Bouziana Stella D, Tziomalos Konstantinos
Stella D Bouziana, Konstantinos Tziomalos, First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, 54636 Thessaloniki, Greece.
World J Gastrointest Pharmacol Ther. 2015 May 6;6(2):17-21. doi: 10.4292/wjgpt.v6.i2.17.
Clopidogrel is a widely used antiplatelet agent for the secondary prevention of cardiovascular events in patients with stable coronary heart disease, acute coronary syndromes and ischemic stroke. Even though clopidogrel is safer than aspirin in terms of risk for gastrointestinal (GI) bleeding, the elderly, and patients with a history of prior GI bleeding, with Helicobacter pylori infection or those who are also treated with aspirin, anticoagulants, corticosteroids or nonsteroidal anti-inflammatory drugs are at high risk for GI complications when treated with clopidogrel. Accordingly, proton pump inhibitors are frequently administered in combination with clopidogrel to reduce the risk for GI bleeding. Nevertheless, pharmacodynamic studies suggest that omeprazole might attenuate the antiplatelet effect of clopidogrel. However, in observational studies, this interaction does not appear to translate into increased cardiovascular risk in patients treated with this combination. Moreover, in the only randomized, double-blind study that assessed the cardiovascular implications of combining clopidogrel and omeprazole, patients treated with clopidogrel/omeprazole combination had reduced risk for GI events and similar risk for cardiovascular events than patients treated with clopidogrel and placebo. However, the premature interruption of the study and the lack of power analysis in terms of the cardiovascular endpoint do not allow definite conclusions regarding the cardiovascular safety of clopidogrel/omeprazole combination. Other proton pump inhibitors do not appear to interact with clopidogrel. Nevertheless, given the limitations of existing observational and interventional studies, the decision to administer proton pump inhibitors to patients treated with clopidogrel should be individualized based on the patient's bleeding and cardiovascular risk.
氯吡格雷是一种广泛应用的抗血小板药物，用于稳定型冠心病、急性冠脉综合征和缺血性卒中患者心血管事件的二级预防。尽管氯吡格雷在胃肠道（GI）出血风险方面比阿司匹林更安全，但老年人、有既往GI出血史、幽门螺杆菌感染或同时接受阿司匹林、抗凝剂、皮质类固醇或非甾体抗炎药治疗的患者，在接受氯吡格雷治疗时发生GI并发症的风险较高。因此，质子泵抑制剂常与氯吡格雷联合使用以降低GI出血风险。然而，药效学研究表明，奥美拉唑可能会减弱氯吡格雷的抗血小板作用。不过，在观察性研究中，这种相互作用似乎并未转化为接受该联合治疗患者心血管风险的增加。此外，在唯一一项评估氯吡格雷与奥美拉唑联合使用对心血管影响的随机双盲研究中，接受氯吡格雷/奥美拉唑联合治疗的患者与接受氯吡格雷和安慰剂治疗的患者相比，GI事件风险降低，心血管事件风险相似。然而，该研究的提前中断以及在心血管终点方面缺乏效能分析，使得无法就氯吡格雷/奥美拉唑联合使用的心血管安全性得出明确结论。其他质子泵抑制剂似乎与氯吡格雷无相互作用。尽管如此，鉴于现有观察性和干预性研究的局限性，对于接受氯吡格雷治疗的患者使用质子泵抑制剂的决策应根据患者的出血和心血管风险进行个体化。
