Author + information
- Received July 12, 2011
- Revision received December 5, 2011
- Accepted December 19, 2011
- Published online April 3, 2012.
- Andrew L. Frelinger III, PhD⁎,⁎ (, )
- Ronald D. Lee, PhD†,
- Darcy J. Mulford, PhD†,
- Jingtao Wu, PhD†,
- Sai Nudurupati, PhD†,
- Anu Nigam, MS⁎,
- Julie K. Brooks, MS⁎,
- Deepak L. Bhatt, MD, MPH‡ and
- Alan D. Michelson, MD⁎
- ↵⁎Reprint requests and correspondence:
Dr. Andrew L. Frelinger III, Children's Hospital Boston, Division of Hematology/Oncology, Karp 07212, 300 Longwood Avenue, Boston, Massachusetts 02115-5737
Objectives The aim of this study was to assess the effects of different proton pump inhibitors (PPIs) on the steady-state pharmacokinetics and pharmacodynamics of clopidogrel.
Background Metabolism of clopidogrel requires cytochrome P450s (CYPs), including CYP2C19. However, PPIs may inhibit CYP2C19, potentially reducing the effectiveness of clopidogrel.
Methods A randomized, open-label, 2-period, crossover study of healthy subjects (n = 160, age 18 to 55 years, homozygous for CYP2C19 extensive metabolizer genotype, confined, standardized diet) was conducted. Clopidogrel 75 mg with or without a PPI (dexlansoprazole 60 mg, lansoprazole 30 mg, esomeprazole 40 mg, or, as a positive control to maximize potential interaction and demonstrate assay sensitivity, omeprazole 80 mg) was given daily for 9 days. Pharmacokinetics and pharmacodynamics were assessed on days 9 and 10. Pharmacodynamic end-points were vasodilator-stimulated phosphoprotein P2Y12 platelet reactivity index, maximal platelet aggregation to 5 and 20 μmol/l adenosine diphosphate, and VerifyNow P2Y12 platelet response units.
Results Pharmacokinetic and pharmacodynamic responses with omeprazole demonstrated assay sensitivity. The area under the curve for clopidogrel active metabolite decreased significantly with esomeprazole but not with dexlansoprazole or lansoprazole. Similarly, esomeprazole but not dexlansoprazole or lansoprazole significantly reduced the effect of clopidogrel on vasodilator-stimulated phosphoprotein platelet reactivity index. All PPIs decreased the peak plasma concentration of clopidogrel active metabolite (omeprazole > esomeprazole > lansoprazole > dexlansoprazole) and showed a corresponding order of potency for effects on maximal platelet aggregation and platelet response units.
Conclusions Generation of clopidogrel active metabolite and inhibition of platelet function were reduced less by the coadministration of dexlansoprazole or lansoprazole with clopidogrel than by the coadministration of esomeprazole or omeprazole. These results suggest that the potential of PPIs to attenuate the efficacy of clopidogrel could be minimized by the use of dexlansoprazole or lansoprazole rather than esomeprazole or omeprazole. (A Study of the Effects of Multiple Doses of Dexlansoprazole, Lansoprazole, Omeprazole or Esomeprazole on the Pharmacokinetics and Pharmacodynamics of Clopidogrel in Healthy Participants; NCT00942175)
The co-administration of proton pump inhibitors (PPI) with clopidogrel reduces the risk for gastrointestinal bleeding associated with the antiplatelet effects of clopidogrel (1). There are conflicting data as to whether PPIs have the potential to reduce the effectiveness of clopidogrel (1). Clopidogrel is a prodrug that requires metabolism by hepatic cytochrome P450 (CYP) enzymes, including CYP2C19, to an active metabolite that blocks platelet P2Y12 adenosine diphosphate (ADP) receptors. Because PPIs are known inhibitors of CYP2C19 (1), they may prevent the conversion of clopidogrel to its active metabolite (clopidogrelAM). However, because not all PPIs inhibit CYP2C19 to the same extent (2–4), the potential for a clinically relevant drug-drug interaction with clopidogrel may not be generalized to all PPIs. The present randomized, open-label, 2-period, crossover study was therefore designed to determine the effects of 4 different PPIs (dexlansoprazole, lansoprazole, omeprazole, and esomeprazole) on the steady-state pharmacokinetics (PK) and pharmacodynamics (PD) of clopidogrel.
