Clopidogrel versus Aspirin and Esomeprazole to Prevent Recurrent Ulcer Bleeding

Chan, Francis K.L.; Ching, Jessica; Hung, Lawrence Cheung–Tsui; Wong, Vincent Wai‐Sun; Leung, Vyl; Kung, Nelson N.S.; Hui, Aric Josun; Wu, Justin C.Y.; Leung, Wai Keung; Lee, Vivian; Lee, Kenneth K. C.; Lee, Yuk T.; Lau, James Y.; To, KF; Chan, Henry Lik‐Yuen; Chung, S. C. S.; Sung, Joseph J.Y.

doi:10.1056/nejmoa042087

Cited by 560 publications

(315 citation statements)

References 24 publications

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“…The combination of esomeprazole and LDA is superior to clopidogrel in preventing ulcer complications in patients who have a past history of LDA-related peptic ulcer bleeding [133,134]. The long-term incidence of recurrent ulcer bleeding with LDA use is low after H. pylori eradication [135].…”

Section: Commentmentioning

confidence: 99%

Evidence-based clinical practice guidelines for peptic ulcer disease 2015

et al. 2016

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The Japanese Society of Gastroenterology (JSGE) revised the evidence-based clinical practice guidelines for peptic ulcer disease in 2014 and has created an English version. The revised guidelines consist of seven items: bleeding gastric and duodenal ulcers, Helicobacter pylori (H. pylori) eradication therapy, non-eradication therapy, drug-induced ulcer, non-H. pylori, non-nonsteroidal anti-inflammatory drug (NSAID) ulcer, surgical treatment, and conservative therapy for perforation and stenosis. Ninety clinical questions (CQs) were developed, and a literature search was performed for the CQs using the Medline, Cochrane, and Igaku Chuo Zasshi databases between 1983 and June 2012. The guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Therapy is initially provided for ulcer complications. Perforation or stenosis is treated with surgery or conservatively. Ulcer bleeding is first treated by endoscopic hemostasis. If it fails, surgery or interventional radiology is chosen. Second, medical therapy is provided. In cases of NSAID-related ulcers, use of NSAIDs is stopped, and anti-ulcer therapy is provided. If NSAID use must continue, the ulcer is treated with a proton pump inhibitor (PPI) or prostaglandin analog. In cases with no NSAID use, H. pylori-positive patients receive eradication and anti-ulcer therapy. If first-line eradication therapy fails, second-line therapy is given. In cases of non-H. pylori, non-NSAID ulcers or H. pyloripositive patients with no indication for eradication therapy, non-eradication therapy is provided. The first choice is PPI therapy, and the second choice is histamine 2-receptor antagonist therapy. After initial therapy, maintenance therapy is provided to prevent ulcer relapse.

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Section: Commentmentioning

confidence: 99%

Evidence-based clinical practice guidelines for peptic ulcer disease 2015

et al. 2016

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“…However, more recent studies have reported a significantly increased risk of GI bleeding during treatment with clopidogrel. 14,15 Importantly, the risk of bleeding increases when combining clopidogrel with aspirin. 16,17 Currently, the use of proton pump inhibitors is the prevailing strategy for the prevention of GI bleeding during antiplatelet therapy.…”

Section: Introductionmentioning

confidence: 99%

Gastrointestinal Events with Clopidogrel: A Nationwide Population-Based Cohort Study

