Had a stent a month ago today and cardiologist wanted me to go back on omeprazole but I insisted on Pantoprazole. I need the omeprazole long term due to severe GERD. He told me that the interaction advice was an old Canadian study and that there have been ample studies to confirm that Ompeprazole did not cause any risks in PCI patients. After 30 days on the Pantoprazole if was having severe acid reflux and eventually got sick which was just pure acid. I emailed him last night and he immediately replied to go back on the Omeprazole as there were no indications in any study about any cardiac harm arising out of their use. I went back on them and felt much better this morning. I am still concerned about the google reports and would welcome any replies that may put my mind at ease. This cardiologist is a professor and top man in the private clinic I attend which is why I went along with him. He also said a tummy bleed could be very serious which is probably why he replied to me at 9PM.
Omeprazole and Clopidogrel: Had a stent... - British Heart Fou...
Omeprazole and Clopidogrel
LIke you I am a long term user of PPIs for reflux, and rely on them to control my symptoms. I used to take esomeprazole (Nexium) but in 2018 I had an NSTEMI and was subsequently prescribed Clopidogrel for a year and simultaneously my PPI was changed to equivalent dose of Lansoprazole due to the apparent interaction between esomeprazole and Clopidogrel. I have been on Lansoprazole ever since and can say that for me it has worked just as well as esomeprazole. Current advice in the UK on the use of both esomeprazole and also omeprazole with Clopidogrel appears to be that should not be prescribed concurrently see below, whereas other PPIs are fine. So my advice is to try Lansoprazole (purely on the basis that it has worked for me) or explore with your prescribing physician whether your Pantoprazole dose needs to be increased. Many years ago I was on the max dose of esomeprazole but then halved the dose as a trial which worked but further reduction brought back my reflux symptoms so I ended up at the half dose. Hope you get sorted, since as you say stomach bleeds are serious (speaking from personal experience) and long term backwash of highly acidic stomach contents into the oesophagus can have very serious consequences.
gov.uk/drug-safety-update/c...
Hi, yes I read that post and many more with it and the evidence is a bit sketchy on them all. They all go back to that 2009 trials which showed that PPIs particuarly omeprazole did seem to impair the effect of Clopidogrel. They all state that the trial did not find any bad cardio outcomes from their use. As you are aware severe acid reflux is very painful to say the least. I take 40mg of Omeprazole for this and wonder what dose of Lansoprazole you are taking now and what dose of Omeprazole you were taking. Pantoprazole is not working in the least for me so would like an idea of what dose to ask my GP for that might work as well. My Pantoprazole dose was 40mg. Thank you for your reply and would appreciate is you told me what dose worked for you.
I initially took 40mg esomeprazole later reducing to 20mg, both once daily. Post NSTEMI I was put on 30mg Lansoprazole once daily and have remained on that although I stopped the Clopidogrel over four years ago. For your info you might find the table in the reference below useful.
cks.nice.org.uk/topics/dysp...
Great thank you, at least I have something to ask my GP about. I will see what he says but difficult to relax when you read too much on the internet. The link above will not open as it is for the UK only and I live in Ireland? strange.
20 mg Esomeprazole is equivalent to 20mg Omeprazole = 30 mg Lansoprazole = 40 mg Pantoprazole, once daily. This is the full or standard dose. A 'double dose' is the same either by twice daily or twice the strength once daily to treat,severe oesophagitis with a further option for esomeprazole and omeprazole only of 40mg twice daily to treat really severe oesophagitis.
