Clinical Question: What is the best...

Clinical Question: What is the best anti-thrombotic for patients with a history of upper gastrointestinal (GI) bleeding?

Setting: Inpatient (any location) with out-patient follow-up

consideration Design: Randomized controlled trial (double-blinded)

Allocation: Concealed

Synopsis: Clopidogrel has been attract favor toed by the American College of Cardiology as the preferr medicine for patients who require an antithrombotic agent to preclude heart disease but have a history of bleeding peptic imposthume This study compared clopidogrel with the combination of aspirin and esomeprazole. Patients with a source of upper GI bleeding (52 percent gastric imposthume 34 percent duodenal ulcer, 8 percent with the two and 6 percent other erosions) who had healing confirmed by dint of endoscopy were randomized to receive clopidogrel in a dosage of 75 mg daily plus esomeprazole placebo twice daily or aspirin in a dosage of 80 mg daily plus esomeprazole in a dosage of 20 mg twice daily. arranges were fairly well balanced at the opening and analysis was by intention to treat. Patients were treated for 12 months

The primary issue (hematemesis, melena, or a decrease in hemoglobin of at least 2 g by means of dL accompanied by endoscopic evidence of imposthume or erosion) occurred in 86 percent of the clopidogrel collection and 0.7 percent of the aspirin plus esomeprazole form into groups (P = .001; number wanted to treat = 13). Three patients in the clopidogrel form into groups had severe bleeding complications not related to the GI tract, including couple intra-ventricular hemorrhages, one of which was fatal; there were no bleeding complications in the aspirin cluster More deaths occurred in the clopidogrel dispose (eight versus four), but this difference was not statistically significant. Also, the collections were similar in the likelihood of adverse cardiovascular marked occurrences (nine in the clopidogrel dispose versus 11 in the aspirin group)

Bottom Line: For patients with a history of bleeding peptic pustule the combination of aspirin and a proton interrogate inhibitor (PPI) twice a day was safer than clopidogrel in expressions of bleeding side effects. Although esomeprazole was used in this application of mind generic omeprazole in a dosage of 20 mg twice daily provides nearly the same stage of acid suppression at a a great quantity [i]or[/i] amount of lower cost. This study calls into question the overall safety of clopiogrel, which has been claimed to not significantly increase the risk of bleeding. (Level of Evidence: 1b)

cogitation Reference: Chan FK, et al. Clopidogrel versus aspirin and esomeprazole to obviate recurrent ulcer bleeding. N Engl J M January 20 2005;352:238-44

Used with permission from Ebell M Aspirin + PPI safer than clopidogrel if history of GI ble Accessed online March 1 2005 at: http://www.InfoPOEMs.com.

COPYRIGHT 2005 American Academy of Family Physicians

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