ABSTRACT
BACKGROUND: Recent pharmacodynamic and retrospective clinical analyses have suggested that proton pump inhibitors (PPIs) may modify the antiplatelet effects of clopidogrel bisulfate. METHODS: We conducted a retrospective cohort study of persons enrolled in a multistate health insurance plan with commercial and Medicare clients to evaluate adverse clinical outcomes in patients using clopidogrel plus a PPI compared with clopidogrel alone. Patients who were discharged from the hospital after myocardial infarction (MI) or coronary stent placement and treated with clopidogrel plus a PPI (n = 1033) were matched 1:1 (using propensity scoring) with patients with similar cardiovascular risk factors treated with clopidogrel alone. Rehospitalizations for MI or coronary stent placement were evaluated for up to 360 days. A subanalysis was conducted to study the impact of pantoprazole sodium, the most used PPI. RESULTS: Patients who received clopidogrel plus a PPI had a 93% higher risk of rehospitalization for MI (adjusted hazard ratio, 1.93; 95% confidence interval, 1.05-3.54; P = .03) and a 64% higher risk of rehospitalization for MI or coronary stent placement (1.64; 1.16-2.32; P = .005) than did patients receiving clopidogrel alone. Increased risk of rehospitalization for MI or coronary stent placement was also observed for the subgroup of patients receiving clopidogrel plus pantoprazole (adjusted hazard ratio, 1.91; 95% confidence interval, 1.19-3.06; P = .008). CONCLUSIONS: Patients who received clopidogrel plus a PPI had a significantly higher risk of rehospitalization for MI or coronary stent placement than did patients receiving clopidogrel alone. Prospective clinical trials and laboratory analyses of biochemical interactions are warranted to further evaluate the potential impact of PPIs on the efficacy of clopidogrel.
Subject(s)
Coronary Restenosis/epidemiology , Myocardial Infarction/drug therapy , Patient Readmission/statistics & numerical data , Proton Pump Inhibitors/therapeutic use , Ticlopidine/analogs & derivatives , Age Factors , Aged , Aged, 80 and over , Case-Control Studies , Clopidogrel , Cohort Studies , Confidence Intervals , Coronary Restenosis/etiology , Drug Interactions , Drug Therapy, Combination , Female , Humans , Male , Middle Aged , Myocardial Infarction/diagnosis , Myocardial Infarction/mortality , Probability , Proportional Hazards Models , Proton Pump Inhibitors/adverse effects , Reference Values , Retrospective Studies , Risk Assessment , Sex Factors , Survival Rate , Ticlopidine/adverse effects , Ticlopidine/therapeutic useABSTRACT
Implementation of a health IT system is an initiative that requires a clear game plan. That plan should entail: Careful initiative planning and vendor selection led by an individual with the appropriate technical expertise, Contract negotiations led by an individual who understands the inherent traps and pitfalls of such negotiations, Choice of a qualified project manager, Ongoing monitoring of the project's status. Implementation including conversion of the right amount of legacy data at the right time, Assignment of a point person or persons to monitor results following implementation.
