Clinical Conundrum: Omeprazole Clopidogrel Interaction – Four Considerations

The omeprazole clopidogrel interaction has always been a challenging one to know precisely what to do.  Since a significant number of media reports came out in 2010 due to information regarding the omeprazole and clopidogrel interaction, it has been hotly debated as to how to manage this drug interaction.  The FDA also had a somewhat recent statement in 2016.  Omeprazole can reduce the serum concentrations of the active metabolite of clopidogrel.  If we connect the dots, we can likely suspect that this will impact our patients clinically.  However, to my knowledge, clinical studies have never been done to show negative outcomes data.  So what should we do with this interaction?

I’ll propose some questions you should think about.

  1. How long has the patient been on clopidogrel?  Remember that clopidogrel is often used for a limited time following stenting.  Make sure to look at the indication for clopidogrel.  We may be able to discontinue clopidogrel and not have to worry about the interaction.
  2. Can aspirin be substituted?  Often aspirin is going to be utilized prior to clopidogrel, but rarely you may run into a situation where a patient is on clopidogrel alone.  Be sure to ask the question and investigate if the patient has tried aspirin.  Keep in mind here that the indication does matter as well.
  3. Is the PPI required long term? PPI’s are some of the most highly utilized medications and often we can get by with an H2 blocker or even a trial taper off the PPI.  Be sure the GI indication for the PPI is reviewed and assess if we can somehow get off the PPI.
  4. Is a switch to a different PPI like pantoprazole appropriate?  This can be a pretty simple switch, but insurance, efficacy, or tolerability challenges can exist.

What else do you think about with this interaction?

4 Comments

  1. Patricia Poczciwinski

    Thanks for your insights on the clopidogrel/omeprazole issue. I practice in the inner city among some teaching hospitals and see this all the time.

    Reply
  2. Frances Rodriguez

    Hello! What if a patient has been for a long period of time using both medications (omeprazole and clopidogrel) and is not showing signs of heart disease and the prescriber doesn’t want to change the therapy?

    Reply
  3. Grant C

    I think the pharmacodynamic interaction exists and you will have less Plavix when you take omeprazole. The clinical outcome is a bit unclear but those numbers can be lost due to inter-patient variability etc. If it were me and I was on DAPT (dual antiplatelet therapy – asa/Plavix) after a heart attack or whatever I would switch to pantoprazole.

    Reply

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Written By Eric Christianson

March 26, 2017

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