质子泵抑制剂-氯吡格雷高炜.pptVIP

实验研究不能等同于临床实践 实验室PPI对氯吡格雷和普拉格雷抗血小板效应的适度抑制作用尚不足以转换到临床增加MACE的风险 —— 达到增加临床MAC风险的阈值相当高，PPI通常难以达到 曾有报道阿托伐他汀与氯吡格雷在CYP3A4水平存在竞争性相互作用，降低氯吡格雷的抗血小板效应，后续的流行病学研究和随机临床试验并未证实阿托伐他汀与氯吡格雷联用增加MACE Cardiologists shocked by new FDA alert on clopidogrel-PPI interaction New data show that when clopidogrel and omeprazole are taken together, the effectiveness of clopidogrel is reduced. Patients at risk for heart attacks or strokes who use clopidogrel to prevent blood clots will not get the full effect of this medicine if they are also taking omeprazole. clopidogrels active metabolite effect on platelets compared the amount of in people who took clopidogrel plus omeprazole vs those who took clopidogrel alone. A reduction in active metabolite levels of about 45% was found in people who received clopidogrel with omeprazole compared with those taking clopidogrel alone. The effect of clopidogrel on platelets was reduced by as much as 47% in people receiving clopidogrel and omeprazole together. These reductions were seen whether the drugs were given at the same time or 12 hours apart, the statement adds. 应避免将对 CYP2C19 有抑制作用的药物与氯吡格雷联合应用 Cimetidine 西咪替丁 Fluconazole 氟康唑 Ketoconazole 酮康唑 Voriconazole 伏立康唑 Etravirine Felbamate 非尔氨酯 Fluoxetine 氟西汀 Fluvoxamine 氟伏沙明 Ticlopidine 噻氯匹定 各种PPI药物对CYP2C19的反应不同，奥美拉唑对氯吡格雷的减效作用并不能代表所有PPI 需要大规模临床试验进一步探讨不同PPI对氯吡格雷药动学和药效学的影响 药理理论研究不能完全代替临床试验 H2受体阻滞剂能否取代PPI安全有效地防治抗血小板药物相关消化道出血还有待证实 氯吡格雷与PPI合用是否增加心血管事件尚无定论 何去何从 何去何从 阿司匹林和氯吡格雷抗血小板治疗有增加消化道出血的风险，严格掌握抗血小板治疗适应证；冠心病患者阿司匹林与氯吡格雷（或其他类似药物）的联合治疗原则不变 药物洗脱支架的适应证选择要慎重 对患者的全面评估，尤其是心脏以外伴随疾病的病史和检查 血栓与出血的评估，识别高危患者，“按需”使用PPI，要注意监测 “合理”用药，尤其是预防用药 期待新药物的临床使用 * * Ho PM, Maddox TM, Wang L, et al. Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome. JAMA. 2009;301(9):937-944. * * Poor responders = 16 placebo and 39 in omeprazole PRI was measured at Day 1 and omeprazole vs. placebo was given for 7 days plus clopidogrel, PRI rechecked Graph represe