Proton pump inhibitor
In medicine, specifically gastroenterology, proton pump inhibitors (PPI) are medications that "inhibit H(+)-K(+)-exchanging atpase. They are used as anti-ulcer agents and sometimes in place of histamine H2 antagonists for gastroesophageal reflux disease." They are also used to eradicate Helicobacter pylori, in combination with antibiotics.
- Esomeprazole. Available as generic.
- Lansoprazole. Available as generic.
- Omeprazole. Available as non-prescription in the United States.
- Pantoprazole. Available as generic.
Proton pump inhibitors are metabolized by the CYP2C19 isoenzyme of cytochrome P-450. Lanzoprazole is the strongest inhibitor of CYP2C19, This may be less true for pantoprazole and esomeprazole. Pantoprazole is the strongest inhibitor of the CYP2C9 isoenzyme
Proton pump inhibitors may improve:
- Non-ulcer dyspepsia
- Gastroesophageal reflux disease Medications may be taken as needed. Two weeks of therapy may be adequate.
- Reflux esophagitis
Proton pump inhibitors may be associated with spontaneous bacterial peritonitis. Recent starting of these drugs may also be associated with pneumonia acquired in the communityor hospital. These drugs may be associated with Clostridium difficile diarrhea, and fractures other than hip fractures.
Proton pump inhibitors may induce acid-related symptoms in healthy volunteers after withdrawal, presumably due to rebound acid hypersecretion.
In the United States, the Food and Drug Administration has issued warnings regarding combining PPIs with clopidogrel. Proton pump inhibitors (especially inhibitors other than pantoprazole), which are metabolized by the CYP2C19 isoenzyme of cytochrome P-450, may or may not increase adverse cardiac events when given to patients taking clopidogrel for coronary heart disease (see evidence table). A consensus statement address this drug interaction.
|COGENT Randomized controlled trial
|3,873 patients with an indication for dual antiplatelet
• 94% were anglo
|1,033 concurrent users of clopidogrel and PPIs
• all used omeprazole
|Placebo||Serious cardiovascular disease|
|Odds ratio = 0.99; 95% CI, 0.68 - 1.44; P=0.96);|
"There was no apparent cardiovascular interaction between clopidogrel"
|Stockl et al Retrospective cohort study
|2,066 patients hospitalized for myocardial infarction or stent||1,033 concurrent users of clopidogrel and PPIs
• 64% used pantoprazole
|1,033 patients not taking PPIs||Serious cardiovascular disease|
|Odds ratio = 1.64 (95% CI 1.16-2.32)|
"Patients who received clopidogrel plus a PPI had a significantly higher risk of rehospitalization for MI or coronary stent placement than did patients receiving clopidogrel alone"
|Tennessee Medicaid cohort study||20,596 patients hospitalized for myocardial infarction, myocardial revascularization, or unstable angina pectoris||7593 concurrent users of clopidogrel and PPIs
• 62% used pantoprazole
|13003 patients not taking PPIs||Serious cardiovascular disease|
|"Serious cardiovascular disease was not increased; however, the 95% CI included a clinically important increased risk"|
|Ontario nested case-control study||13,636 subjects taking clopidogrel after myocardial infarction||782 subjects readmitted for myocardial infarction||2057 subjects not readmitted||Rate of PPI usage other than pantoprazole||Odds ratio = 1.40 (95% CI 1.10–1.77)|
|Cohort study from the VA Cardiac Care Follow-up Clinical Study||8205 subjects with acute coronary syndrome|| 64% were taking PPIs:
• 0.2% used pantoprazole
• 50% received stents
• Probably < 50% used drug eluting stents
|Subjects not taking PPIs||Major vascular events||29.8%||20.8%|
|Odds ratio = 1.25 (95% CI: 1.11-1.41)|
• "each 10% increase in the proportion of time taking clopidogrel plus PPI during follow-up was associated with a higher risk"
|Cohort study taken from TRITON-TIMI 38 randomized controlled trials
2 of 14 authors disclosed payments from AstraZenca, the maker of omeprazole and esomeprazole
|6795 subjects with acute coronary syndrome who were randomized to the clopidogrel arm of the trial||33% (4529) were taking PPIs at randomization:
• 2814 took PPIs for duration of study
• 41% used pantoprazole
• 94% received stents
• 47% received at least one drug eluting stent
|Subjects not taking PPIs||Major vascular events||11.8%||12.2%|
|• Patients taking any PPI HR = 0.94, (95% CI 0.80–1.11)|
• Patients taking any PPI for duration of study HR = 1.05 (95% CI 0.85–1.30)
• Results similar for each individual PPI
• Results also insignificant when restricted to analysis of patients with a reduced function allele
|Medco cohort study||16,718 subjects who took clopidogrel for 12 months after coronary stent||41% were taking PPIs:
• 24% used pantoprazole
• 100% received stents
• Unknown use of drug eluting stents
|Subjects not taking PPIs||Major vascular events||24% to 29%||17.9%|
|• Pantoprazole HR=1.61 (pantoprazole had most GI bleeding)|
• Esoprazole HR=1.57
• Lansoprazole HR=1.39
• Omeprazole HR=1.39
• Histamine H2 antagonists HR=1.14 (insignicant)
|Danish cohort study||56,406 subjects discharged after first-time myocardial infarction||• 44% received clopidogrel
• 41% were taking PPIs:
• 30% of PPIs were pantoprazole
|Subjects not taking PPIs||Cardiovascular deaths and rehospitalization for myocardial infarction or strokes||26.3%||18.6%|
|• Any PPI HR=1.29|
• Clopidogrel was associated with more adverse outcomes among patients taking PPIs and patient not taking PPIs. The increase due to clopidogrel was the same in both groups.
