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Plavix, PPI Combo: Risky for Heart Patients?

Study Shows Risks of Combining Plavix and Proton Pump Inhibitors
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WebMD Health News

March 3, 2009 -- Heart attack patients who take an acid-reducing proton pump inhibitor (PPI) drug like Prilosec or Nexium in combination with the antiplatelet drug Plavix are more likely to have a second heart attack than patients who don't take PPIs, according to new research.

The findings confirm several smaller trials and one larger one, reported just weeks ago, suggesting that PPIs can inhibit the blood clot-inhibiting activity of Plavix, also known as clopidogrel.

Heart patients in the study who took Plavix with a PPI had a 25% increased risk of dying or of requiring hospitalization for heart-related issues, compared to patients who took Plavix alone, says study researcher P. Michael Ho, MD, PhD of the Denver VA Medical Center. Even after adjusting for factors such as patient age and other health factors, the concomitant use of Plavix and a PPI was still associated with a substantially higher risk of subsequent heart attacks or need for revascularization procedures.

The study appears in the March 4 issue of TheJournal of the American Medical Association.

"It is increasingly clear that PPIs should not be prescribed to patients taking clopidogrel unless there is a good indication for doing so," Ho tells WebMD.

PPIs Routinely Given With Plavix

Along with aspirin, Plavix is routinely prescribed after a heart attack or as part of treatment for heart conditions like unstable angina to prevent potentially life-threatening blood clots from forming.

PPIs, such as Prilosec, Nexium, Prevacid, Aciphex, and Protonix, are often prescribed as well to reduce the risk of gastric bleeding from the blood-thinning combination treatment.

But several recent studies suggest that patients who take Plavix and PPIs together have an increased risk for recurrent heart attacks and death from other heart-related causes.

In an effort to shed light on the issue, Ho and colleagues followed more than 8,000 patients treated for heart attacks or unstable angina at 127 Veterans Administration hospitals across the country.

Plavix was prescribed to all the patients, and 64% were prescribed a PPI.

Over three years of follow-up, about 30% of the patients who took Plavix plus a PPI either died or were hospitalized for heart-related causes, compared to 21% of the patients who took the antiplatelet drug without a PPI.

Taking Plavix with a PPI at any time during the follow-up was associated with a 25% increase in risk for death or hospitalization.

American Heart Association president Timothy Gardner, MD, tells WebMD that it is now clear that PPIs should be prescribed cautiously to heart patients taking Plavix.

"If a patient has a history of GI bleeding, we know that [Plavix] can increase the risk of recurrence," he says. "It may be that we need to limit the use of PPIs to these patients and other patients who have a clear need for protection."

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