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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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Demcsák A, Lantos T, Bálint ER, Hartmann P, Vincze Á, Bajor J, Czopf L, Alizadeh H, Gyöngyi Z, Márta K, Mikó A, Szakács Z, Pécsi D, Hegyi P, Szabó IL. PPIs Are Not Responsible for Elevating Cardiovascular Risk in Patients on Clopidogrel-A Systematic Review and Meta-Analysis. Front Physiol 2018; 9:1550. [PMID: 30510515 PMCID: PMC6252380 DOI: 10.3389/fphys.2018.01550] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/16/2018] [Indexed: 12/29/2022] Open
Abstract
Background: Clopidogrel and proton pump inhibitors (PPIs) are metabolized by cytochrome P450 enzymes. Contradictory results have been reported on possible complications of simultaneous PPI and clopidogrel use. Our aim was to investigate the clinical relevance of this debate with a systematic review and meta-analysis. Methods: The PubMed, Embase, and Cochrane Central Register of Controlled Trials electronic databases were searched for human studies [randomized controlled trials (RCTs) and observational studies] using the PICO format (P: patients on clopidogrel; I: patients treated with PPI; C: patients without PPI treatment; O: cardiovascular risk). We screened eligible studies from 2009 to 2016. After study exclusions, we extracted data from 27 articles for three outcomes: major adverse cardiac event (MACE), myocardial infarction (MI) and cardiovascular (CV) death. The meta-analysis was registered on PROSPERO (CRD42017054316). Results: Data were extracted on 156,823 patients from the 27 trials included (MACE: 23, CV death: 10, MI: 14). The risks of MACE (RR = 1.22, 95% CI = 1.06-1.396, p = 0.004) and MI (RR = 1.43, 95% CI = 1.24-1.66, p < 0.001) were significantly higher in the PPI plus clopidogrel group. However, subgroup analysis demonstrated that this significance disappeared in RCTs (RR = 0.99, 95% CI = 0.76-1.28, p = 0.93) in the MACE outcome group. There was no effect of combined PPI and clopidogrel therapy on CV death outcome (RR = 1.21, 95% CI = 0.97-1.50, p = 0.09). Conclusion: Concomitant use of PPIs and clopidogrel has been proved not to be associated with elevated cardiovascular risks according to RCTs. Based on our results, no restrictions should be applied whenever PPIs and clopidogrel are administered simultaneously.
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Affiliation(s)
- Alexandra Demcsák
- Department of Pediatrics and Pediatric Health Centre, University of Szeged, Szeged, Hungary
| | - Tamás Lantos
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Emese Réka Bálint
- First Department of Internal Medicine, University of Szeged, Szeged, Hungary
| | - Petra Hartmann
- Institute of Surgical Research, University of Szeged, Szeged, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Judit Bajor
- Division of Gastroenterology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary
| | - László Czopf
- Division of Cardiology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Hussain Alizadeh
- Division of Hematology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Zoltán Gyöngyi
- Department of Public Health Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Alexandra Mikó
- Division of Gastroenterology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Dániel Pécsi
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Division of Gastroenterology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
- Momentum Translational Gastroenterology Research Group, Hungarian Academy of Sciences, University of Szeged, Szeged, Hungary
| | - Imre László Szabó
- Division of Gastroenterology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary
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Tett SE, Sketris I, Cooke C, van Zanten SV, Barozzi N. Differences in utilisation of gastroprotective drugs between 2001 and 2005 in Australia and Nova Scotia, Canada. Pharmacoepidemiol Drug Saf 2013; 22:735-43. [PMID: 23559528 DOI: 10.1002/pds.3442] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 01/06/2013] [Accepted: 03/06/2013] [Indexed: 12/23/2022]
Abstract
PURPOSE This study aimed to compare use of histamine H2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs), 2001-2005, in the elderly and social security beneficiaries in Australia (AUS) and Nova Scotia, Canada (NS). METHODS Prescription dispensing data were collected for all subsidised H2RAs and PPIs. In AUS, dispensing data for concession beneficiaries were obtained from the Pharmaceutical Benefits Scheme database. In NS, data were sourced from the Pharmacare database. Relevant population data were used to convert to World Health Organisation Anatomic Therapeutic Chemical defined daily doses (2005) per 1000 beneficiaries per day (DDD/1000/day). RESULTS Overall use of gastroprotective agents was similar and rising in NS and AUS (100-160 DDD/1000/day) over this 5-year time window. However, the proportion of this use accounted for by PPIs was far higher in AUS (over 85% by 2005) than in NS (23% rising to 35% over the 5 years). In AUS, PPI use rose from 50 to about 140 DDD/1000/day over the 5 years, whereas PPI use in NS rose slowly to less than 60 DDD/1000/day by 2005. H2RA use in NS was always high (over 100 DDD/1000/day), whereas in AUS, H2RA use fell from 54 to around 24 DDD/1000/day over this period. CONCLUSIONS AUS had much higher use of PPIs than NS over 2001-2005. The proportion of PPIs in all gastroprotective agents rose in AUS to be nearly 90%. The differences in utilisation during this time window could lead to differences in health outcomes from either lower gastro-intestinal bleeding risk or higher long-term adverse effects of PPIs.
