Studies reassure on PPI interactions

Contrary to recent findings, a study presented at the European Society of Cardiology congress concludes that PPIs do not need to be avoided in patients taking the thienopyridine antiplatelet agents clopidogrel or prasugrel. Regardless of the type of PPI used, the study authors found no association between PPI use and the risk of either the primary endpoint of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke or myocardial infarction. “Although only a randomised trial of PPI use can definitively establish the clinical implications… our findings do not support the need to avoid concomitant use of PPIs for gastric protection in patients receiving thienopyridine therapy who are at increased risk for gastrointestinal bleeding,” the study authors said. However, in a Lancet Comment Dr Dirk Sibbing (Deutsches Herzzentrum, Munich, Germany), who has conducted some of the platelet-function studies of PPIs and clopidogrel, questioned whether the interaction of PPIs with thienopyridines was fact or fiction. “[It] is a fact in terms of pharmacodynamics. For clinical outcomes, this interaction seems to be a fiction for most patients with a risk profile similar to that of patients enrolled in the trial,” he said. “However, caution is needed when prescribing PPIs for selected high-risk patients with an intrinsically reduced response to thienopyridines”. PPIs that are less likely to interfere with platelet response could be given to high-risk patients if “absolutely needed”, Sibbing concluded. Lancet 2009; published online before print...