Heart patients with gastrointestinal complications should use low doses of aspirin combined with drugs that treat stomach ulcers rather than taking the anti-platelet drug Plavix, thought to reduce bleeding ulcers.
Physicians are challenged in treating heart patients who may be at high-risk for gastrointestinal bleeding from aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). Factors that place patients at high-risk include a history of ulcers or gastrointestinal complications such as bleeding, increased age and congestive heart failure.
Low-dose aspirin (325 milligrams or less daily) has been shown to lower the risk of cardiovascular and cerebrovascular blood clots. It can, however, cause gastrointestinal ulceration and major bleeding, thereby limiting its overall usefulness even at the lowest effective amount. In an editorial in the current issue of The New England Journal of Medicine, Dr. Byron Cryer, associate professor of internal medicine at UT Southwestern Medical Center, said current cardiology guidelines suggest patients who cannot take aspirin because of previous bleeding ulcers be given the drug clopidogrel (Plavix), which has been found to be marginally better than low-dose aspirin in preventing heart attacks and reducing bleeding ulcers. But, Plavix’s effectiveness has not been proven in heart patients at greatest risk due to their history of gastrointestinal bleeding, and recent research indicates it actually may impair ulcer healing and markedly increase rates of bleeding.
"Clopidogrel inhibits new growth of small blood vessels in ulcers – which is important for ulcer healing," said Dr. Cryer, a VA physician. "Although Plavix may not primarily cause gastrointestinal ulcers, through inhibition of new blood vessel growth, it may impair healing of background ulcers. When combined with the propensity to increase bleeding, these agents may convert small, silent ulcers into large ulcers that bleed profoundly."
Consequently, Dr. Cryer recommends that patients at high-risk for gastrointestinal complications who require blood clot-preventing therapy should consume the lowest effective dose of aspirin combined with drugs used to treat stomach ulcers (such as Aciphex, Nexium, Prevacid, Prilosec or Protonix) rather than take clopidogrel.
The New England Journal of Medicine editorial accompanies a study in the same issue of the journal by researchers from Hong Kong. The study evaluates the use of antiplatelet therapies in patients with a history of aspirin-induced upper gastrointestinal bleeding and found those who took clopidogrel had a 900 percent increase in recurrent bleeding from ulcers when compared to patients who took aspirin with esomeprazole (Nexium).
Dr. Cryer has been a paid consultant for McNeil Consumer and Specialty Pharmaceuticals and TAP Pharmaceutical Products and a paid speaker for AstraZeneca, the maker of Nexium, and TAP Pharmaceutical Products.
The New England Journal of Medicine Jan 18, 2005
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