Should patients who are taking both aspirin and clopidogrel routinely be prescribed a proton pump inhibitor (PPI), irrespective of whether they have any symptoms, as prophylaxis to prevent a GI bleed?
You should first question why the patient is on both antiplatelet agents simultaneously. In many instances it is appropriate to stop one or the other (usually clopidogrel).
Exceptions include a recent episode of unstable coronary syndrome and the use of a drug-eluting stent in the coronary circulation, where the risk of acute stent thrombosis if clopidogrel is stopped is appreciable.
In my view, routine prophylactic use of a PPI is not indicated. The increase in the absolute risk of bleeding with the combination of clopidogrel and aspirin over aspirin alone is modest.
In the CURE study there was a 1 per cent increase in the absolute risk of major bleed, but there was no difference in the number of fatal bleeding episodes, bleeding requiring surgical intervention or haemorrhagic stroke.
In the absence of any evidence that PPI inhibitors can change that risk, I do not think it reasonable to expose patients routinely to the potential hazard of another medication. Having said that, there are some patients who might be judged to be at particularly high risk of life-threatening haemorrhage in whom simultaneous PPI therapy might be appropriate. Examples would include people with a history of undiagnosed and untreated GI bleed, patients with a recent history of peptic ulceration who have not had H pylori eradication therapy, patients on other potentially dangerous medication such as NSAIDs for arthritis.
Dr Andrew Clark, consultant cardiologist, Castle Hill Hospital, Hull
If someone has been given the two hepatitis A injections, as recommended, what immunity does this confer and when would they need a booster? I remember reading somewhere that this may confer immunity for 25 years. Is this correct?
Provided the patient being vaccinated, aged one year and over is an immunocompetent person who has received the first and second dose of a licensed hepatitis A monovalent vaccine, and within the intervals between the two doses recommended by the manufacturer, immunity should be long-term.
The Joint Committee on Vaccination and Immunisation has accepted this protection to be of at least 20 years duration.
It is possible that such immunity is life-long but for now we should advise our patients that protection will last for at least 20 years.
Dr George Kassianos is a GP in Bracknell Forest, Berkshire, RCGP spokesperson on immunisation and honorary secretary and spokesperson for the British Travel Health Association