當發生上胃腸道出血時，心血管疾病患者由aspirin改為clopidogrel的迷思

The myth associated with changing aspirin to clopidogrel in carduovassulor disease when upper gastrointestinal bleeding occurs

本篇主要回顧近年來有關心血管疾病患者先前已有使用阿斯匹靈(aspirin)造成上胃腸道出血病史或者是先前已有上胃腸道出血者使用抗血小板藥物clopidogrel後發生胃腸道出血風險的研究，最近的研究發現在上述狀況下單獨使用clopidogrel並沒有減少上胃腸道再度出血的風險，但不論是aspirin或是clopidogrel併用質子幫浦抑制劑(proton pump inhibitor, PPI)都可以有效的降低再度上消化道出血的風險。大於70歲的老人，有上胃腸道出血病史，併用其他抗血小板藥物、抗凝血劑、非類固醇消炎藥都是使用抗血小板藥物患者發生上胃腸道出血的重要危險因子。我們也同時回顧與clopidogrel同屬thienopyridine類衍生物的ticlopidine，其每日劑量不超過250 毫克時較低劑量aspirin有較少的上胃腸道出血風險，但是由於其他如白血球低下、血小板低下、肝功能異常等的副作用，ticlopidine的使用仍舊有較多的限制。隨著越來越多的證據，我們建議當患者之前已有上胃腸道出血的病史時，或者是因aspirin所導致的上胃腸道出血，抗血小板藥物加上PPI是長期有服用抗血小板藥物需要的患者目前的最佳選擇。

This paper focus on re-bleeding risk when clopidogrel is used in carduovassulor disease after the occurrence of aspirin related upper gastrointestinal bleeding or when there is a previous history of upper gastrointestinal bleeding. Recent evidence has shown that clopidogrel alone, when used for the above conditions, does not reduce the risk of recurrent upper gastrointestinal bleeding. Furthermore, aspirin with a proton pump inhibitor (PPI) or clopidogrel with a PPI are each able to reduce the effective recurrence rates of upper gastrointestinal bleeding. (Patients who are older than 70 years old, who have a history of upper gastointenstinal bleeding or who are concomitantly using other antiplatelet, anticoagulant or nonsteroidal anti- inflammatory drugs are major gastrointestinal bleeding risk fators of antiplatelet drug users.) We also review ticlopidine, which belongs to fhie nopyridine derivative group of drugs like clopidogrel. Ticlopidine at doses under 250mg/ day shows a lower risk of upper gastrointestinal bleeding than low dose aspirin. The use of this drug is limited by side effects such as neutropenia, thrombocytopenia, abnormal liver function, etc. After assessment using evidence-base medicine, we suggest that an antiplatelet drug plus a PPI is the best solution for patients who need long-term antiplatelet therapy and who have a past history of upper gastrointestinal bleeding or aspirin related gastrointestinal bleeding.