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Review
. 2022 Feb 3;14(2):e21885.
doi: 10.7759/cureus.21885. eCollection 2022 Feb.

Co-prescription of Dual-Antiplatelet Therapy and Proton Pump Inhibitors: Current Guidelines

Hannah Saven  1 , Lynna Zhong  1 , Isabel M McFarlane  2
Affiliations
Review

Co-prescription of Dual-Antiplatelet Therapy and Proton Pump Inhibitors: Current Guidelines

Hannah Saven et al. Cureus. .

Abstract

Dual-antiplatelet therapy (DAPT) prevents thrombotic complications associated with coronary artery disease, acute coronary syndrome, and stent thrombosis following the percutaneous coronary intervention or coronary artery bypass grafting. When initiating DAPT, the risk of thrombosis must be balanced with the increased risk of upper gastrointestinal bleed (UGIB). Proton-pump inhibitors (PPIs) are concurrently prescribed with DAPT to reduce bleeding risk. In this review, we discuss the benefits and potential complications of DAPT/PPI co-prescription. The only large international randomized control trial (RCT), Clopidogrel and the Optimization of Gastrointestinal Events Trial (COGENT), shows robust evidence that PPIs are a safe and effective method to reduce the risk of bleeding in patients on DAPT. However, more large-scale RCTs are needed to study potential long-term effects and draw a stronger conclusion on this topic.

Keywords: cyp450 pathway; dapt/ppi prescription; dual-antiplatelet therapy (dapt); proton-pump inhibitors (ppi); upper gastrointestinal bleed (ugib).

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Proposed mechanism for DAPT/PPI drug interaction.
Clopidogrel is metabolized by cytochrome CYP450 2C19. Omeprazole has inhibitory effects and is metabolized by CYP450 2C19, therefore, potentially limiting the active form of clopidogrel and its antiplatelet effects. Omeprazole inhibits the H+/K+-ATPase on the luminal side of parietal cells, which decreases the acid production in the stomach. This could limit the absorption of aspirin. On its own, aspirin increases the risk of UGIB by decreasing mucus secretion, decreased bicarbonate secretion, and decreasing mucosal blood flow. The addition of PPI to aspirin typically works to decrease the risk of ulcer formation via decreased acid production. Omeprazole has the potential to affect the absorption and metabolism of aspirin and clopidogrel, respectively. Created with BioRender.com. DAPT, dual-antiplatelet therapy; PPI, proton pump inhibitor; UGIB, upper gastrointestinal bleed; COX1, cyclooxygenase-1; H+/K+-ATPase, hydrogen potassium adenosine triphosphatase.
See this image and copyright information in PMC

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