title: Prescribing proton pump inhibitor and clopidogrel together:  current state of recommendations.
abstract: OBJECTIVE
  Conflicting evidence has contributed to confusion regarding the safety of co-prescribing a proton pump inhibitor (PPI) and clopidogrel. This review will quantify the risk of gastrointestinal bleeding associated with common cardioprophylactic regimens, review the evidence regarding a PPI-clopidogrel interaction and assess its clinical relevance, and reinforce best-practice recommendations for gastrointestinal bleeding prevention among patients prescribed clopidogrel.
  
  
  RESULTS
  The COGENT trial confirmed a substantial reduction in gastrointestinal bleeding risk without apparent increase in cardiovascular events when clopidogrel was co-prescribed with omeprazole. These data are consistent with secondary data analyses of large cardiovascular trials and well adjusted observational studies that also failed to confirm a consistent, clinically relevant increase in cardiovascular endpoints or mortality. Individual genetic variations in drug metabolism may contribute to increased cardiac event rates observed in small subsets of the population when PPI is co-prescribed. In the future, pharmacogenomics and point-of-care testing will likely play an emerging role in individualizing prescription strategy.
  
  
  CONCLUSIONS
  A pragmatic approach dictates an explicit risk-benefit assessment prior to co-prescription to maximize cardiac benefit and minimize the risk of gastrointestinal bleeding.
authors: Sections of Gastroenterology and Health Services Research at the Michael E. DeBakey VAMC and Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA. nabraham@bcm.edu
authors: Neena S
authors: NS
authors: Abraham
mesh_terms: D000077144:Clopidogrel; D004347:Drug Interactions; D011307:Drug Prescriptions; D004359:Drug Therapy, Combination; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced* / Q000517:prevention & control; D006801:Humans; D009853:Omeprazole / Q000627:therapeutic use*; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D054328:Proton Pump Inhibitors / Q000627:therapeutic use*; D018570:Risk Assessment; D012307:Risk Factors; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use
chemical_list: D010975:Platelet Aggregation Inhibitors; D054328:Proton Pump Inhibitors; D000077144:Clopidogrel; D009853:Omeprazole; D013988:Ticlopidine