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From the Department of Medicine (Juurlink, Ko, Tu), Sunnybrook Health Sciences Centre, Toronto, Ont.; the Institute for Clinical Evaluative Sciences (Juurlink, Gomes, Ko, Austin, Tu, Henry, Kopp, Mamdani), Toronto, Ont.; the Department of Medicine (Szmitko, Mamdani), St. Michael's Hospital, Toronto, Ont.; and the Department of Medicine (Juurlink, Ko, Tu, Henry, Mamdani), the Department of Health Policy, Management and Evaluation (Austin, Henry) and the Dalla Lana School of Public Health (Austin), University of Toronto, Toronto, Ont.
Correspondence to: Dr. David Juurlink, G Wing 106, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto ON M4N 3M5; fax 416 480-6048; dnj{at}ices.on.ca
Background: Most proton pump inhibitors inhibit the bioactivation of clopidogrel to its active metabolite. The clinical significance of this drug interaction is unknown.
Methods: We conducted a population-based nested case–control study among patients aged 66 years or older who commenced clopidogrel between Apr. 1, 2002, and Dec. 31, 2007, following hospital discharge after treatment of acute myocardial infarction. The cases in our study were those readmitted with acute myocardial infarction within 90 days after discharge. We performed a secondary analysis considering events within 1 year. Event-free controls (at a ratio of 3:1) were matched to cases on age, percutaneous coronary intervention and a validated risk score. We categorized exposure to proton pump inhibitors before the index date as current (within 30 days), previous (31–90 days) or remote (91–180 days).
Results: Among 13 636 patients prescribed clopidogrel following acute myocardial infarction, we identified 734 cases readmitted with myocardial infarction and 2057 controls. After extensive multivariable adjustment, current use of proton pump inhibitors was associated with an increased risk of reinfarction (adjusted odds ratio [OR] 1.27, 95% confidence interval [CI] 1.03–1.57). We found no association with more distant exposure to proton pump inhibitors or in multiple sensitivity analyses. In a stratified analysis, pantoprazole, which does not inhibit cytochrome P450 2C19, had no association with readmission for myocardial infarction (adjusted OR 1.02, 95% CI 0.70–1.47).
Interpretation: Among patients receiving clopidogrel following acute myocardial infarction, concomitant therapy with proton pump inhibitors other than pantoprazole was associated with a loss of the beneficial effects of clopidogrel and an increased risk of reinfarction.
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