heartburn
Proton pump inhibitors (PPI質子幫浦抑制劑) are for severe heartburn.
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台灣消化系內視鏡醫學會理事長林肇堂指出，國外研究報告證實，長期服用俗稱「嬰兒阿斯匹靈」（即低劑量阿斯匹靈），能預防腦中風和心血管疾病，但也可能產生腸胃道出血的副作用。
林肇堂建議，民眾在決定長期服用低劑量阿斯匹靈前，可先做胃鏡檢查，確定有否潰瘍，及腸胃道中有無幽門桿菌，如果發現有幽門桿菌，應該先投藥，殺死細菌，再投用相關藥物。
台北榮民總醫院心臟內科主任林幸榮表示，華人對阿斯匹靈耐受性較低，有些人長期服用後，會有黑便、貧血、走路喘、臉色蒼白等症狀，對因此發生腸胃道出血的病人，給一般胃藥常只能中和胃酸，改善有限。
昨天應邀參加亞太心臟學大會的香港腸胃科醫學會理事長陳家亮，也發表他日前刊登在「新英格蘭期刊」一篇研究結果，指出質子幫浦抑制劑（ Proton pump inhibitors (PPI) are for severe heartburn. ）與阿斯匹靈合併使用，患者上消化道出血復發機率可降至0.7% 。
搭配質子幫浦抑制劑 吃阿斯匹靈 可「心胃兩全」
記者王昶閔／台北報導
對部分瀕臨中風病患來說，長期服用暢通心血管的防中風藥物，容易胃出血，但只要一停藥，中風就虎視眈眈。90歲的葉奶奶，就在這樣的困境中，10年內前後中風10次，如今醫界已找出解決之道，打破「心胃難兩全」的僵局。
葉奶奶所服用的藥物就是知名的老藥阿斯匹靈，近年發表在權威的新英格蘭醫學期刊上的一項研究顯示，合併使用阿斯匹靈及質子幫浦抑制劑，患者一年內上消化道出血復發機率下降至0.7%。
論文作者香港腸胃科醫學會理事長陳家亮教授表示，應是質子幫浦抑制劑具有強力抑制胃酸的效果，保護胃壁，因此可大幅減少服用阿斯匹靈所引發的腸胃道出血問題。
陳家亮表示，一天服用80到160毫克的阿斯匹靈，消化道出血的風險會增加兩到三倍，每100位服用阿斯匹靈的病人中，在治療兩年後，約有一人會罹患消化道出血。
國外研究就發現，就算服用低劑量阿斯匹靈，雖然只有正常劑量的三分之一，長期服用，卻還是可能引發腸胃道出血。
台灣消化系內視鏡醫學會理事長林肇堂教授表示，長期服用阿斯匹靈來預防腦中風及心血管疾病的民眾，如果被評估為腸胃道出血的高危險群，在接受胃鏡檢查後證明有消化性潰瘍，健保也會給付質子幫浦抑制劑的藥費。
Aspirin + PPI is safer than clopidogrel if patient has history of GI bleeding
Question What is the best antithrombotic for patients with a history of upper gastrointestinal (GI) bleeding?
Synopsis Clopidogrel has been recommended by the American College of Cardiology as the preferred drug for patients who require an antithrombotic agent to prevent heart disease but who also have a history of bleeding peptic ulcer.
This study compared clopidogrel with the combination of aspirin and esomeprazole in this setting. Patients with a source of upper gastrointestinal bleeding (52% gastric ulcer, 34% duodenal ulcer, 8% both, 6% other erosions) who had healing confirmed by endoscopy were randomised to clopidogrel 75 mg daily plus esomeprazole placebo twice daily or aspirin 80 mg daily plus esomeprazole 20 mg twice daily. Groups were fairly well balanced at the outset, allocation was concealed, and analysis was by intention to treat. Patients were treated for 12 months.
The primary outcome (haematemesis, melaena, or a decrease in haemoglobin of at least 20 g/l accompanied by endoscopic evidence of ulcer or erosion) was seen in 8.6% of the clopidogrel group and 0.7% of the aspirin plus esomeprazole group (P = 0.001; number needed to treat = 13). Three patients in the clopidogrel group had severe bleeding complications not related to the gastrointestinal tract, including two intraventricular haemorrhages, one of which was fatal; there were no bleeding complications in the aspirin group. More deaths occurred in the clopidogrel group (8 v 4), but this difference was not statistically significant. There was no difference between groups in the likelihood of adverse cardiovascular events (9 v 11).
Bottom line For patients with a history of bleeding peptic ulcer, the combination of aspirin and a proton pump inhibitor twice a day was safer than clopidogrel in terms of bleeding side effects. Although esomeprazole (Nexium) was used in this study, generic omeprazole 20 mg given twice a day provides nearly the same degree of acid suppression at a much lower cost. This study calls into question the overall safety of clopidogrel (Plavix), which has been claimed to not significantly increase the risk of bleeding.
Level of evidence 1b (see www.infopoems.com/levels.html). Individual randomised controlled trials (with narrow confidence interval).
Chan FK, Ching JY, Hung LC, et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med 2005;352: 238-44
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