The study design, enrollment criteria, clopidogrel PK and PD, and statistics are described in detail in the Online Appendix. To eliminate variables known to influence clopidogrel and/or PPI metabolism, homozygous CYP2C19 extensive metabolizer genotype healthy subjects were enrolled and confined in a clinical research unit.
The disposition of subjects is shown in Online Figure 1. Demographic characteristics of the 160 subjects who were randomized to receive study drug are shown in Table 1. One hundred fifty subjects completed study drug and all study visits (Online Fig. 1).
PK of clopidogrel in the presence and absence of PPIs
Clinically relevant daily doses of clopidogrel (75 mg), dexlansoprazole (60 mg), lansoprazole (30 mg), and esomeprazole (40 mg) were used, and the timing of PPI dosing relative to clopidogrel was adjusted to synchronize times to reach peak concentration. Omeprazole 80 mg/day, a potent inhibitor of CYP2C19, was used as a positive control for the interaction of a PPI with clopidogrel PK. As expected, peak plasma concentration of clopidogrelAM and area under the plasma concentration–time curve (AUCt) were lower when clopidogrel was administered with omeprazole 80 mg compared with clopidogrel alone (Table 2,Figs. 1B and 1D).
ClopidogrelAM AUCt on day 9 of the administration of clopidogrel with dexlansoprazole or lansoprazole was similar to that observed on day 9 of the administration of clopidogrel alone (Table 2, Fig. 1). In contrast, clopidogrelAM AUCt on day 9 of the administration of clopidogrel with esomeprazole was reduced compared with that observed at 9 days of the administration of clopidogrel alone (Fig. 1B, Table 2).
Clopidogrel was rapidly absorbed (median time to reach peak concentration for intact clopidogrel 1 h), and this was unaffected by lansoprazole, dexlansoprazole, omeprazole, or esomeprazole (data not shown).
PD of clopidogrel in the presence and absence of PPIs
Omeprazole 80 mg, the positive control, when coadministered with clopidogrel, caused significant changes in vasodilator-stimulated phosphoprotein (VASP) platelet reactivity index (PRI), light transmission aggregation maximal platelet aggregation (MPA), and VerifyNow P2Y12 (Accumetrics, Inc., San Diego, CA) platelet response units (PRU) compared with clopidogrel alone (Figs. 2, 3, and 4⇓⇓⇓, Tables 3, 4, and 5).⇓⇓⇓
VASP P2Y12 Assay
The least squares mean differences in VASP PRI 24 h after 9 days administration of clopidogrel with lansoprazole or clopidogrel with dexlansoprazole compared with clopidogrel alone were small (4.1% and 2.0%, respectively) with 90% confidence interval upper boundaries <15% (Table 3, Fig. 2), that is, less than the pre-specified upper no-effect boundary. In contrast, the difference in VASP PRI 24 h after 9 days administration of clopidogrel with esomeprazole compared with clopidogrel alone was larger, 11.4%, and its 90% confidence interval upper boundary, 15.71%, extended beyond the upper no-effect boundary of 15% (Table 3, Fig. 2). The magnitude of the change in VASP PRI with esomeprazole (11.4%) was similar to that observed with omeprazole (11.0%).
