Friday, February 25, 2011

Use of proton pump inhibitors with thienopyridines

---especially clopidogrel (Plavix).

I first blogged about the clopidogrel-PPI interaction here and updated the topic here. At that time there was considerable controversy although it was believed that some PPIs interacted less than others and that pantoprazole was probably safe. Recently an ACCF/ACG/AHA consensus statement has been published along with an evidence synthesis and recommendations. If you're expecting a definitive answer you won't find it there. Unfortunately the evidence doesn't come through in the way we'd like.

In outcome based studies you'd think pantoprazole would have proven safer. Not necessarily so. You'd expect prasugrel (Effient) to perform better than clopidogrel. Not necessarily so. The degree of clinical risk from the interactions among all these drugs is far from clear. The authors make eleven summary recommendations based on precautionary principles which include a reminder that among all the PPIs omeprazole is associated with the strongest interaction but again the clinical significance is not clear.

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