Pharmacy Geneva University Hospitals Geneva Switzerland.
Division of Clinical Pharmacology and Toxicology Geneva University Hospitals Geneva Switzerland.
Pharmacol Res Perspect. 2016 Apr 21;4(3):e00234. doi: 10.1002/prp2.234. eCollection 2016 Jun.
The antiplatelet clopidogrel and the proton pump inhibitor esomeprazole demonstrate a pharmacokinetic interaction through CYP2C19 that could translate into clinical inefficacy of clopidogrel. No medical consensus as to their coprescription has been reached, and different guidelines are available. We evaluated the prescribing practices at the Geneva University Hospitals (HUG) by measuring whether the coprescription was staggered as suggested by experts. We estimated the financial impact of different implementation guidelines. We used the HUG electronic patient records to follow the physicians' prescriptions and the administration by nurses from January 2013 to April 2014. We performed a time series analysis to assess 15 years of proton pump inhibitors (PPIs) and antiplatelet drug use. "Extra costs" were calculated assuming that clopidogrel or esomeprazole would replace prasugrel or ticagrelor and pantoprazole or ranitidine, respectively. Only 10.8% of the patient medical orders for the clopidogrel and esomeprazole coprescription specified to stagger the administration, 12.6% specified a concomitant coprescription, and 76.6% had no clear information. A high rate of 49.6% of the nurses staggered the clopidogrel and esomeprazole coprescription when no clear information was given. We found a statistically significant decrease in clopidogrel use after the publication of the OCLA (Omeprazole-CLopidogrel-Aspirin) study and a significant increase in the trend of esomeprazole. Alternative treatments to avoid this interaction are cost ineffective or offer therapeutic options of lesser quality. We observed a high rate of 56.2% of the clopidogrel and esomeprazole coprescription in our hospital and can therefore not ignore the PK/PD interaction. The most common prescription practice was to not specify the time frame of administration, which was translated by nurses in 49.6% of the cases to a scheduled staggered coprescription of clopidogrel and esomeprazole. As long as no consensus has been reached, the medical orders time frame information should be mandatory to allow a clear and harmonious staggering strategy.
抗血小板药物氯吡格雷和质子泵抑制剂埃索美拉唑通过 CYP2C19 表现出一种药代动力学相互作用，可能导致氯吡格雷的临床疗效降低。目前还没有达成关于两者联合使用的医学共识，不同的指南也存在差异。我们通过测量专家建议的错开给药时间，评估了日内瓦大学附属医院（HUG）的处方实践。我们还估计了不同实施指南的经济影响。我们使用 HUG 的电子病历，从 2013 年 1 月至 2014 年 4 月，跟踪医生的处方和护士的给药情况。我们进行了时间序列分析，以评估 15 年来质子泵抑制剂（PPIs）和抗血小板药物的使用情况。假设氯吡格雷或埃索美拉唑分别替代普拉格雷或替格瑞洛和泮托拉唑或雷尼替丁，我们计算了“额外成本”。只有 10.8%的氯吡格雷和埃索美拉唑联合处方的患者医嘱明确规定错开给药时间，12.6%的医嘱同时开具联合处方，而 76.6%的医嘱没有明确信息。当没有明确信息时，护士错开氯吡格雷和埃索美拉唑联合处方的比例高达 49.6%。我们发现，在 OCLA（奥美拉唑-氯吡格雷-阿司匹林）研究发表后，氯吡格雷的使用显著减少，而埃索美拉唑的使用趋势显著增加。避免这种相互作用的替代治疗方案不具有成本效益，或者提供的治疗选择质量较差。我们观察到我院氯吡格雷和埃索美拉唑联合处方的比例很高（56.2%），因此不能忽视 PK/PD 相互作用。最常见的处方实践是不指定给药时间框架，而护士在 49.6%的情况下将其翻译为氯吡格雷和埃索美拉唑的预定错开联合处方。只要没有达成共识，医嘱的时间框架信息就应该是强制性的，以允许制定明确和协调的错开策略。
