The results are published in an Article Online First and in an upcoming edition of the Lancet, written by Dr Michelle O’Donoghue, Brigham and Women’s Hospital, and colleagues.
Proton pump inhibitors are often administered with clopidogrel and prasugrel, to help reduce the risk of gastrointestinal bleeding, a strategy that is endorsed by existing guidelines. But several studies have raised concerns that proton pump inhibitors could negate the clinical benefit of clopidogrel. The authors studied the effects of proton pump inhibitors in the TRITON-TIMI 38 trial. The trial enrolled 13608 patients after a heart attack or unstable angina and randomly assigned them to clopidogrel or prasugrel. Use of a proton pump inhibitor in combination with these drugs did not increase the risk of cardiovascular events, including death, heart attack, or stroke.
The authors conclude: “The current findings do not support the need to avoid concomitant use of proton pump inhibitors, when clinically indicated, in patients receiving clopidogrel or prasugrel.”
In an accompanying Comment, Dr Dirk Sibbing and Dr Adnan Kastrati, Technische Universität München, Munich, Germany, agree that patients with a risk profile similar to those patients in the TRITON-TIMI 38 study can be safely treated with a proton pump inhibitor on top of clopidogrel or prasugrel. They say: “Caution is however required when prescribing proton pump inhibitors in selected high risk patients with intrinsic reduced response to thienopyridines,” adding that, if absolutely needed, PPIs less likely to interfere with the anticlotting effect of thienopyridines may be given to such patients.