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PPIs associated with 'raised cardiovascular event risk'

By Lilian Anekwe

Prescribing proton-pump inhibitors to patients discharged following a myocardial infarction raises their risk of cardiovascular events in the following month by almost a third, new research shows.

Previous studies suggesting a risk of adverse events in patients co-prescribed clopidogrel and PPIs prompted the European Medicines Agency to warn GPs of a ‘significant interaction' and the UK Medicines and Healthcare Products Regulatory Agency to advise GPs to consider switching patients to other gastroprotectants.

But this new study of over 56,000 Danish patients discharged after an MI – published in the Annals of Internal Medicine - suggests PPIs are associated with an increased risk of adverse cardiovascular outcomes regardless of whether patients were also prescribed clopidogrel.

Patients who had at least one prescription for a PPI – but were not prescribed clopidogrel - had a 29% increased risk of cardiovascular death or rehospitalisation for an MI or stroke in the 30 days after discharge- compared with those who did not receive a PPI.

But that figure was exactly the same for those prescribed a PPI and clopidogrel, compared to those not prescribed a PPI.

Lead author Dr Mette Charlot, a cardiologist at Copenhagen University hospital, concluded: ‘PPIs seem to be associated with an increased risk for adverse cardiovascular outcomes regardless of clopidogrel use, but concomitant PPI and clopidogrel use was not associated with any additional increase in risk over that observed for patients who received a PPI alone.'

‘These results seem to refute concerns about increased risk for ischemic events during concomitant PPI and clopidogrel therapy.'

In an accompanying editorial, Professor James Brophy, professor of cardiology at McGill University in Montreal, wrote: ‘In assessing the risk–benefit ratio of combining clopidogrel and PPIs, it is essential to include all relevant health outcomes.'

‘Narrow interpretations of regulatory recommendations that examine only part of this clinical equation do a disservice to those seeking to optimize the overall quality of patient care.'

Dr John Pittard, a GPSI and hospital practitioner in cardiology in Staines, Middlesex said: ‘We need a double-blind prospective trial to test the different hypothesis, whether there's any increase in risk, and whether that's due to an interaction or PPIs' own vascular effects.'

‘PPIs are commonly prescribed to people when they are discharged from hospital after a heart attack. PPIs are popular with patients but can lead to symptom dependence. I have used a lot more ranitidine in the last few years so that people don't end up over using PPIs or being put at risk of harm.'

33.2 million prescriptions for omeprazole and lansoprazole were dispensed in the community in 2009, according to statistics compiled by the NHS Information Centre.

PPIs are commonly prescribed to patients on discharge from hospital PPIs are commonly prescribed to patients on discharge from hospital

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