To the Editor: Dr Ho and colleagues1 reported that concomitant use of clopidogrel and a proton pump inhibitor (PPI) after discharge from hospital for acute coronary syndrome (ACS) was associated with an increased risk of rehospitalization for ACS, compared with use of clopidogrel without PPI. Based on their observations, the authors concluded that, although causality cannot be claimed, PPIs should be used based on clear clinical indications rather than prophylactic prescription. Reconsideration of prophylactic prescription of PPIs in patients with ACS has been ongoing.2 However, the recent American College of Cardiology Foundation/American College of Gastroenterology/American Heart Association (ACCF/ACG/AHA) guidelines still recommend using PPIs for aspirin users with a history of myocardial infarction, many of whom are also using clopidogrel.3
The study by Ho et al found differences only in hospitalization for ACS, not in mortality. We therefore suggest that the authors compare the incidences of gastrointestinal hemorrhage and related hospitalization rates between clopidogrel users with and without routine prophylactic PPI use within their cohort.
In addition, authors should be more cautious in using the general term PPI. They found an increased risk of adverse outcomes among ACS patients using clopidogrel that was related only to use of omeprazole and labeprazole. This may not be due to a PPI class effect. Pantoprazole and esomeprazole, other PPIs also widely used in different institutions, do not inhibit CYP450 2C19.4 Moreover, in a Canadian trial including more than 13 000 patients, omeprazole, rabeprazole, and lansoprazole were associated with an increased risk of reinfarction, but there was no association for pantoprazole.5
Finally, the main purpose of this study was to investigate the interaction effect between PPI and clopidogrel on adverse outcomes in patients with ACS. However, the authors have only shown the effect of PPI on the odds ratios of adverse outcome in 2 groups: clopidogrel users and nonusers. We believe that it would also be clinically meaningful to demonstrate the effect of clopidogrel on the odds ratios of adverse outcome among PPI users and nonusers, since it may better quantify the interactive effect of PPI on the cardioprotective effect of clopidogrel.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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