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Aspirin/Esomeprazole vs. Clopidogrel for Patients with Aspirin-Related Bleeding Ulcers

Which is the better approach for a patient on prophylactic aspirin who develops upper GI bleeding but has compelling indications for antiplatelet therapy?

The scenario is not uncommon: A patient taking prophylactic aspirin develops upper gastrointestinal bleeding but has compelling indications for antiplatelet therapy. What is the best approach for this patient?

In this randomized, double-blind study from Hong Kong, researchers enrolled 320 patients who had developed bleeding gastroduodenal ulcers or erosions while taking aspirin (325 mg daily) to prevent vascular events. After endoscopic documentation of ulcer healing, patients received either clopidogrel (75 mg daily) plus placebo or aspirin (80 mg daily) plus esomeprazole (20 mg twice daily). Patients who tested positive for Helicobacter pylori were included if their H. pylori were successfully eradicated.

During 1 year of therapy, the incidence of recurrent ulcer bleeding was significantly greater in the clopidogrel group than in the aspirin-plus-esomeprazole group (8.6% vs. 0.7%). The incidence of vascular ischemic events did not differ significantly between the two groups. Eight clopidogrel recipients and four aspirin-plus-esomeprazole recipients died.

Comment: In this study, aspirin plus the proton-pump inhibitor esomeprazole was safer than clopidogrel in patients with previous aspirin-associated gastroduodenal ulceration who required ongoing antiplatelet therapy. An editorialist discusses mechanisms (e.g., inhibition of the release of platelet-derived growth factors) whereby clopidogrel might impair ulcer healing and promote ulcer bleeding. Guidelines that advise the use of clopidogrel instead of aspirin in such patients should be revised.

— Allan S. Brett, MD

Published in Journal Watch General Medicine January 25, 2005

Citation(s):

Chan FKL et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med 2005 Jan 20; 352:238-44.

• Original article (Subscription may be required)
• Medline abstract (Free)

Cryer B. Reducing the risks of gastrointestinal bleeding with antiplatelet therapies. N Engl J Med 2005 Jan 20; 352:287-9.

• Original article (Subscription may be required)
• Medline abstract (Free)