This is the article "Choice of proton pump inhibitorTable 1 shows the recommended doses of proton pump inhibitors (PPIs) for the management of people with gastro-oesophageal reflux disease (GORD) and severe oesophagitis.Table 1. PPI doses for management of GORD and severe oesophagitis symptoms.PPIFull or standard doseLow dose (on-demand dose)Double doseOmeprazole20 mg once a day (40 mg once a day if severe oesophagitis)* 10 mg once a day (20 mg once a day if severe oesophagitis)40 mg once a day (40 mg twice a day if severe oesophagitis)Lansoprazole30 mg once a day15 mg once a day* 30 mg twice a dayPantoprazole40 mg once a day20 mg once a day* 40 mg twice a dayRabeprazole20 mg once a day10 mg once a day* 20 mg twice a dayEsomeprazole† 20 mg once a day (40 mg once a day if severe oesophagitis)Not available (20 mg once a day if severe oesophagitis)‡ 40 mg once a day (40 mg twice a day if severe oesophagitis)Doses in brackets are specifically for use in severe oesophagitis.Doses should be given 30 minutes before breakfast and (if needed) 30 minutes before the evening meal, to provide optimal control of gastric pH.* Off-label dose for GORD.† This is lower than the licensed starting dose in GORD, but is considered to be dose-equivalent to other PPIs.‡ This dose is recommended for double dose, because the 20 mg dose of esomeprazole is considered to be equivalent to omeprazole 20 mg.Data from: [NICE, 2019]Contraindications and cautionsProton pump inhibitors (PPIs) should not be prescribed to people:With alarm symptoms before endoscopy, as PPIs may mask the symptoms of upper gastrointestinal malignancy. If the person is already taking a PPI and subsequently needs an endoscopy, the PPI should be stopped at least 2 weeks before the procedure.PPIs should be prescribed with caution to people:At risk of osteoporosis — the person should maintain an adequate intake of calcium and vitamin D, and if necessary, be given additional bone-sparing therapy.At risk of hypomagnesaemia — if possible, magnesium levels should be checked before starting PPI therapy and intermittently during long-term treatment, for example if the person is prescribed drugs that can cause hypomagnesaemia, such as digoxin and diuretics.[MHRA, 2012a; BNF, 2022]Adverse effectsAdverse effects of proton pump inhibitors (PPIs) are usually mild and reversible.Adverse effects include headache, diarrhoea, nausea, vomiting, abdominal pain, constipation, and dizziness.Less common adverse effects include dry mouth, peripheral oedema, sleep disturbance, fatigue, paraesthesia, arthralgia, myalgia, pruritus, and rash.Rare or very rare adverse effects include:Subacute cutaneous lupus erythematosus (SCLE), which can occur weeks, months, or years after exposure to a PPI. If suspected discontinue the PPI and seek specialist advice if needed [MHRA, 2015].Severe cutaneous adverse reactions (SCARs) including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP) have been reported very rarely and rarely with omeprazole treatment.Taste disturbance, hepatitis, jaundice, depression, confusion, hallucinations, hyponatraemia, interstitial nephritis, leucopenia, leucocytosis, pancytopenia, thrombocytopenia, visual disturbances, sweating, photophobia, and alopecia.Long-term PPI treatment may be associated with uncommon, serious adverse effects such as:Hypomagnesaemia — symptoms include muscle twitching, tremors, vomiting, fatigue, and loss of appetite. Case reports after one year of PPI therapy, but may occur after 3 months. This usually improves after magnesium replacement therapy and discontinuation of the PPI [MHRA, 2012a]. Hypomagnesaemia may lead to hypocalcaemia and/or hypokalaemia.Increased risk of fractures — especially when used at high doses for over a year in the elderly [MHRA, 2012b].Clostridium difficile infection — due to the effect of decreasing gastric acidity.Rebound acid hypersecretion syndrome — may occur after stopping long-term PPI therapy, although this may be more a theoretical risk than clinical phenomenon.[NICE, 2019; BNF, 2022]Drug interactionsPossible drug interactions with proton pump inhibitors (PPIs) include:Citalopram and escitalopram — co-exposure to omeprazole or esomeprazole can lead to increased levels of citalopram and escitalopram. Dose adjustment may be necessary depending on side-effects.Digoxin — PPIs may cause a small rise in serum digoxin levels (although not considered clinically significant). The manufacturer of lansoprazole suggests that digoxin levels should be monitored if lansoprazole is started or stopped.Warfarin — PPIs can occasionally enhance the effects of warfarin. The international normalized ratio (INR) should be monitored in people taking warfarin if omeprazole, pantoprazole, or esomeprazole is started or stopped.Methotrexate — PPIs possibly reduce excretion of methotrexate, leading to an increased risk of methotrexate toxicity.Phenytoin — omeprazole and esomeprazole can occasionally enhance the effects of phenytoin. The manufacturers recommend that people taking phenytoin are carefully monitored if omeprazole or esomeprazole is started or stopped.Azole antifungals — the absorption of ketoconazole or itraconazole may be reduced during PPI treatment. Dose adjustment of the antifungal drug may be required during long-term PPI treatment.Clopidogrel — omeprazole and esomeprazole reduce the antiplatelet effect of clopidogrel, and concomitant use should be avoided. The other PPIs may also reduce the efficacy of clopidogrel, and this risk should be weighed against the potential benefit of the PPI [MHRA, (2010)].Protease inhibitors — PPIs can significantly affect plasma levels of some protease inhibitor drugs, including:Atazanavir — concurrent use of PPIs and atazanavir is not recommended as the absorption of atazanavir may be affected by a PPI (due to changes in gastric acidity). This may lead to a reduced plasma concentration of atazanavir which may affect its efficacy. If concurrent use is necessary, seek specialist advice.Saquinavir — plasma concentration of saquinavir may be increased by PPI treatment, leading to increased risk of adverse effects.Tipranavir — concurrent use with omeprazole or esomeprazole is not recommended, as tipranavir may reduce the plasma concentration of the PPI. If concurrent use is necessary, seek specialist advice. [ABPI, 2021; BNF, 2022; Preston, 2022]Back to topGuidanceStandards and indicatorsLife sciencesBritish National Formulary (BNF)British National Formulary for Children (BNFC)Clinical Knowledge Summaries (CKS)Knowledge resourcesAbout NICEInto practiceGet involved "
Thank you for taking the time to put this up. Took 30mg twice daily yesterday and feel much more normal today. Just want to get over the 12 months I will be on the Clopidegrel and can go back on the Omeprazole. Omeprazole appears to have a really bad press when combined with Clopidegrel although ny cardiologist does not agree for some reason.
