Proton pump inhibitor and clopidogrel interaction: fact or fiction?

Am J Gastroenterol. 2010 Jan;105(1):34-41. doi: 10.1038/ajg.2009.638. Epub 2009 Nov 10.

Abstract

Current consensus recommendations state that patients prescribed clopidogrel plus aspirin should receive a proton pump inhibitor (PPI) to reduce gastrointestinal bleeding. Clopidogrel is converted to its active metabolite by cytochrome P450 (CYP) enzymes. Clopidogrel users with decreased CYP2C19 function have less inhibition of platelet aggregation and increased cardiovascular (CV) events. As PPI metabolism also involves CYP2C19, it was hypothesized that competition by PPIs might interfere with clopidogrel's action. Omeprazole, but not other PPIs, worsens surrogate markers of clopidogrel efficacy. Some (but not all) observational studies show that clopidogrel users prescribed PPIs have increased risks of CV events (hazard/odds ratios=1.25-1.5). When effect sizes are small to moderate (relative risks<1.5-2.0), however, it is only possible to conclude whether statistical associations are valid in randomized trials. A randomized trial of omeprazole vs. placebo in clopidogrel users showed no difference in CV events (hazard ratio=1.02,0.70-1.51). Thus, current evidence does not justify a conclusion that PPIs are associated with CV events among clopidogrel users, let alone a judgment of causality. Nonetheless, positive results from some observational studies and biological plausibility have led some health-care providers to accept that PPIs reduce clopidogrel's efficacy. The US Food and Drug Administration (FDA) recommends that "concomitant use of drugs that inhibit CYP2C19 (e.g., omeprazole) should be discouraged." As the presence of PPIs and clopidogrel in plasma is short lived, separation by 12-20 h should in theory prevent competitive inhibition of CYP metabolism and minimize any potential, though unproven, clinical interaction. PPI may be given before breakfast and clopidogrel at bedtime, or PPI may be taken before dinner and clopidogrel at lunchtime.

Publication types

  • Review

MeSH terms

  • Cardiovascular Diseases / etiology
  • Cardiovascular Diseases / prevention & control
  • Clopidogrel
  • Cytochrome P-450 Enzyme System / metabolism
  • Drug Interactions
  • Drug Therapy, Combination
  • Gastrointestinal Hemorrhage / chemically induced
  • Humans
  • Omeprazole / adverse effects
  • Omeprazole / metabolism
  • Omeprazole / pharmacokinetics
  • Platelet Aggregation Inhibitors / adverse effects*
  • Platelet Aggregation Inhibitors / metabolism
  • Platelet Aggregation Inhibitors / pharmacokinetics
  • Proton Pump Inhibitors / adverse effects*
  • Proton Pump Inhibitors / metabolism
  • Proton Pump Inhibitors / pharmacokinetics
  • Randomized Controlled Trials as Topic
  • Risk Factors
  • Ticlopidine / adverse effects
  • Ticlopidine / analogs & derivatives*
  • Ticlopidine / metabolism
  • Ticlopidine / pharmacokinetics

Substances

  • Platelet Aggregation Inhibitors
  • Proton Pump Inhibitors
  • Cytochrome P-450 Enzyme System
  • Clopidogrel
  • Omeprazole
  • Ticlopidine