Proton pump inhibitors (PPIs) were found to be superior to histamine 2 receptor antagonists (H2RAs) for preventing gastrointestinal (GI) complications in patients on dual antiplatelet therapy (DAPT), according to a study published in the journal Cardiology.

While PPIs are generally used to reduce the risk of GI bleeding in patients on DAPT, they have been associated with serious side effects such as Clostridium difficile-associated diarrhea and community-acquired pneumonia. In addition, through CYP450 inhibition, PPIs may impact the platelet inhibitory effects of certain antiplatelet agents (i.e., clopidogrel).

For this study, researchers searched several large databases (from 1980 to 2016) for randomized, controlled trials (RCTs) that compared clinical outcomes in patients on DAPT taking PPIs or H2RAs. Ten trials were identified for the systematic review; GI complications, major adverse cardiovascular events (MACE) and high on-treatment platelet reactivity (HTPR) were chosen as the clinical outcomes of interest.

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Results showed that in terms of gastroprotection, PPIs were found to be superior to H2RAs, reducing the risk of GI complications in DAPT patients (odds ratio [OR] 0.28, 95% CI 0.17-0.48, P<.001). However, PPIs were also associated with reduced platelet inhibition, thereby potentially increasing the risk for MACE, although the incidence of MACE did not differ between the 2 treatment groups (OR 0.99, 95% CI 0.55-1.77, P=0.97).  In addition, PPIs were linked to an increased risk of having HTPR vs H2RAs (OR 1.28, 95% CI 1.03-1.60, P=0.03).

“Overall, our analysis supports current clinical practice guidelines suggesting that clinicians should balance the risks of less effective platelet inhibition and theoretical risk of MACE against the benefits of gastroprotection when prescribing acid-suppressive medications in patients on DAPT with risk factors for GI bleeding,” the authors concluded, adding that “in patients being treated with DAPT deemed at risk for GI bleeding, PPIs should be utilized for gastroprotection.”

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