I took omeprazole with clopidogrel for a few months last year, as prescribed by the cardiologist. Pharmacist didn't have a problem with it, and I suffered no apparent ill effects.
Disclaimer to say this was only my experience and therefore anecdotal.
Thank you for your reply as its a bit of a minefield when you compare different drugs and interactions etc. Will try and take the lansoprazole for a while as it is not indicated to interact with Clopidogrel at all. Appointment with GP tomorrow so will see if he is willing to alter my cardiologists advice. Hope he does and the Lansoprazole work on me as its stressful enough just having heart problems alone.
I normally always say go with the health professionals - but if you have concerns then always good to get it clarified.
In my case I was only on this for a short time and had aspirin as well... so it might be down to individual circumstance
Yes in my case belts and braces, I had a stent so will be on it for a year as far as I know. Sometimes ignorance can be bliss methinks.
The reason that esomeprazole and omeprazole are not recommended to be prescribed along with clopidogrel is that there is evidence that they interfere with the efficacy of clopidogrel, (apparently unlike other PPIs) which puts you at some degree of increased risk, which of course you won't normally notice.
And here's the scientific justification for the concern taken from the gov.uk report I reference above
"The available evidence for an interaction between clopidogrel and PPIs is therefore not completely consistent. Nevertheless, pharmacokinetic, pharmacodynamic, and some clinical outcome data suggest a significant interaction for omeprazole, and there is also some evidence in relation to esomeprazole."
"In light of the most recent evidence, the previous advice (to avoid all PPIs unless absolutely necessary for patients taking clopidogrel) is no longer considered necessary. Nevertheless, as a precaution, concomitant use of clopidogrel with omeprazole or esomeprazole should be discouraged. Information for prescribers and patients will be updated with the latest advice."
How this is passed on to individual health professionals and how they use the information is another thing however.
I read the studies while I was studying pharmacology (feels like a long time ago now), and remember asking the pharmacist who didn't have an issue... but I suspect it was because it was short term to be honest as I've not kept up with the research and haven't seen anything more recent.
Always good to run things past the health professionals!
Yes I read that advice and also dozens of other studies carried out since the 2009 survey which showed that people on 160mg Emeprazole daily following a loading dose were shown to have reduced platelet reduction, while other studies said they found no evidence of any dangers with any of the PPIs including Omeprazole. The study also said that while there was a increase in platelet activity that no adverse effects were noted in any of the patients. Confusing to say the least especially when one of the top cardiologists can not see a problem at all. I am hoping to get the Lansopraloze 30mg twice daily and see if I need that much. As 30mg is the same as 20mg Omeprazole and I am on 40mg Omeprazole, if I can get away with just the one in the morning and maybe the occasional second one I would be very happy indeed. Hoping my GP will prescribe them and of course I do not have problems with them. Thank you for taking the time to give me such a detailed informative reply and much appreciated.
I was on Omeprozole and was taken off it when I had a stent and put on lanzoprasole for the same reasons told Omeprozole stopped the clopidogerol working properly. Unfortunately the lanzoprasole gave me very upset stomach so now take pantoperzole which I personally have been fine on.
Hoping I do not have that problem with Lanzoprazole as the pantoprazole is not working for me?. Glad you got one to suit you.
I was put on Lansoprazole with Clopidogrel when I had my atrial septal closure with 2 titanium devices. It never seemed to keep my reflux under control, and I'm now back on Omeprazole, as I have finished Clopidogorel. My reflux is now behaving it's self!
am I on Lansoprazole and this is my 3rd day and I agree that its not working as I am getting tummy pain, burning and bad headaches. I am currently on 30mg and changing today to 30mg one day and one night. Have tried Pantoprazole and that was useless although no headaches. Never had any problems with my omeprazole 40mg once daily and if this does not work I will have to go back on it. My cardiologist told me Omeprazole is fine and that it did not cause any problems so who do you believe. What doses of each were you taking?.
I was on 15mg Lansoprazole twice a day, but am back on 20mg Omeprazole twice a day, as I was pre surgery.
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