Expert consensus says PPIs, antiplatelets can be used together

Proton-pump inhibitors (PPIs) and antiplatelet drugs can be used together in cardiovascular disease patients who are at high risk of upper gastrointestinal (GI) bleeds, according to an expert consensus document drafted by three medical societies.

New recommendations include the following:

• PPIs are recommended for patients with a history of upper GI bleeding, or for those with multiple risk factors such as a history of peptic ulcers, advanced age, Helicobacter pylori infection, or the use of antiplatelets, steroids or nonsteroidal anti-inflammatory drugs.PPIs are not recommended to reduce upper GI bleeding in low-risk patients, and those who are less likely to benefit from prophylaxis.Future studies are required to assess the impact of PPIs and antiplatelets among high-risk cardiac patients who poorly metabolize antiplatelet drugs.

The document will be released by the American College of Cardiology (ACC) , the American College of Gastroenterology (ACG) , and the American Heart Association (AHA) in their respective journals and on their websites, a press release said.

The three organizations recommended concomitant PPI and antiplatelet use in a 2008 document. But subsequent research suggested PPIs possibly lessened the efficacy of antiplatelet drugs. However, the consensus group noted, much of the published data used platelet function tests as surrogate markers of cardiovascular risk. The clinical significance of laboratory test results has not been substantiated in large patient studies using clinically relevant endpoints, such as heart attacks or strokes.

The only published randomized controlled trial specifically designed to assess the clinical occurrence of GI bleeding, heart attacks and strokes associated with the prescription of clopidogrel alone versus clopidogrel with a PPI found no significant difference in cardiac events. Recent publication of a randomized trial (COGENT) of 3,761 patients with cardiovascular disease demonstrated a 56% decrease in GI bleeding.