PPI cuts GI events from low- and high-dose aspirin

The new analysis of COGENT provides important insights into patients treated with clopidogrel and aspirin. The data show that patients on low-dose aspirin do not have an increased risk of cardiovascular events, and that patients who take low-dose aspirin still face a significant risk for upper-gastrointestinal events. Patients taking low-dose aspirin have about the same rate of upper-GI events as patients on high-dose aspirin.

The issue of GI safety for patients on low-dose aspirin as part of dual-antiplatelet therapy has been long overshadowed by concern over a hypothetical interaction between clopidogrel and proton pump inhibitors. The issue has also been distorted by a false sense of security that when patients receive low-dose aspirin they do not require protection against GI events.

Treatment of patients taking low-dose aspirin with a PPI is underutilized. The confirmation this analysis provides, that PPI treatment gives GI protection without causing an excess of cardiovascular events, calls for a change in current practice when clinicians prescribe low-dose aspirin. I’m concerned by the apparent lack of enthusiasm by clinicians to prescribe PPIs to their patients on low-dose aspirin despite their significant risk for GI events. The real question is whether all patients on low-dose aspirin should receive a PPI long term or only the subgroup of patients with high risk for an upper-GI bleed.

Dr. Michael E. Farkouh is a cardiologist at Mount Sinai Hospital in Toronto. He has no disclosures. He made these comments in an editorial that accompanied the published report (J Am Coll Cardiol. 2016 April 12;67[14]:1672-3).