|FAST-MI Registry cohort study||3670 subjects||•||%||%|
|"PPI use was not associated with an increased risk of cardiovascular events or mortality in patients administered clopidogrel for recent MI, whatever the CYP2C19 genotype, although harm could not be formally excluded in patients with 2 loss-of-function alleles."|
- Anonymous (2015), Proton pump inhibitor (English). Medical Subject Headings. U.S. National Library of Medicine.
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- Gray SL, LaCroix AZ, Larson J, Robbins J, Cauley JA, Manson JE et al. (2010). "Proton pump inhibitor use, hip fracture, and change in bone mineral density in postmenopausal women: results from the Women's Health Initiative.". Arch Intern Med 170 (9): 765-71. DOI:10.1001/archinternmed.2010.94. PMID 20458083. Research Blogging.
- Reimer C, Søndergaard B, Hilsted L, Bytzer P (2009). "Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy.". Gastroenterology 137 (1): 80-7, 87.e1. DOI:10.1053/j.gastro.2009.03.058. PMID 19362552. Research Blogging.
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- Anonymous. (2009) Early Communication about an Ongoing Safety Review of clopidogrel bisulfate (marketed as Plavix)
- Anonymous (11/17/2009) Information for Healthcare Professionals: Update to the labeling of Clopidogrel Bisulfate (marketed as Plavix) to alert healthcare professionals about a drug interaction with omeprazole (marketed as Prilosec and Prilosec OTC)
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- American College of Cardiology Foundation Task Force on Expert Consensus Documents. Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ et al. (2010). "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.". J Am Coll Cardiol 56 (24): 2051-66. DOI:10.1016/j.jacc.2010.09.010. PMID 21126648. Research Blogging.
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- Stockl, Karen M.; Lisa Le, Armen Zakharyan, Ann S. M. Harada, Brian K. Solow, Joseph E. Addiego, Scott Ramsey (2010-04-26). "Risk of Rehospitalization for Patients Using Clopidogrel With a Proton Pump Inhibitor". Arch Intern Med 170 (8): 704-710. DOI:10.1001/archinternmed.2010.34. Retrieved on 2010-04-27. Research Blogging.
- Ray WA, Murray KT, Griffin MR, Chung CP, Smalley WE, Hall K et al. (2010). "Outcomes with concurrent use of clopidogrel and proton-pump inhibitors: a cohort study.". Ann Intern Med 152 (6): 337-45. DOI:10.1059/0003-4819-152-6-201003160-00003. PMID 20231564. Research Blogging.
- Ho PM, Maddox TM, Wang L, et al. (March 2009). "Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome". JAMA 301 (9): 937–44. DOI:10.1001/jama.2009.261. PMID 19258584. Research Blogging.
- O'Donoghue ML, Braunwald E, Antman EM, Murphy SA, Bates ER, Rozenman Y et al. (2009). "Pharmacodynamic effect and clinical efficacy of clopidogrel and prasugrel with or without a proton-pump inhibitor: an analysis of two randomised trials.". Lancet 374 (9694): 989-97. DOI:10.1016/S0140-6736(09)61525-7. PMID 19726078. Research Blogging.
- Stanek EJ et al. (2009) A National Study of the Effect of Individual Proton Pump Inhibitors on Cardiovascular Outcomes in Patients Treated with Clopidogrel Following Coronary Stenting: The Clopidogrel Medco Outcomes Study Society for Cardiovascular Angiography and Interventions 2009 Annual Meeting
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- Simon T, Steg PG, Gilard M, Blanchard D, Bonello L, Hanssen M et al. (2011). "Clinical Events as a Function of Proton Pump Inhibitor Use, Clopidogrel Use, and Cytochrome P450 2C19 Genotype in a Large Nationwide Cohort of Acute Myocardial Infarction: Results From the French Registry of Acute ST-Elevation and Non-ST-Elevation Myocardial Infarction (FAST-MI) Registry.". Circulation 123 (5): 474-82. DOI:10.1161/CIRCULATIONAHA.110.965640. PMID 21262992. Research Blogging.
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