et al. 2012

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BACKGROUND: Clopidogrel prevents cardiovascular events, but has been linked with adverse gastrointestinal (GI) complications, particularly bleeding events. OBJECTIVE: We aimed to investigate the risk of adverse GI events in patients treated with clopidogrel. DESIGN: A nationwide population-based cohort study based on linkage of three administrative registries in Denmark. PARTICIPANTS: All individuals who redeemed at least one prescription of clopidogrel from 1996 to 2008 were included as exposed subjects (n = 77,503). For each exposed subject, three matched controls were randomly selected from the background population (n = 232,510). ANALYSES: Follow-up began on January 1, 1996, and was censored on December 31, 2007, or if patients emigrated or died. The study endpoint was the occurrence of any gastritis, GI ulcer or bleeding. Analyses were adjusted for comorbidity and medication. RESULTS: Regardless of dose, adjusted odds ratios associating clopidogrel use with the study endpoint were statistically significant and followed a doseresponse pattern. The crude absolute risk of GI events were: never users: 2.2 %; <0.1 defined daily dose (DDD) of clopidogrel per day: 7.1 %; 0.1-0.39 DDD: 6.0 %; 0.4-0.79 DDD: 5.7 %; ≥0.80 DDD: 4.4 %. Adjusted odds ratios were: <0.1 DDD: 1.34, 95 % CI: 1.26-1.42; 0.1-0.39 DDD: 1.58, 95 % CI: 1.48-1.68; 0.4-0.79 DDD: 1.91, 95 % CI: 1.77-2.06; ≥0.80 DDD: 1.77, 95 % CI: 1.66-1.89, all p-values<0.01. Depending on the dose, numbers needed to harm ranged from 58 to 33 patients receiving 12 months of clopidogrel treatment. CONCLUSIONS: The well-known cardioprotective effect of clopidogrel must be carefully weighed against an increased risk of GI events.

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“…Esta "mejor tolerancia" gastrointestinal de clopidogrel sugiere que su empleo sería ventajoso en pacientes con riesgo de úlceras por AAS, sin embargo recientemente se ha descrito que en pacientes con historial de úlceras sangrantes causadas por AAS, el tratamiento con AAS+esomeprazol presenta una menor incidencia de recurrencia de la úlcera que el uso de clopidogrel 13 . Asimismo, un estudio de ingresos hospitalarios confirma que el riesgo de hemorragias gastrointestinales es menor en la asociación AAS+ un inhibidor de la bomba de protones que con clopidogrel 14 .…”

Section: Discussionunclassified

Tendencia en la utilización de antiagregantes en la Comunidad Valenciana (2000-2005)

Llamosí¹,

Solaz²,

Izquierdo³

et al. 2007

Rev. Esp. Salud Publica

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Fundamento: Los antiagregantes plaquetarios son fárma-cos básicos para la prevención de enfermedades isquémicas arteriales. El objetivo de este trabajo es conocer la evolución de su utilización en Atención Primaria en la Comunidad Valenciana durante el periodo 2000-2005.Métodos: Estudio descriptivo del consumo de los antiagregantes plaquetarios (código ATC: B01AC) dispensados con cargo al Sistema Nacional de Salud en la Comunidad Valenciana en el ámbito de Atención Primaria. Datos expresados en dosis diarias definidas (DDD) por 1.000 habitantes y día.Resultados: En 2005 tres fármacos representaron el 98% de la prescripción global (ácido acetilsalicílico (AAS) 66%, clopidogrel 23% y triflusal 9%). El consumo de antiagregantes orales se incrementó en un 23% entre 2000 y 2005 (desde 29,6 DDD/1.000 hab y día hasta 36,5). El clopidogrel mostró un incremento del 218%, mientras que el ácido acetilsalicílico fue el principio de mayor consumo con una cuota de utilización bastante estable durante todo el periodo (próxima al 70%). El gasto generado por este grupo de fármacos se duplicó, el clopidogrel fue el fármaco con mayor coste/DDD (2,14t), en 2005 su utilización constituyó un 23% del total de antiagregantes pero su gasto representó el 76% del total.Conclusiones: En este periodo se incrementó el consumo de antiagregantes en la Comunidad Valenciana. El AAS mantuvo estable su utilización, mientras que el clopidogrel aumentó su cuota de mercado pese a las recomendaciones de las guías terapéu-ticas y las restricciones para su uso. El consumo del clopidogrel contribuyó de forma notable al gasto farmacéutico de este grupo.Palabras clave: Antiagregantes plaquetarios. Clopidogrel. Ácido acetilsalicícico. Utilización de medicamentos.

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Clopidogrel versus Aspirin and Esomeprazole to Prevent Recurrent Ulcer Bleeding

Cited by 560 publications

References 24 publications

Evidence-based clinical practice guidelines for peptic ulcer disease 2015

Evidence-based clinical practice guidelines for peptic ulcer disease 2015

Gastrointestinal Events with Clopidogrel: A Nationwide Population-Based Cohort Study

Tendencia en la utilización de antiagregantes en la Comunidad Valenciana (2000-2005)

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