H2 Receptor Antagonists versus Proton Pump Inhibitors in Patients on Dual Antiplatelet Therapy for Coronary Artery Disease: A Systematic Review

Abstract

Objectives: Mitigating the gastrointestinal (GI) bleeding risks of dual antiplatelet therapy (DAPT) is a common clinical concern. While proton pump inhibitors (PPIs) remain the most effective therapy, their adverse events warrant considering alternatives, including Histamine 2 receptor antagonists (H2RAs). Methods: We searched for randomized controlled trials in MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials, published from 1980 to 2016. After screening, 10 trials were eligible. We compared PPIs to H2RAs in patients on DAPT in terms of 2 clinical and one laboratory outcomes; GI complications, major adverse cardiovascular events (MACE) and high on-treatment platelet reactivity (HTPR). Clinical and statistical inter-study heterogeneity was low for all 3 outcomes (I² = 0%, p > 0.05 for all). Results: Fixed effects meta-analysis suggested that PPIs were superior to H2RAs in preventing GI complications (OR 0.28, 95% CI 0.17–0.48) but with higher risk of HTPR (OR 1.28, 95% CI 1.030–1.60) though without a higher incidence of MACE (OR 0.99, 95% CI 0.55–1.77). Conclusions: PPIs are superior to H2RAs for gastroprotection in patients on DAPT. However, PPIs are associated with HTPR, with no significant difference demonstrated in MACE. Based on currently available data, the use of PPIs may be warranted in selected patients on DAPT deemed at risk for GI complications.

The efficacy and safety of acid suppressants for gastrointestinal bleeding prophylaxis in cardiac care unit patients

“…Data comparing the efficacy of PPIs and H2RAs for CIGIB prophylaxis in CCU patients are limited. A systemic review of RCTs indicated that PPIs were superior to H2RAs for gastrointestinal protection in patients on DAPT; however, the end‐points of the studies were not CIGIB 30 . Our sensitivity analyses failed to detect any plausible scenario in which PPIs were superior to H2RAs or the control for the prevention of CIGIB in CCU patients, and we did not find significant differences in the efficacy of different acid suppressant types or drug administration routes for GIB prophylaxis among the three groups; this supports the result that prophylactic PPI use does not reduce the incidence of GIB in patients receiving DAPT 13…”

Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO)

“…However, in a large analysis of administrative claims from commercial and Medicare Supplemental plans from 2001 to 2014 in the United States, it was found no evidence that prescription of PPIs increased the risk of MI compared with prescription H 2 RA [57]. In patients taking antiplatelet agents, both as monotherapy and DAT, PPIs were superior to H 2 RA in preventing GI bleeding [58]. However, an increased risk (OR 1.40, 95% CI: 1.10-1.77) of recurrent MI was reported in 2009 in patients taking clopidogrel and PPIs [59].…”

Possible Effects of Proton Pump Inhibitors on Hearing Loss Development

“…They are a group of drugs commonly used as a standard therapy in gastroesophageal reflux disease (GERD) and acidity disorders of the upper gastrointestinal tract. Due to their proven effectiveness in suppression of acid secretion by gastric parietal cells [1], PPI are used both in the treatment and the prevention of gastric and duodenal ulcers, gastroesophageal reflux disease and in the eradication of Helicobacter pylori. Their ubiquitous use is also due to the administration of PPI to patients receiving non-steroidal anti-inflammatory drugs or antiplatelet agents [2,3].…”