Light Transmission Aggregation
MPA in response to ADP 5 μmol/l 24h after 9 days coadministration of clopidogrel with dexlansoprazole was not significantly different from MPA after clopidogrel alone. As with dexlansoprazole, the difference in MPA after clopidogrel with lansoprazole compared with clopidogrel alone was also small but, unlike that with dexlansoprazole, was statistically significant. Similar results for both dexlansoprazole and lansoprazole were observed when ADP 20 μmol/l was used as the agonist for platelet aggregation (Table 4). In contrast, the coadministration of esomeprazole with clopidogrel led to larger increases in ADP 5 μmol/l MPA, which was similar to the least squares mean difference observed with versus without the positive control, omeprazole (Table 4). Likewise, large, numerically similar differences were seen for both omeprazole and esomeprazole when ADP 20 μmol/l was used as the agonist for platelet aggregation (Table 4). Similar results were obtained analyzing the percent inhibition of platelet aggregation (Table 4).
Verifynow P2Y12 Assay
Compared with clopidogrel alone, the increases in PRU when clopidogrel was coadministered with dexlansoprazole, lansoprazole, omeprazole, or esomeprazole were statistically significant; however, these changes were greatest for omeprazole and esomeprazole compared with dexlansoprazole and lansoprazole (Table 5). Results using VerifyNow P2Y12 percent inhibition to assess the effect of clopidogrel with and without PPIs were similar to results obtained using PRU (Online Table 5).
High On-Treatment Platelet Reactivity (HPR)
The frequency of HPR as defined by the recommended cutoffs (5) of VASP PRI >50%, MPA 5 μmol/l ADP >46%, and PRU ≥236 was not significantly different 24 h after 9 days administration of clopidogrel with lansoprazole or dexlansoprazole compared with the administration of clopidogrel alone (Table 6). In contrast, 24 h after 9 days administration of clopidogrel with omeprazole, HPR by VASP PRI and VerifyNow P2Y12 PRU was significantly increased and, by MPA, approached significance compared with that after clopidogrel alone. Additionally, HPR as defined by VASP and MPA 5 μmol/l ADP was significantly greater 24 h after 9 days administration of clopidogrel with esomeprazole than after clopidogrel alone (Table 6).
The main PK findings are as follows. 1) The study design and assay methods were appropriate to detect the effects of PPIs on clopidogrel PK parameters, as evidenced by significant effects of coadministered omeprazole 80 mg. 2) ClopidogrelAM AUCt values were equivalent when clopidogrel was coadministered with or without dexlansoprazole 60 mg or lansoprazole 30 mg, whereas clopidogrelAM AUCt values were decreased when clopidogrel was coadministered with omeprazole 80 mg or esomeprazole 40 mg compared with clopidogrel alone. 3) All tested PPIs significantly decreased peak plasma concentrations of clopidogrelAM, but esomeprazole and omeprazole did so to a greater degree than lansoprazole and dexlansoprazole. 4) ClopidogrelAM times to reach peak concentration were not altered by any of the PPIs tested.
The main PD findings of this study are as follows. 1) The study design and assay methods were appropriate to detect the effects of PPIs on clopidogrel PD parameters, as evidenced by significant effects of coadministered omeprazole 80 mg on clopidogrel inhibition of VASP PRI, light transmission aggregation MPA, and VerifyNow P2Y12 PRU. 2) VASP PRI values were not different when clopidogrel was coadministered with or without dexlansoprazole or lansoprazole, whereas VASP PRI values were greater than the pre-specified no-effect limit when clopidogrel was coadministered with omeprazole or esomeprazole. 3) The coadministration of dexlansoprazole did not have a significant effect on MPA, while the coadministration of lansoprazole had a small effect on MPA, numerically similar to that of dexlansoprazole but statistically significant compared with that of clopidogrel alone. In contrast, omeprazole and esomeprazole had larger, numerically similar, highly significant effects on MPA. 4) All PPIs tested significantly reduced clopidogrel inhibition of VerifyNow P2Y12 PRU. However, the magnitudes of the effects of dexlansoprazole or lansoprazole on VerifyNow P2Y12 PRU were approximately one-third as large as the effects of omeprazole or esomeprazole.
