Plavix vs. PPI Drug Interaction

ItsOverZyvox · Mar 28, 2009

I'm surprised no one brought it up yet. There have been some large studies, granted not double blinded and placebo controlled, that showed increased risk of reinfarction on patients on plavix with PPI, especially the PPIs with a higher affinity for inhibition of cytochrome p450 2C19. I thought the inhibition of CYP 450 2C19 and 3A4 were a PPI class effect.

If indeed true, it can have siginificant implications. Currently AHA and ACCP recommend the use of PPI on high risk patients who are on both clopidogrel and NSAID who are at risk for GI-Bleeds. Has it caused an increased in mortality worldwide?

I recently read 2 articles, Juurlink - Canadian study, and Ho- Last month JAMA.

What say you?

PharmDstudent · Mar 28, 2009

WVUPharm2007 · Mar 28, 2009

See, this is why prodrugs suck balls. I believe Protonix inhibits that enzyme the least, so perhaps we should go with it in this theoretical situation. My hospital has protonix and lansoprazole on formulary, so omeprazole and its analogue can't **** everything up for us. Another thought - are there any studies with H2 blockers and clopidogrel? Perhaps pH affects the absorption of the drug, too?

Well, the solution is simple...Sanofi just "invents" the post-hepatic metabolite version of Plavix. Oxoclopidogrel (or whatever they would call it), anyone? There we go, problem solved. $200 says it happens at some point down the road.

I wonder if increased dosing would help any...or perhaps taking a "therapeutic" C19 inducer...lol. That's an interesting niche of drugs that hasn't been invented and marketed yet. Selective enzyme modulators...now that's an interesting idea. Imagine if someone has a 2C19 inducer on the market...right there's a blockbuster combo drug. Clopidogrel/2C19+/Esomeprazole. $12/capsule, easy.

ItsOverZyvox · Mar 28, 2009

WVUPharm2007 said:
My hospital has protonix and lansoprazole on formulary, so omeprazole and its analogue can't **** everything up for us.

Why hasn't your DOP and Clinical Coordinator make an effort to convert Protonix to generic Omeprazole? There's a substantial pricing difference.

And I'm not really convinced that 2C19 is the culprit. The real isozyme is 3A4.

Another thought - are there any studies with H2 blockers and clopidogrel? Perhaps pH affects the absorption of the drug, too?

There have been. No drug interaction there. Yet, there are studies that show PPI is superior than H2 for clopidogrel patients. That's why there are recommendations from different organizations to use PPI.

Well, the solution is simple...Sanofi just "invents" the post-hepatic metabolite version of Plavix. Oxoclopidogrel (or whatever they would call it), anyone? There we go, problem solved. $200 says it happens at some point down the road.

Good point Mikey but little too late. Eli Lily has Prasugrel which will have no interaction with PPI. Perhaps all this press we're seeing is really driven by Lily to knock clopidogrel off the market ...even the generic.

I wonder if increased dosing would help any...or perhaps taking a "therapeutic" C19 inducer...lol. That's an interesting niche of drugs that hasn't been invented and marketed yet. Selective enzyme modulators...now that's an interesting idea. Imagine if someone has a 2C19 inducer on the market...right there's a blockbuster combo drug. Clopidogrel/2C19+/Esomeprazole. $12/capsule, easy.

Dood please.

Aznfarmerboi · Mar 28, 2009

I read the JAMA one from last month (or rather earlier this month). Here is the result from JAMA "Risk of Adverse Outcomes Associated With Concomitant Use of Clopidogrel and Proton Pump Inhibitors Following Acute Coronary Syndrome"

P. Michael Ho, MD, PhD; Thomas M. Maddox, MD, MSc; Li Wang, MS; Stephan D. Fihn, MD, MPH; Robert L. Jesse, MD, PhD; Eric D. Peterson, MD, MPH; John S. Rumsfeld, MD, PhD

JAMA. 2009;301(9):937-944.

"Of 8205 patients with ACS taking clopidogrel after hospital discharge, 63.9% (n = 5244) were prescribed PPI at discharge, during follow-up, or both and 36.1% (n = 2961) were not prescribed PPI. Patients taking clopidogrel after hospital discharge and prescribed PPI at any point in time were older and had more comorbid conditions (Table 1). Median follow-up after hospital discharge was 521 days (interquartile range, 305-779 days). Death or rehospitalization for ACS occurred in 20.8% (n = 615) of patients prescribed clopidogrel without PPI and 29.8% (n = 1561) of patients prescribed clopidogrel plus PPI. In multivariable analysis, use of clopidogrel plus PPI at any point in time was associated with an increased risk of death or rehospitalization for ACS compared with use of clopidogrel without PPI (adjusted OR [AOR], 1.25; 95% confidence interval [CI], 1.11-1.41) (Table 2). "

The data is pretty convincing even if the study was a restrospective cohort study. On one hand, we are putting people at risk for stomach ulcers, and on the other, its mortality and morbidity. Other data only adds to the point and does not say otherwise. Now the question is what is our recommendation? Do we stop PPI use all together and put on H2 antagonists like Famotidine?

ItsOverZyvox · Mar 28, 2009

Aznfarmerboi said:
The data is pretty convincing even if the study was a restrospective cohort study. On one hand, we are putting people at risk for stomach ulcers, and on the other, its mortality and morbidity. Other data only adds to the point and does not say otherwise. Now the question is what is our recommendation? Do we stop PPI use all together and put on H2 antagonists like Famotidine?

Aint you a retail druggist?? 😛

Good points you make. You should read the Juurlink article. That pits Pantoprazole vs. Omeprazole and the rest.

You're absolutley right in that without PPI, people on plavix + ASA are at high risk of GI ADR which I'm not sure H2RA will suffice.

