This review on the recent research suggesting an interaction between clopidogrel and proton pump inhibitors (PPIs) is conducted from the perspective of a gastroenterologist.  The author notes that there “is a lot at stake, since the volume of patients taking the dual aspirin-clopidogrel antiplatelet therapy and thereby needing gastroprotection is immense, rendering a huge responsibility to the societies and committees who are making proposals on the selection of appropriate PPIs”. 

The following issues are discussed:

• The scope of the problem
• First results on the PPI-clopidogrel interaction
• Class effect or not?
• Current FDA and EMEA standpoints

The author concludes with their recommendations for the PPI-clopidogrel interaction issue, as follows:

• Patients requiring clopidogrel treatment, especially the ones taking dual aspirin-clopidogrel therapy and/or with a history of previous gastrointestinal haemorrhages, should be considered to be given PPI for gastroprotection.

• According to the current standings, this PPI should be pantoprazole.

• Esomeprazole may later prove to be an alternative.

• Since clopidogrel has several competitive antagonists, the risk of interactions affecting the clopidogrel function and thereby leading to major cardiac adverse events (MACEs) rises if patients taking clopidogrel and PPI are treated with certain statins and calcium channel blockers additionally. The optimal approach to these patients would be to perform an ex vivo vasodilator-stimulated phosphoprotein (VASP) test before the introduction of the required combined therapy in order to prevent myocardial (re-) infarction due to adverse drug interactions.