Gastroprotection with Omeprazole in Dual Antiplatelet Therapy: Does Aspirin Dose Matter?

March 31, 2016

Gastroprotection with Omeprazole in Dual Antiplatelet Therapy: Does Aspirin Dose Matter?

  1. Kirsten E. Fleischmann, MD, MPH

In a placebo-controlled trial, omeprazole prevented adverse gastrointestinal events regardless of aspirin dose.

  1. Kirsten E. Fleischmann, MD, MPH

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.


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.

At the time NEJM Journal Watch General Medicine reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Editor Disclosures at Time of Publication

  • Disclosures for Kirsten E. Fleischmann, MD, MPH at time of publication Grant / Research support NIH/NHLBI; Bluefield Project to Cure Frontotemporal Dementia Leadership positions in professional societies American College of Cardiology and American Heart Association (Vice Chair, Writing Committee for Guidance on Cardiovascular Evaluation and Care for Noncardiac Surgery)


Reader Comments (2)

Ketut SANG General Practitioner, Indonesia Resident, Palliative Medicine, University of Indonesia

Patients who taking orally clopidogrel plus aspirin, PPI therapy such as Omenpazole can Interferes with the absorption and bioavailability of aspirin by altering the acidity of the stomach. It is advisable to use PPI with aspirin should be given pause in administration, not given simultaneously.

Kasim SALIM Physician, Internal Medicine, NHS England

I firmly believe that this study is an Industry sponsored one just meant to support PPI sales as there was a bad reputation for Oeprazol( and other related PPIs) causing Stent Thrombosis from interacting with a Clopidogrel metabolite making its Platelet P2Y12 blocking action ineffective ! Later Prasugrel the next generation P2Y12 blockers came in with a reputation not to have such interaction with PPIs.
As a person who is on DAPT with Clopidogrel and Enteric Coated Aspirin(150mg) from 2009(7 years by now) without any PPIs I can assertion that there is NO NEED for Omeprazole or any other PPIs with all its deleterious side effects like Atrophic Gadtritis, B12 deficiency related Spinal Vord damage, Stent thrombosis, Hip fracture from Osteopetroricketts, , Chronic Kidney disease, Gadtric tumours like GIST and Carcinoma and the recently detected chances for Dementia, Omeprazole should never be combined with DAPT if the patient is able to take enough roughage vegetables and fruits in diet prior to taking the tablets at night after supper. Using a good enteric coated preparationnof Aspirin is much better than combining Omeprazoke with DAPT !

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