More Risk for Heart Patients on Plavix?
by Dr. T.M. Kalra, MD
Recent concerns about concurrent use of Plavix and the acid reducing PPI (Proton Pump Inhibitor) class of drugs have prompted many calls and questions from patients and referring physicians. I thought it would be timely to provide an update on the subject in terms of what the medical world knows today and some suggestions about how to overcome the dilemma as best as we can until more answers from future studies become available.
- Q: Why are anti-acids like PPIs used with Plavix?
- A: One potential side effect of blood thinners such as Plavix is GI bleeding, often seen in cardiac patients who receive stents for example. PPIs are prescribed to hopefully prevent this adverse reaction from occurring.
- Q: What is the fuss about using both the drugs together (Plavix and PPIs like Prilosec, Nexium, Protonix, Aciphex, Zegerid etc)?
- A: Plavix, a type of prodrug, needs to be converted to its active from in order to elicit the anti-platelet or ”blood thinning” effect. Unfortunately, several PPIs have been shown to inhibit that conversion and thus potentially decrease the anti-platelet activity of Plavix.
- Q: Does this drug interaction between Plavix and PPIs translate into any meaningful clinical impact on patient care?
- A: In a nutshell, it is possible, though not confirmed yet. In the last couple of years there have been a few studies indicating more major cardio-vascular events in patients receiving Plavix with PPIs compared to those receiving Plavix alone. At the same time however, there are other studies that do not report adverse effect of combining the two drugs. In January, 2009 the US Food and Drug Administration (FDA) announced it was continuing to study the effectiveness of Plavix in patients taking other medications, particularly PPIs, as well as in those with genetic variants linked with Plavix resistance. Existing data were considered to be insufficient to make firm recommendations pending data for leading investigators to analyze the drug interaction in a large cohort of Veterans Affairs patients.
- Q: In this situation of divergent and some still pending results from further studies, what should a patient do?
- A: A joint statement by the American College of Cardiology (ACC), American Heart Association (AHA) and American College of Gastroenterology (ACG) advises patients who are currently taking Plavix and a PPI, not to change their medication regimen, unless advised by their health care provider.
After studying this issue in depth (based on the current available data), we attempt to make following RECOMMENDATIONS:
- PPIs should not be prescribed “prophylactically”, just because the patient is on Aspirin or Plavix.
- Unless there is a clear indication for the PPI medication, one may consider use of alternative acid-reducing medications such as H2RAs some examples of which include Zantac, Pepcid, and Tagamet.
- The half life of most PPIs is fairly short---if you separate Plavix and PPI administration by at least 6-8 hours, that may prevent interference of Plavix metabolism and drug effectiveness.
Should you have further questions regarding this issue, please feel free to pick up a brochure in our office or speak to Dr. Kalra during your next appointment. Dr. Kalra will be happy to discuss your individual medical needs with your primary care or referring physician after he officially consults with you and with your permission.
DISCLAIMER: This article has been put forth in an effort to help answer some of our patients questions and address their concerns. The statements made above are generalizations and not specifically forecasting the results of pending or future studies.