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In the COGENT study, patients who were taking aspirin plus clopidogrel (in most cases after coronary stenting) were randomized to receive the proton-pump inhibitor (PPI) omeprazole or placebo. Omeprazole protected against gastrointestinal (GI) bleeding without affecting adverse cardiovascular event rates (NEJM JW Gen Med Dec 1 2010 and N Engl J Med 2010; 363:1909). In this post hoc analysis of COGENT data, investigators examined whether omeprazole was effective and safe regardless of aspirin dose; 2480 patients received low-dose aspirin (≤100 mg daily) and 1272 patients received high-dose aspirin (>100 mg daily). Median follow-up was 110 days.
High-dose and low-dose aspirin were associated with similar rates of adverse GI events (about 2%) and adverse cardiovascular events (about 5%). Omeprazole recipients had lower rates of adverse GI events than placebo recipients among both high-dose aspirin users (0.9% vs. 2.6%) and low-dose users (1.2% vs. 3.1%). Among both high-dose and low-dose aspirin users, rates of adverse cardiovascular events were similar in the omeprazole and placebo groups.
Vaduganathan M et al. Proton-pump inhibitors reduce gastrointestinal events regardless of aspirin dose in patients requiring dual antiplatelet therapy. J Am Coll Cardiol 2016 Mar 16; [e-pub]. (http://dx.doi.org/10.1016/j.jacc.2015.12.068)
Comment
This analysis suggests that in patients who receive clopidogrel plus aspirin, PPI therapy prevents adverse GI events regardless of aspirin dose. Aspirin dosing in this trial was at the providers' discretion and was quite variable, with approximately one third of participants receiving high-dose aspirin. Keep in mind that the specific antiplatelet drug being used also can influence aspirin dose. For example, lower aspirin doses are recommended when ticagrelor is used.