ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use

Abraham, Neena S.; Hlatky, Mark A.; Antman, Elliott M.; Bhatt, Deepak L.; Bjorkman, David J.; Clark, Claire D.; Furberg, Curt D.; Johnson, David A.; Kahi, Charles J.; Laine, Loren; Mahaffey, Kenneth W.; Quigley, Eamonn Martin; Scheiman, James M.; Sperling, Laurence; Tomaselli, Gordon F.

doi:10.1038/ajg.2010.445

Cited by 183 publications

(102 citation statements)

References 84 publications

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“…Antithrombotic agents, including the thienopyridine P2Y12 platelet inhibitors (clopidogrel, prasugrel, ticagrelor), and anticoagulant agents such as Coumadin are not thought to independently cause GI mucosal injury; but they exacerbate bleeding from existing mucosal breaks or injury. 3,30 Among patients in whom an ASA prescription was not recorded (ie, ACAP), the risk of UGIE and LGIE hovered at ≈30% to 40% over baseline, in keeping with the range of an ASA bleed. This may represent bleeding associated with surreptitious ASA or NSAID use, placing both the upper and lower GI tract at risk, or undocumented H pylori infection with injury in the upper GI tract, or it may simply reflect the baseline risk of bleeding in an elderly, highly comorbid cardiovascular population.…”

Section: Discussionmentioning

confidence: 99%

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Risk of Lower and Upper Gastrointestinal Bleeding, Transfusions, and Hospitalizations With Complex Antithrombotic Therapy in Elderly Patients

et al. 2013

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Background-Complex antithrombotic therapy (CAT) prescribed to elderly patients increases the risk of gastrointestinal bleeding. We quantified upper (UGIE) and lower gastrointestinal (LGIE) events, transfusions, and hospitalizations in a national cohort of elderly veterans prescribed CAT. Methods and Results-Veterans ≥60 years of age prescribed anticoagulant-antiplatelet, aspirin (ASA)-antiplatelet, ASAanticoagulant, or triple therapy (ie, TRIP, anticoagulant-antiplatelet-ASA) were identified from the national pharmacy database (October 1, 2002 to September 30, 2008. Prescription-fill data were linked to Veteran Affairs and Medicare encounter files, each person-day of follow-up was assessed for CAT exposure, and outcomes were defined by using diagnostic code algorithms derived following chart abstraction. Incidence density ratios (compared with the reference category of no CAT) and survival analysis was conducted. Among 78 133 veterans (98.6% white; mean age, 72.3 [standard deviation 7.7]), 64% were prescribed ASA-antiplatelet and anticoagulant-antiplatelet and 6% were prescribed TRIP. The incidence of UGIE was 20.1/1000 patient-years, and the incidence of LGIE was 70.1/1000 patient-years. ASA-anticoagulant and TRIP were associated with the highest incidence of transfusion and hospitalization. A 40% to 60% increased risk of UGIE was observed with all strategies.LGIE was 30% higher with anticoagulant-antiplatelet, and transfusion increased with ASA-anticoagulant (hazard ratio, 6.1; 95% confidence interval, 5.2-7.1) and TRIP (hazard ratio, 5.0; 95% confidence interval, 4.2-5.8). Increased risk of hospitalization was noted with all strategies. The number needed to harm for UGIE or LGIE ranged from 52 to 65 and 15 to 23, respectively. The number needed to harm for hospitalization was 39 (anticoagulant-antiplatelet), 34 (ASA-anticoagulant), 67 (ASA-antiplatelet), and 45 (TRIP) patients. Conclusions-Among

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Section: Discussionmentioning

confidence: 99%

“…However, this would be unethical, given the known GI bleeding risk factor of advanced age. 3 To quantify the risk of CAT-related GI bleeding, we examined…”

Section: Clinical Perspective On P 1877mentioning

confidence: 99%

Risk of Lower and Upper Gastrointestinal Bleeding, Transfusions, and Hospitalizations With Complex Antithrombotic Therapy in Elderly Patients

et al. 2013

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“…32 Although the current guidelines do not recommend routine use of PPIs with DAPT in patients at low gastrointestinal bleeding risk, trials such as COMPASS (see below) are ongoing to test the value of routine PPI use in patients on potent antithrombotic therapy. 33,34 …”

