Plavix Not Best for Heart Patients With History of Ulcers

Can lead to stomach bleeding, although second study finds blood thinner generally safe

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HealthDay Reporter

WEDNESDAY, Jan. 19, 2005 (HealthDayNews) -- New research suggests the blood thinner Plavix may be more dangerous to heart patients with a history of bleeding ulcers than the alternative, an aspirin-based treatment.

Those who took Plavix were more likely to develop the problem again than those who took a combination of aspirin and a drug to reduce stomach acid, according to the study in the Jan. 20 issue of the New England Journal of Medicine.

A gastroenterologist said heart patients shouldn't panic, especially considering that Plavix remains an effective treatment for many people with cardiovascular problems. However, "if they're in a high-risk category and they've had a bleeding ulcer in the past, they should probably talk to their health-care provider about whether Plavix is the right medicine for them," said Dr. Byron Cryer, an associate professor of medicine at University of Texas Southwestern Medical School, who wrote a commentary about the study.

Many heart patients are at risk for developing blood clots, which cause strokes and other problems if they travel to the brain, heart or lungs. Traditional blood thinners -- including aspirin and Coumadin (warfarin) -- work by tinkering with chemical processes in blood, making clots less likely.

Aspirin and Coumadin aren't perfect, however. They can make it easier for bleeding to occur, and some patients develop painful stomach ulcers.

Enter the drug clopidogrel, known by the brand name Plavix, which appeared on the market in 1997. Like its counterparts, Plavix is a blood thinner, but doctors think it leads to less dangerous bleeding.

According to Cryer, cardiologists figure Plavix "is a little better than aspirin at preventing heart attacks and safer than aspirin."

On the other hand, aspirin costs pennies a pill, while Plavix is much more expensive, preventing it from being the first line of defense in some cases, Cryer said. Plavix can cost several dollars a pill.

In the latest study, researchers in Hong Kong looked at 320 heart patients who had taken aspirin but developed bleeding stomach ulcers. Of those, 161 patients received Plavix, and the rest got doses of aspirin plus the heartburn drug esomeprazole (Nexium). (Cryer has been a paid speaker for AstraZeneca, the manufacturer of Nexium.)

Only one of the patients taking the aspirin regimen developed ulcer bleeding, but 13 of the patients on Plavix did.

So, should heart patients go off Plavix?

Not necessarily, said Dr. Richard Stein, a cardiologist at Beth Israel Hospital in New York City and a spokesman for the American Heart Association. The drug appears to be good for patients who have had operations to keep their arteries open, such as angioplasties or the placement of stents, he said. And research suggests that aspirin therapy doesn't help an estimated 10 percent to 15 percent of heart patients, he said.

However, he added that the new study suggests that some patients at higher risk -- such as those who have had ulcers before -- can take aspirin with a heartburn drug, he said. "These are things you need to discuss with your doctor."

Heart patients can take comfort in another study, published in the Jan. 18 issue of the Journal of the American College of Cardiology, that found Plavix will not lead to problems for most heart patients in most cases.

Despite concerns about "clopidogrel resistance" in the medical community, the study authors, from the University of Kentucky, Duke University and the Cleveland Clinic, said their analysis of 544 cases over seven years showed that, despite a small number of adverse outcomes, the overall response to the anti-clotting drug was positive. They did state that larger studies are needed to confirm their findings.

More information

Learn more about Plavix from the National Institutes of Health.

SOURCES: Byron Cryer, M.D., associate professor, medicine, University of Texas Southwestern Medical School, Dallas; Richard Stein, M.D., cardiologist, Beth Israel Hospital, New York City; Jan. 20, 2005, New England Journal of Medicine; Jan. 18, 2005, Journal of American College of Cardiology

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