By 3 distinct platelet function assays, the frequency of subjects who would be categorized as at risk for ischemic or thrombotic events after percutaneous coronary intervention using the consensus group cutoffs (5) was unchanged by the coadministration of dexlansoprazole or lansoprazole with clopidogrel but increased by the coadministration of omeprazole or esomeprazole with clopidogrel (Table 6).
In addition to a drug-drug interaction via CYP2C19, it has been proposed that PPIs may induce drug interactions by elevating gastric pH and altering drug absorption rates (1). The present study demonstrates that the rapid absorption of clopidogrel is unaffected by lansoprazole, dexlansoprazole, omeprazole, or esomeprazole.
This study's randomized, 2-period, crossover design was a strength, as were enrollment criteria eliminating variables known to influence clopidogrel and/or PPI metabolism, including CYP2C19 polymorphisms and provided a uniform study population. Subjects were confined and received a standardized, restricted diet, eliminating potential confounding factors (including smoking, concurrent medications, and noncompliance with drug administration). Finally, the study was well powered to detect both PK and PD effects, as demonstrated by the statistically significant effects of the positive control (omeprazole 80 mg).
Results for omeprazole 80 mg do not necessarily apply to the more commonly used doses of 20 and 40 mg. Also, this study was conducted in confined healthy volunteers, not patients, because this enabled us to use a randomized, crossover design while controlling for concurrent medications, diet, smoking, exercise, and other factors. Last, for uniformity, this study included only homozygous CYP2C19 wt/wt extensive metabolizers; consequently, our conclusions are limited to this population.
In this randomized, open-label, 2-period, crossover study of healthy subjects, generation of clopidogrelAM and inhibition of platelet function were reduced less by the coadministration of dexlansoprazole or lansoprazole with clopidogrel than by the coadministration of esomeprazole or omeprazole. These results suggest that the potential of PPIs to attenuate clopidogrel efficacy could be minimized by the use of dexlansoprazole or lansoprazole rather than esomeprazole or omeprazole.
The authors thank Children's Hospital Boston contributors Marc Barnard and Michael Lampa (VASP assays) and Leslie Kalish, ScD (independent statistical verification) and Takeda contributors Tracey Kisly (coordination of study conduct) and M. Claudia Perez (medical monitoring of the study).
For an expanded Methods section and supplementary tables and figures and their legends, please see the online version of this article.
This study was sponsored by Takeda Global Research & Development Center, Inc. In addition, this study was funded in part by a research grant from Takeda Global Research & Development Center to Children's Hospital Boston (Alan D. Michelson, principal investigator). Drs. Frelinger and Michelson have been principal investigators or co-investigators on research grants to the University of Massachusetts Medical School, Children's Hospital Boston, or both from Arena Pharmaceuticals, GLSynthesis, Eli Lilly/Daiichi Sankyo, and Sanofi Aventis/Bristol-Myers Squibb; and have been consultants to Eli Lilly/Daiichi Sankyo and PLx Pharma. Drs. Lee, Mulford, Wu, and Nudurupati are employees of Takeda Global Research & Development Center, Inc. Dr. Bhatt has received honoraria from WebMD; research grants from Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, and The Medicines Company; and is a research collaborator with PLx Pharma and Takeda and served as the Chair of the COGENT trial. Dr. Michelson has been a member of the data safety monitoring boards of clinical trials sponsored by Eli Lilly/Daiichi Sankyo and Sanofi Aventis/Bristol-Myers Squibb. All other authors have reported that they have no relationship relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- adenosine diphosphate
- area under the plasma concentration–time curve
- clopidogrel active metabolite
- cytochrome P450
- high on-treatment platelet reactivity
- maximal platelet aggregation
- proton pump inhibitor
- platelet reactivity index
- platelet response units
- vasodilator-stimulated phosphoprotein
- Received July 12, 2011.
- Revision received December 5, 2011.
- Accepted December 19, 2011.
- American College of Cardiology Foundation
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