What are the guidelines for using Proton Pump Inhibitors (PPI) with dual antiplatelet therapy post Percutaneous Coronary Intervention (PCI)?

From the Guidelines

Proton pump inhibitors (PPIs) are recommended for patients on dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) who have high gastrointestinal bleeding risk, as stated in the 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease 1.

Guidelines for PPI Use with DAPT Post-PCI

The guidelines suggest that PPIs should be used in patients with a history of prior GI bleeding who require DAPT, as well as in patients with an increased risk of GI bleeding, such as advanced age, concomitant use of warfarin, steroids, NSAIDs, or Helicobacter pylori infection 1.

Preferred PPI Options

The preferred PPI options include pantoprazole 40mg daily, omeprazole 20mg daily, or esomeprazole 40mg daily, which should be continued for the duration of DAPT.

High Bleeding Risk Factors

High bleeding risk factors include:

• History of GI bleeding
• Peptic ulcer disease
• Age over 65
• Concurrent anticoagulation
• Chronic steroid or NSAID use
• H. pylori infection

PPI Mechanism and Interaction with Antiplatelet Therapy

PPIs work by reducing gastric acid production, thereby decreasing the risk of GI bleeding associated with antiplatelet therapy. While there were historical concerns about potential interactions between PPIs (particularly omeprazole) and clopidogrel reducing antiplatelet effectiveness, current evidence suggests this interaction has minimal clinical significance 1.

Routine PPI Prophylaxis

For patients without elevated bleeding risk, routine PPI prophylaxis is not necessary. If a PPI is prescribed, it's best taken in the morning before breakfast to maximize effectiveness, and patients should be reassessed periodically for continued need, especially after DAPT is completed.

Bleeding Mitigation Strategy

Every effort should be pursued to mitigate the risk of bleeding complications while the patient is on DAPT, including access site selection, modulation of modifiable risk factors for bleeding, low dose aspirin, low dose of P2Y12 inhibitor as appropriate, and routine use of PPI 1.

From the FDA Drug Label

Proton Pump Inhibitors Advise patients not to take omeprazole or esomeprazole while taking clopidogrel. Dexlansoprazole, lansoprazole, and pantoprazole had less pronounced effects on the antiplatelet activity of clopidogrel than did omeprazole or esomeprazole [see Drug Interactions (7.2)].

The guidelines for using Proton Pump Inhibitors (PPI) with dual antiplatelet therapy post Percutaneous Coronary Intervention (PCI) are to avoid concomitant use of omeprazole or esomeprazole with clopidogrel, as they may decrease the antiplatelet activity of clopidogrel.

• Dexlansoprazole, lansoprazole, and pantoprazole have less pronounced effects on the antiplatelet activity of clopidogrel and may be considered as alternatives.
• Patients should be advised not to take omeprazole or esomeprazole while taking clopidogrel 2.
• The clinical impact of concomitant administration of pantoprazole and clopidogrel had no clinically important effect on exposure to the active metabolite of clopidogrel or clopidogrel-induced platelet inhibition 3.

From the Research

Guidelines for Using Proton Pump Inhibitors (PPI) with Dual Antiplatelet Therapy Post Percutaneous Coronary Intervention (PCI)

There are no specific guidelines mentioned in the provided studies regarding the use of Proton Pump Inhibitors (PPI) with dual antiplatelet therapy post Percutaneous Coronary Intervention (PCI).

Dual Antiplatelet Therapy (DAPT) Post PCI

• DAPT reduces ischemic and thrombotic events after PCI 4
• The standard duration of DAPT is 6-12 months after PCI, followed by aspirin monotherapy indefinitely 5
• Short-duration DAPT has been evaluated as a strategy to reduce bleeding rates, with aspirin monotherapy or P2Y12 inhibitor monotherapy after a short duration of DAPT 4, 6

P2Y12 Inhibitor Monotherapy Post PCI

• P2Y12 inhibitor monotherapy has been shown to reduce the risk of bleeding complications without a significant increase in ischemic events compared to standard DAPT 6
• Clopidogrel monotherapy has been associated with reductions in major adverse cardiac events (MACE) and stroke compared to aspirin monotherapy 5

De-escalation of Anti-platelet Therapy Post PCI

• De-escalation of anti-platelet therapy, such as switching from a more potent P2Y12 inhibitor to clopidogrel, may be considered as a strategy to reduce bleeding risk 7
• However, the optimum time, loading dose, and interval of transition between P2Y12 inhibitors are still controversial and require further evidence 7