“Cosidering PPI when prescribing NOAC in high-risk patient"

Professor Kim Min-su of Cardiology Department at Chungnam National University Sejong Hospital

Professor Kim Min-su

Already, it has been ten years since new oral anticoagulant (NOAC) has launched in the South Korean market.

 

Experts are actively discussing the practical use of NOAC as relevant prescription records have been accumulated.

 

Regarding the off-label prescription of the drug, the interest has heightened recently on optimizing the dose and bleeding control in Asian population.

 

An example would be simultaneously using proton pump inhibitors (PPIs) with NOAC or dual antiplatelets therapy (DAPT) to manage gastrointestinal bleeding.

 

Clinical evidences are collected to support the East Asian Paradox theory that claims antiplatelets therapy in East Asians and Westerners demonstrate different outcomes in efficacy and safety.

 

Professor Kim Min-su of Cardiology Department at Chungnam National University Sejong Hospital spoke to Daily Pharm that, “In a clinical scene where there a patient has gastrointestinal bleeding while using NOAC, the therapy is maintained with PPI-like gastric mucous membrane protector, if the case is not critical.” As for DAPT, PPI prescription is recommended by American College of Chest Physicians (CHEST) guideline for antiplatelet therapy in patients with atrial fibrillation (AF).

 

The guideline recommends minimizing the risk of gastrointestinal bleeding in patients with AT, who uses aspirin and oral anticoagulant together, by administering 75 mg to 100 mg of PPI.

 

Professor Kim stressed, “DAPT has reportedly increased the risk of gastrointestinal bleeding and led to death.

 

As long-term DAPT is prevalently used in high-risk patients having myocardial infarction, the use of PPI to manage gastrointestinal bleeding should be taken in account.” He added, “We need to be careful on the interaction between antiplatelets and PPI.

 

It dpends, but a drug-drug interaction definitely exists.

 

Also the risk of bleeding could vary for NOAC based on the range of doses like once-daily or twice-daily.” So how about the private clinics prescribing NOAC, when the concern on bleeding still exists?

 

Actually, experts claim the clinics prescribing the drug is not problematic.

 

In fact, the Korean Heart Rhythm Society apparently provides training sessions on NOAC in six different regions with carefully selected speakers.

 

The organization is also expanding programs to raise awareness of the disease.

 

Professor Kim stated, “Even tertiary hospitals, most of the time, provide no other treatment than NOAC prescription for the first-time treated patient with chronic AF.

 

A primary healthcare institute can sufficiently prevent and manage stroke after giving essential exams.” The professor added, “There shouldn’t be any issue for a primary healthcare provider to prescribe NOAC.

 

In the age of warfarin, the prescription of anticoagulants was difficult with lack of international normalized ratio (INR) monitoring equipment and prescription management.

 

But, the time has changed now.

 

The issue is irrelevant with using PPI and NOAC.

 

Personally, promoting prescription of anticoagulants in private clinics would enhance the management of AF in South Korea.”