Chan FKL, Ching JYL, Hung LCT, et al: Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med 2005;352(3):238-44.
Cryer B: Reducing the risks of gastrointestinal bleeding with antiplatelet therapies. N Eng J Med 2005;352(3):287-9 (editorial).
Current cardiology guidelines recommend clopidogrel for patients unable to take aspirin because of previous gastrointestinal intolerance. Chan and colleagues studied 320 patients with upper gastrointestinal bleeding. After healing and eradication of Helicobacter pylori bacteria, patients were randomly assigned to receive clopidogrel (Plavix) 75 mg daily or the proton pump inhibitor esomeprazole (Nexium) 20 mg twice daily plus 80 mg aspirin daily. After one year, 8.6% of the patients in the clopidogrel group had a recurrent ulcer compared to 0.7% in the aspirin plus esomeprazole group (p = .001). These surprising results reinforce the need to focus on baseline gastrointestinal risk factors in patients being considered for any type of antiplatelet therapy. Even among patients taking no medications, asymptomatic gastroduodenal ulcers spontaneously form at a rate of 2% a month. Platelet aggregation plays a critical role in healing. Perhaps any antiplatelet agent may impair healing and convert asymptomatic ulcers into clinically apparent bleeding ulcers. This study indicates that replacing aspirin with clopidogrel does not protect patients at high risk of gastrointestinal complication. Instead, patients who need antiplatelet therapy to prevent thrombotic complication should be given the lowest effective dose of aspirin plus a proton pump inhibitor.