Being cautious with clopidogrel ▸

Clopidogrel prevents vascular ischaemic events by inhibiting the platelet adenosine diphosphate receptor and causes fewer gastrointestinal bleeds compared with aspirin. It is indicated for patients that need an antiplatelet drug but are unable to take aspirin because of a previous gastrointestinal bleed. The efficacy of this approach compared with aspirin and acid suppression is unclear.

Chan et al evaluated this in a randomised double blind controlled trial of 320 patients who presented with a peptic ulcer bleed on aspirin. All were Helicobacter pylori negative or had the infection successfully treated and the ulcer was healed with acid suppression. A total of 161 patients were randomised to receive clopidogrel 75 mg daily and 159 aspirin 80 mg daily plus esomeprazole 20 mg twice daily. Patients were followed up for one year and recurrent peptic ulcer bleeding occurred in 13 of the clopidogrel group compared with one of the aspirin–esomeprazole group (absolute difference in rate 7.9% (95% confidence interval 3.4–12.4%)).

This is another well designed and important trial on the prevention of ulcer bleed from Hong Kong. It is unfortunate that an aspirin only arm was not …