnitudes of the effects are small, with <100 attributable events per 1000 patients treated, and the effects are inconsistent among specific drugs. Among individual PPIs, the concomitant use of pantoprazole or esomeprazole, but not omeprazole or lansoprazole, is associated with an increased risk for all-cause mortality, nonfatal myocardial infarction, or stroke. Clopidogrel is associated with a greater risk for myocardial infarction compared with prasugrel. Conflicting results between randomized controlled trials and observational studies and high risk for bias in the body of evidence lessened our confidence in the results. IMPLICATIONS Available evidence suggests a greater risk for adverse patient outcomes after the concomitant use of PPIs and medications from 9 drug classes and warns against inappropriate drug combinations.
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Affiliation(s)
- Tatyana A Shamliyan
- Evidence-Based Medicine Center, Quality Assurance, Elsevier, Philadelphia, Pennsylvania.
| | - Maria Middleton
- Evidence-Based Medicine Center, Elsevier, Philadelphia, Pennsylvania
| | - Clarissa Borst
- Clinical Drug Information, Elsevier, Philadelphia, Pennsylvania
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