Pharmacodynamic effect and clinical efficacy of clopidogrel and prasugrel with or without a proton-pump inhibitor: an analysis of two randomised trials
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Authors
O'Donoghue, Michelle L.Braunwald, Eugene
Antman, Elliott M.
Murphy, Sabina A.
Bates, Eric R.
Rozenman, Yoseph
Michelson, Alan D.
Hautvast, Raymond W.
Ver Lee, Peter N.
Close, Sandra L.
Shen, Lei
Mega, Jessica L.
Sabatine, Marc S.
Wiviott, Stephen D.
UMass Chan Affiliations
Department of PediatricsDocument Type
Journal ArticlePublication Date
2009-09-19Keywords
Acute Coronary SyndromeAged
Cardiovascular Diseases
Drug Interactions
Drug Therapy, Combination
Female
Humans
Kaplan-Meier Estimate
Logistic Models
Male
Middle Aged
Multivariate Analysis
Piperazines
Platelet Aggregation
Platelet Aggregation Inhibitors
Proportional Hazards Models
Proton Pump Inhibitors
Pyridines
Randomized Controlled Trials as Topic
Risk Factors
Thiophenes
Ticlopidine
Treatment Outcome
Hematology
Oncology
Pediatrics
Metadata
Show full item recordAbstract
BACKGROUND: Proton-pump inhibitors (PPIs) are often prescribed in combination with thienopyridines. Conflicting data exist as to whether PPIs diminish the efficacy of clopidogrel. We assessed the association between PPI use, measures of platelet function, and clinical outcomes for patients treated with clopidogrel or prasugrel. METHODS: In the PRINCIPLE-TIMI 44 trial, the primary outcome was inhibition of platelet aggregation at 6 h assessed by light-transmission aggregometry. In the TRITON-TIMI 38 trial, the primary endpoint was the composite of cardiovascular death, myocardial infarction, or stroke. In both studies, PPI use was at physician's discretion. We used a multivariable Cox model with propensity score to assess the association of PPI use with clinical outcomes. FINDINGS: In the PRINCIPLE-TIMI 44 trial, 201 patients undergoing elective percutaneous coronary intervention were randomly assigned to prasugrel (n=102) or high-dose clopidogrel (n=99). Mean inhibition of platelet aggregation was significantly lower for patients on a PPI than for those not on a PPI at 6 h after a 600 mg clopidogrel loading dose (23.2+/-19.5% vs 35.2+/-20.9%, p=0.02), whereas a more modest difference was seen with and without a PPI after a 60 mg loading dose of prasugrel (69.6+/-13.5% vs 76.7+/-12.4%, p=0.054). In the TRITON-TIMI 38 trial, 13,608 patients with an acute coronary syndrome were randomly assigned to prasugrel (n=6813) or clopidogrel (n=6795). In this study, 33% (n=4529) of patients were on a PPI at randomisation. No association existed between PPI use and risk of the primary endpoint for patients treated with clopidogrel (adjusted hazard ratio [HR] 0.94, 95% CI 0.80-1.11) or prasugrel (1.00, 0.84-1.20). INTERPRETATION: The current findings do not support the need to avoid concomitant use of PPIs, when clinically indicated, in patients receiving clopidogrel or prasugrel. FUNDING: Daiichi Sankyo Company Limited and Eli Lilly and Company sponsored the trials. This analysis had no funding.Source
Lancet. 2009 Sep 19;374(9694):989-97. Epub 2009 Aug 31. doi 10.1016/S0140-6736(09)61525-7DOI
10.1016/S0140-6736(09)61525-7Permanent Link to this Item
http://hdl.handle.net/20.500.14038/43314PubMed ID
19726078Related Resources
Link to article in PubMedae974a485f413a2113503eed53cd6c53
10.1016/S0140-6736(09)61525-7