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Clopidogrel–proton pump inhibitor interaction in a patient requiring gastroprotection during dual antiplatelet

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Hardall topics relevant for this examClopidogrel–proton pump inhibitor interaction in a patient requiring gastroprotection during dual antiplatelet therapyMSRA

A 74-year-old woman is reviewed in general practice 3 days after discharge following NSTEMI treated with percutaneous coronary intervention and a drug-eluting stent. Her discharge medication includes aspirin 75 mg once daily and clopidogrel 75 mg once daily, planned for 12 months. Two years earlier, she was admitted with a bleeding duodenal ulcer. Helicobacter pylori eradication was subsequently confirmed. She remains on omeprazole 20 mg once daily and has no current dyspepsia, melaena or anaemia. Renal and liver function are normal. What is the most appropriate medicines-management action now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Change omeprazole to pantoprazole and continue dual antiplatelet therapy

Explanation lettering: B = shown as A · E = shown as B · A = shown as C · C = shown as D · D = shown as E

This patient has an ongoing high risk of upper gastrointestinal bleeding: she is older, has had previous ulcer bleeding and is now taking dual antiplatelet therapy. She should therefore remain on gastroprotection; successful Helicobacter pylori eradication removes one risk factor but does not negate drug-related bleeding risk. Omeprazole should, however, be avoided with clopidogrel. Clopidogrel requires CYP2C19-mediated conversion to its active metabolite, and omeprazole inhibits CYP2C19. SPS advises switching patients who require clopidogrel from omeprazole or esomeprazole to lansoprazole, pantoprazole or rabeprazole. Pantoprazole is an appropriate choice here. A retains the avoidable interaction. C inappropriately withdraws part of indicated dual antiplatelet therapy immediately after an MI and PCI; NICE recommends continuing dual antiplatelet therapy for up to 12 months after MI unless contraindicated. D is incorrect because the interaction is metabolic rather than a simple absorption interaction: even administration 12 hours apart reduces active clopidogrel exposure. E overlooks her substantial continuing gastrointestinal-risk profile.

Reference: Using clopidogrel with proton pump inhibitors (PPIs) (Updated 14 September 2023) — https://sps.nhs.uk/articles/using-clopidogrel-with-proton-pump-inhibitors-ppis/ Acute coronary syndromes: recommendations (2020) — https://www.nice.org.uk/guidance/NG185/chapter/recommendations Clopidogrel 75 mg film-coated tablets - Summary of Product Characteristics (Accessed August 2026) — https://www.medicines.org.uk/emc/product/14736/smpc