Aspirin plus esomeprazole reduced recurrent ulcer bleeding more than clopidogrel in high-risk patients.

and commentary also appear in ACP Journal Club. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . For correspondence: Dr F K Chan, Chinese University of Hong Kong, Shatin, Hong Kong, China. [email protected] Source of funding: no external funding. Clopidogrel v aspirin plus esomeprazole for patients with previous aspirin induced bleeding* Outcomes at 12 months Clopidogrel Aspirin + esomeprazole Difference (95% CI) Cumulative incidence of recurrent ulcer bleeding 8.6% 0.7% 7.9% (3.4 to 12.4) Cumulative incidence of lower gastrointestinal bleeding 4.6% 4.6% No difference *CI defined in glossary. Commentary T he use of antiplatelet agents (eg, low dose aspirin or clopidogrel) for the prevention of cardiovascular events is widespread. Low dose aspirin is ulcerogenic, so its use alone is contraindicated in patients at high risk of ulcer bleeding. Alternative approaches in such patients include adding a proton-pump inhibitor (PPI) to aspirin or using a nonaspirin agent (clopidogrel) instead. The study by Chan et al is the first to directly compare these 2 approaches in patients who have bled once from an aspirin associated ulcer. Somewhat surprisingly, the results of this study clearly show that the second option is not acceptable. Although clopidogrel had been believed to be non-ulcerogenic, it was associated with a substantially higher incidence of recurrent ulcer bleeding than was low dose aspirin plus a PPI (esomeprazole). Because the incidence of adverse events prevented by antiplatelet therapy was similar in the 2 groups, the recommendation to switch patients with a previous aspirin associated bleeding ulcer to clopidogrel alone is not justified. In patients who truly cannot take aspirin, clopidogrel could be used with a concomitant PPI, although this has not yet been proven to be safe. Walter L Peterson, MD University of Texas Southwestern Medical Center at Dallas Dallas, Texas, USA 1 Lai KC, Lam SK, Chu KM, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med 2002;346:2033–8. 2 Garcı́a Rodrı́guez LA, Ruigómez A. Secondary prevention of upper gastrointestinal bleeding associated with maintenance acid-suppressing treatment in patients with peptic ulcer bleed. Epidemiology 1999;10:228–32. 112 THERAPEUTICS www.evidence-basedmedicine.com EBM Volume 10 August 2005 group.bmj.com on June 19, 2017 Published by http://ebm.bmj.com/ Downloaded from