Risk of adverse cardiovascular outcomes and all-cause mortality associated with concomitant use of clopidogrel and proton pump inhibitors in elderly patients.
OBJECTIVE
To examine the effect of concomitant use of clopidogrel and PPIs in a national sample of elderly Medicare beneficiaries (age ≥65 years).


METHODS
A nested case-control design was employed. A cohort of Medicare beneficiaries who initiated clopidogrel and did not have any gap of ≥30 days between clopidogrel fills between July 1, 2006 and December 31, 2008 was identified from a 5% national sample of Medicare claims data. Within this cohort, cases (beneficiaries who experienced any major cardiovascular event [MCE] [acute myocardial infarction, stroke, coronary artery bypass graft, or percutaneous coronary intervention] or all-cause mortality) and controls (beneficiaries who did not experience any MCE or all-cause mortality) were identified from inpatient and outpatient claims. Cases and controls were matched on age and the time to first clopidogrel fill. Conditional logistic regression was performed on the matched sample to evaluate the association between concomitant use of clopidogrel and PPIs and adverse health outcomes (MCEs and all-cause mortality).


RESULTS
A total of 43,159 clopidogrel users were identified. Among them, 15,415 (35.7%) received clopidogrel and a PPI concomitantly at any time during the study period, 3502 (8.1%) experienced a MCE, 7306 (17.1%) died, and a total of 9908 (22.8%) experienced the primary composite outcome (any MCE or all-cause mortality) during follow-up. The odds ratio (OR) for the primary composite outcome was 1.26 (95% confidence interval [CI]: 1.18-1.35). Secondary analyses indicated that elderly patients using clopidogrel and a PPI concomitantly were more likely to experience all-cause mortality (OR: 1.40; 95% CI: 1.29-1.53) as compared to those receiving clopidogrel only, but not MCEs (OR: 1.06; 95% CI: 0.95-1.18).


CONCLUSIONS
Concomitant use of clopidogrel and PPIs was associated with a slightly increased risk of all-cause mortality but not MCEs.
The University of Mississippi, MS 38677, USA.
Rohan K
RK
Mahabaleshwarkar
Yi
Y
Yang
Manasi V
MV
Datar
John P
JP
Bentley
Matthew W
MW
Strum
Benjamin F
BF
Banahan
Kyle D
KD
Null
D053799:2-Pyridinylmethylsulfinylbenzimidazoles / Q000009:adverse effects / Q000627:therapeutic use; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D000077144:Clopidogrel; D015331:Cohort Studies; D001026:Coronary Artery Bypass; D004347:Drug Interactions; D004359:Drug Therapy, Combination; D064098:Esomeprazole / Q000009:adverse effects / Q000627:therapeutic use; D005260:Female; D006801:Humans; D064747:Lansoprazole; D008297:Male; D009203:Myocardial Infarction / Q000139:chemically induced / Q000401:mortality*; D009853:Omeprazole / Q000009:adverse effects / Q000627:therapeutic use; D000077402:Pantoprazole; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects* / Q000627:therapeutic use; D054328:Proton Pump Inhibitors / Q000009:adverse effects* / Q000627:therapeutic use; D064750:Rabeprazole; D012306:Risk; D020521:Stroke / Q000139:chemically induced / Q000401:mortality*; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use
D053799:2-Pyridinylmethylsulfinylbenzimidazoles; D010975:Platelet Aggregation Inhibitors; D054328:Proton Pump Inhibitors; D064747:Lansoprazole; D064750:Rabeprazole; D000077144:Clopidogrel; D000077402:Pantoprazole; D009853:Omeprazole; D064098:Esomeprazole; D013988:Ticlopidine