Which patients on aspirin should get PPI

Abdelwahab Ward, BS Pharm, PharmD

As a pharmacist, you will be asked, which patients on low-dose aspirin should also get a proton pump inhibitor. New recommendations will clarify which patients on low-dose aspirin should also get a proton pump inhibitor.

Daily low-dose aspirin at least DOUBLES GI risk. There's one additional serious GI ulcer or bleed for every 200 patients on low-dose aspirin per year. And the risk increases with higher doses. Stick with 81 mg/d for most patients who need daily aspirin. Suggest enteric-coated or buffered aspirin if needed to decrease stomach upset. But these don't prevent GI ulcers and bleeding, which are also due to aspirin's systemic effects.

  1. Consider adding a proton pump inhibitor (PPI) for high-risk patients. These are patients with a history of ulcers, or those also taking chronic NSAIDs, clopidogrel (Plavix), or an anticoagulant.
  2. Also add a PPI for patients with MULTIPLE risk factors (dyspepsia, over age 60, concomitant oral corticosteroids, etc).

Don't use H2-blockers such as famotidine. These do NOT prevent most ulcers related to aspirin. If the patient has a history of ulcers, test and treat for H. pylori before starting chronic aspirin or clopidogrel. Eradicating H. pylori can significantly reduce the risk of recurrent bleeding. There's concern that PPIs might decrease the efficacy of clopidogrel by inhibiting its conversion to the active drug. With this POSSIBLE problem in mind, consider whether a PPI is really needed. Or use one that's less likely to interact like rabeprazole (Parit, Bepra), pantoprazole (Controloc), or lansoprazole (Lanzor).

References

  1. Yeomans N, Lanas A, Labenz J, et al. Efficacy of esomeprazole (20 mg once daily) for reducing the risk of gastroduodenal ulcers associated with continuous use of low-dose aspirin. Am J Gastroenterol. 2008;103(10):2465-2473.
  2. Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2008;118(18):1894-1909.
  3. Chin MW, Yong G, Bulsara MK, Rankin J, Forbes GM. Predictive and protective factors associated with upper gastrointestinal bleeding after percutaneous coronary intervention: a case-control study. Am J Gastroenterol. 2007;102(11):2411-2416.
  4. Jones R, Rubin G, Berenbaum F, Scheiman J. Gastrointestinal and cardiovascular risks of nonsteroidal anti-inflammatory drugs. Am J Med. 2008 Jun;121(6):464-74.
Abdelwahab Ward, BS Pharm, PharmD