Section: Dual Antiplatelet Therapy: Clopidogrel Plus Aspirinmentioning

confidence: 99%

Antiplatelet and Anticoagulation Therapy for Acute Coronary Syndromes

Bhatt

Hulot

Moliterno

et al. 2014

Circulation Research

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Abstract:The past 2 decades have witnessed the introduction and demise of several different antithrombotic medications for acute coronary syndromes. Part of the assessment of these compounds has been their effect on thrombotic events relative to the degree of increase in bleeding events. This review will outline the data supporting various antiplatelet and anticoagulant therapies and their combinations in patients with acute coronary syndromes and related disorders in both the acute and chronic phases of therapy. (Circ Res. 2014;114:1929-1943 stroke. Bleeding events with aspirin are more commonly of gastric origin and occur at a frequency of ≈2% per year. The Clopidogrel Optimal Loading Dose Usage to Reduce Recurrent Events-Organization to Assess Strategies in Ischemic Syndromes (CURRENT-OASIS 7) trial is the only large-scale ACS randomized study to compare outcomes with lower-dose (75-100 mg daily) versus higher-dose (300-325 mg daily) aspirin. 5 In a 2-by-2 factorial design (lower-dose versus higher-dose clopidogrel was also tested), 25 086 patients with ACS received lower-dose versus higher-dose aspirin, and there was no difference in the composite of death, MI, or stroke at 30 days (4.4% versus 4.2%, respectively). There was also no difference in overall bleeding events (2.3% for both aspirin doses) with this short duration of follow-up, although an increased rate of gastrointestinal bleeds in the higher-dose group (0.2% versus 0.4%; P=0.04) was observed. 5,6 Much had been written about aspirin resistance in the previous decade. 7 The most recent research suggests that biochemical aspirin resistance is rare in patients who are actually taking and absorbing aspirin, and routine testing is not indicated. 8,9 Clopidogrel MonotherapyThe Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial tackled the question of whether it was possible to have a better antiplatelet than aspirin for secondary prevention.10 A total of 19 185 patients with previous MI, ischemic stroke, or symptomatic peripheral artery disease (PAD) were randomized to clopidogrel (75 mg per day) or aspirin (325 mg per day). Clopidogrel monotherapy emerged as the superior antiplatelet, although the 8.7% relative risk reduction (P=0.04) was modest.A subsequent analysis of the CAPRIE trial examined rehospitalization and found that clopidogrel reduced the rate of ischemic rehospitalizations compared with aspirin.11 Interestingly, there was also a reduction in hospitalization for gastrointestinal bleeding with clopidogrel versus aspirin. Whether this difference would have been observed had lower aspirin dosing been used is unknown.Subgroup analyses of the CAPRIE trial showed that enrolled patients at the higher end of the risk spectrum benefited the most.12 For example, patients with previous ischemic events (before their qualifying event), with diabetes mellitus, or with a history of previous cardiac surgery had larger reductions in ischemic events than seen in the overall trial. 13-15 Dual Antiplatelet Therapy: Clopidogrel P...

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“…As such, gastroprotection with PPIs in patients requiring DAPT at high risk for bleeding events is supported by consensus guidelines. 5,6 …”

mentioning

confidence: 99%

“…22 Histamine-2 receptor antagonists may be considered, but are less efficacious at preventing gastrointestinal bleeding complications compared with PPI therapy. 5,6 Clinician concerns regarding a potential adverse DAPT-PPI interaction will likely persist in the near future because of the (1) aging cardiovascular population with numerous medical comorbidities requiring concomitant PPI use; (2) advent of newer, more potent antithrombotic combinations which amplify bleeding risk; and (3) accumulating data to support prolonged DAPT in ACS patients. Ongoing data collection will continue to inform the risk-benefit profile of concurrent administration of PPIs with longer durations of more potent antithrombotic regimens in the contemporary cardiovascular patient.…”

mentioning

confidence: 99%