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Affiliation(s)
- Susan E Tett
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
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Han J, Do ER, Kim TS, Zhang C, Park DH. Clinical Application and Evaluation of Preoperative Bleeding Tendency using Platelet Function Analyzer (PFA®)-100. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2013. [DOI: 10.14730/aaps.2013.19.1.56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jihu Han
- Department of Plastic and Reconstructive Surgery, Dalian University Affiliated Xinhua Hospital, Dalian, China
| | - Eon Rok Do
- Department of Plastic and Reconstructive Surgery, Collage of Medicine, Daegu Catholic University, Daegu, Korea
| | - Tae Seob Kim
- Department of Plastic and Reconstructive Surgery, Collage of Medicine, Daegu Catholic University, Daegu, Korea
| | - Chen Zhang
- Department of Plastic and Reconstructive Surgery, Dalian University Affiliated Xinhua Hospital, Dalian, China
| | - Dae Hwan Park
- Department of Plastic and Reconstructive Surgery, Collage of Medicine, Daegu Catholic University, Daegu, Korea
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Wijeyeratne YD, Joshi R, Heptinstall S. Ticagrelor: a P2Y12 antagonist for use in acute coronary syndromes. Expert Rev Clin Pharmacol 2012; 5:257-69. [PMID: 22697589 DOI: 10.1586/ecp.12.17] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Agents that inhibit platelet function are used routinely in the treatment and prevention of acute coronary syndromes. The main antiplatelet treatments used combine aspirin with one of the thienopyridine P2Y(12) antagonists, either clopidogrel or prasugrel. By blocking the synthesis of thromboxane A(2) in platelets and by blocking the effects of ADP, respectively, these agents reduce platelet activity, platelet aggregation and thrombus formation. Ticagrelor (marketed by AstraZeneca as Brilinta™ in the USA, and as Brilique(®) or Possia(®) in Europe) is a cyclopentyl-triazolo-pyrimidine, a new chemical class of P2Y(12) antagonist that is now approved for use in the wide spectrum of acute coronary syndromes. In this article we provide an overview of ticagrelor. We discuss the differences in mode of action compared with other P2Y(12) antagonists, examine its pharmacodynamic, pharmacokinetic and safety profile, and summarize the various clinical trials that have provided information on its efficacy in combination with aspirin. Ticagrelor appears to overcome some of the difficulties that have been encountered with other antiplatelet treatments, clopidogrel in particular.
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Schiff M, Peura D. HZT-501 (DUEXIS(®); ibuprofen 800 mg/famotidine 26.6 mg) gastrointestinal protection in the treatment of the signs and symptoms of rheumatoid arthritis and osteoarthritis. Expert Rev Gastroenterol Hepatol 2012; 6:25-35. [PMID: 22149579 DOI: 10.1586/egh.11.88] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Arthritis affects nearly 50 million people in the USA and, with the aging of the population, the prevalence is expected to rise. While NSAIDs are very effective in relieving pain associated with osteoarthritis (OA) and rheumatoid arthritis (RA), they are associated with side effects, including gastrointestinal (GI) toxicity, which may manifest as dyspepsia, ulcers and/or bleeding. A number of approaches have been employed in an effort to either completely avoid or reduce the risk of GI toxicities associated with NSAID use. Two new products combining an NSAID with a gastroprotective agent have recently been approved and other agents are in the pipeline. Patient adherence to prescribed gastroprotective therapy is known to be poor, often resulting in an increased risk of GI events in patients taking NSAIDs. These newer combination products may fulfill an important need for many patients who need to receive NSAIDs for the pain of OA and RA, but who are also at risk of upper GI events. This article reviews preclinical and clinical results for a new fixed-dose combination of ibuprofen and famotidine, DUEXIS(®) (HZT-501), which has recently been approved in the USA for the relief of signs and symptoms of RA and OA and to decrease the risk of developing upper GI ulcers.
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Affiliation(s)
- Michael Schiff
- Division of Rheumatology, University of Colorado School of Medicine, Denver, CO, USA.
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Schmidt M, Johansen MB, Robertson DJ, Maeng M, Kaltoft A, Jensen LO, Tilsted HH, Bøtker HE, Sørensen HT, Baron JA. Concomitant use of clopidogrel and proton pump inhibitors is not associated with major adverse cardiovascular events following coronary stent implantation. Aliment Pharmacol Ther 2012; 35:165-74. [PMID: 22050009 DOI: 10.1111/j.1365-2036.2011.04890.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cytochrome P450 inhibition by proton pump inhibitors (PPIs) may attenuate the effectiveness of clopidogrel. AIM To examine whether PPI use modifies the association between clopidogrel use and major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI) with stent implantation, using time-varying drug exposure ascertainment. METHODS We conducted this population-based cohort study in Western Denmark (population 3 million) using medical databases. We identified all 13,001 patients with coronary stent implantation between 2002 and 2005 and ascertained their reported comorbidities. During the recommended 12-month postintervention treatment period, we tracked use of clopidogrel and PPI and the rate of MACE. We used Cox regression to compute hazard ratios (HRs), controlling for potential confounders. RESULTS During follow-up, one or more prescriptions were redeemed by 91% of patients for clopidogrel and by 21% of patients for PPIs. Of the patients, 15% experienced a MACE. The adjusted HR for MACE comparing clopidogrel use with non-use was 0.57 [95% confidence interval (CI): 0.44-0.74] among PPI users and 0.47 (95% CI: 0.42-0.53) among PPI non-users, yielding an interaction effect (i.e. relative rate increase) of 1.20 (95% CI: 0.91-1.58). PPI users treated from before PCI had a 25% increased rate of MACE compared to PPI non-users, independent of clopidogrel use [adjusted HR = 1.24 (95% CI: 0.97-1.58) for clopidogrel users and 1.26 (95% CI: 0.97-1.63) for clopidogrel non-users]. CONCLUSIONS The use of PPIs as a class did not modify the protective effect of clopidogrel, but its use was associated with major adverse cardiovascular events itself, particularly among patients having used PPIs before percutaneous coronary intervention.
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Affiliation(s)
- M Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
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