Trip Answers

Question answered:04/12/07 Warning! this question is over two years old.

We searched the NLH Gastroenterology and Liver Diseases Specialist Library and TRIP and Medline databases but found no guidelines or studies examining the effectiveness and safety of clopidogrel for cardiovascular protection in patients with Barrett’s oesophagus.

 

The CKS guideline on antiplatelet therapy makes some general recommendations for reducing gastrointestinal adverse effects in patients on low-dose aspirin. However, patients with Barrett’s oesophagus are not specifically mentioned.

 

“What should I do if a person on aspirin is at increased risk of gastrointestinal adverse effects, or develops severe dyspepsia?
• For people at high risk of GI adverse effects or who continue to have dyspepsia, the options are:
o Low-dose aspirin with a proton pump inhibitor for gastroprotection
o Clopidogrel instead of aspirin
o To avoid antiplatelet drugs (but this may not be advisable in a person at high cardiovascular risk)
• There is evidence that taking aspirin with a proton-pump inhibitor (PPI) may be a safer option than switching to clopidogrel.
• In addition, if a person develops dyspepsia while taking aspirin, there is evidence that switching to clopidogrel may not improve dyspeptic symptoms.” [1]

 

Given the lack of guidance on this issue, the NLH Primary Care Q & A Service can only recommend seeking advice from a local specialist.

 

As an aside during our literature search, we came across references to several trials examining the use of aspirin and proton pump inhibitors in Barrett’s oesophagus to reduce the risk of oesophageal cancer that may be of interest. For example, a paper by Leedham and Jankowski notes:

 

“ … Proton pump inhibitors (PPIs) are the mainstay of therapy in Barrett's esophagus, and have numerous beneficial effects including symptom control, reduction of inflammation, and promotion of the development of squamous islands. However, PPI therapy causes hypergastrinemia and has not prevented recent increase in the incidences of esophageal cancer. Additionally, evidence presented here by Feagins et al. suggests that acid exposure has a p53-mediated, antiproliferative effect on a nondysplastic Barrett's epithelial cell line, an effect that acid suppression might abrogate. These complex pH, inflammation, and growth factor biological interactions can be most reliably tested in large clinical trials with hard end points like cancer conversion or all causes of mortality. Combining the anti-inflammatory effects of acid suppression with aspirin, a nonsteroidal anti-inflammatory agent, is the subject of the AspECT clinical trial, and this may be the future of chemoprevention in Barrett's.” [2]

 

References
1. CKS. Antiplatelet treatment. October 2006. (http://www.cks.library.nhs.uk/antiplatelet_treatment/in_depth/management_issues)
2. Leedham S and Jankowski J. The evidence base of proton pump inhibitor chemopreventative agents in Barrett's esophagus--the good, the bad, and the flawed! Am J Gastroenterol. 2007 Jan;102(1):21-3. (http://www.hubmed.org/display.cgi?uids=17266685).

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