How long before we start to see "Have you been on Plavix and PPI" class action lawsuit? This issue not only has clinical implications but also legal and political ramifications.

njac · Mar 28, 2009

ItsOverZyvox said:
Why hasn't your DOP and Clinical Coordinator make an effort to convert Protonix to generic Omeprazole? There's a substantial pricing difference.

We have Protonix IV, Prevacid SoluTabs and Suspension, and Nexium caps.

We write a lot of per P&T substitutions.

WVUPharm2007 · Mar 28, 2009

ItsOverZyvox said:
Why hasn't your DOP and Clinical Coordinator make an effort to convert Protonix to generic Omeprazole? There's a substantial pricing difference.

And I'm not really convinced that 2C19 is the culprit. The real isozyme is 3A4.

How many things inhibit 3A4? I don't buy that. See if there is any evidence of, say, verapamil causing the same thing.

And we get Protonix/Prevacid because we get a great deal for them that makes them cheaper than generic omeprazole..

ItsOverZyvox · Mar 28, 2009

WVUPharm2007 said:
How many things inhibit 3A4? I don't buy that. And we get Protonix/Prevacid because we get a great deal for them that makes them cheaper than generic omeprazole..

BULL ****.

Your Protonix contract pricing is right around $1.50 per 40mg tab.

Generic Omeprazole 20mg costs 24 cents. TEVA brand.

If you go with 40mg to 40mg... then you're saving $1 per dose dispensed.

How many 10's of thousands of PPI does your hospital dispense per year?

Unless, your hospital is a non for profit 340B/DSH hospital. Then you're right.

ItsOverZyvox · Mar 28, 2009

WVUPharm2007 said:
How many things inhibit 3A4? I don't buy that. See if there is any evidence of, say, verapamil causing the same think.

You left out the statins.

Quiksilver · Mar 28, 2009

ItsOverZyvox said:
I'm surprised no one brought it up yet. There have been some large studies, granted not double blinded and placebo controlled, that showed increased risk of reinfarction on patients on plavix with PPI, especially the PPIs with a higher affinity for inhibition of cytochrome p450 2C19. I thought the inhibition of CYP 450 2C19 and 3A4 were a PPI class effect.

If indeed true, it can have siginificant implications. Currently AHA and ACCP recommend the use of PPI on high risk patients who are on both clopidogrel and NSAID who are at risk for GI-Bleeds. Has it caused an increased in mortality worldwide?

I recently read 2 articles, Juurlink - Canadian study, and Ho- Last month JAMA.

What say you?

i heard about this, anyone have the link to the article without the pharmacist's letter login? I don't remember the school's login info for that.

This is interesting because I will be doing platelet aggregation studies with clopidegrel and ASA in stroke prophylaxis next year and this may be an interesting thing to look at.

WVUPharm2007 · Mar 28, 2009

ItsOverZyvox said:
.

Your Protonix contract pricing is right around $1.50 per 40mg tab.

Unless, your hospital is a non for profit 340B/DSH hospital. Then you're right.

Lol...it is a non profit...and a bottle of 100 Protonix is like $4 or something.

ItsOverZyvox · Mar 28, 2009

WVUPharm2007 said:
Lol...it is a non profit...and a bottle of 100 Protonix is like $4 or something.

No it's not. It would be around $20 per bottle. Around 20 cents per tab.
Go ask your purchaser.

ItsOverZyvox · Mar 28, 2009

Also ask her/him if y'all get DSH pricing. In order to get this, you have to have a pretty high level of indigent patients.

WVUPharm2007 · Mar 28, 2009

ItsOverZyvox said:
No it's not. It would be around $20 per bottle. Around 20 cents per tab.
Go ask your purchaser.

Nope. We do prescriptions for employees...and we charge cost...and it's like $1 and change for a month. Plus, the bottles themselves have the AWP and our cost on them. The invoice says 4 and change....unless the invoice lies. I think the deal for the Protonix is tied into some other deals or some ****.

WVUPharm2007 · Mar 28, 2009

ItsOverZyvox said:
Also ask her/him if y'all get DSH pricing. In order to get this, you have to have a pretty high level of indigent patients.

lol...dude we are >90% medicaid/medicare WHEN we get paid. I work in one of the poorest areas in the country...

Omegadramon · Mar 28, 2009

Our Drug information pharmacist had let us know about this about 6 weeks ago (apparently, one of our big wig cardiologist was the first to know about it). What our hospital has done is to completely switch over to Protonix po and iv except for NG-tubes, which we'll still use nexium and monitor closely.

i know the folks who make nexium are probably kicking themselves right about now.

Also, I saw today in the P&T magazine that there's a formulation of amiodarone that comes pre-mixed. You think there will be any takers on it?

ItsOverZyvox · Mar 28, 2009

WVUPharm2007 said:
Nope. We do prescriptions for employees...and we charge cost...and it's like $1 and change for a month. Plus, the bottles themselves have the AWP and our cost on them. The invoice says 4 and change....unless the invoice lies. I think the deal for the Protonix is tied into some other deals or some ****.

4 cents per Protonix is not DSH nor 340B pricing. And Wyeth Protonix contract is not tied to other deals. Also 340B pricing which is the lowest pricing available can be only used for indigent patients, otherwise it's a serious fraud. Then again, 4 cents deal is something I've never seen before even in our poorest hospitals. I'm going to have our national purchasing and contracting service contact Wyeth to get the details of this contract.

ItsOverZyvox · Mar 28, 2009

What I'm trying to say is that drugs purchased under 340B program can not be used for your employee scripts. Then again, your Protonix pricing is far below 340B which is puzzling.

ItsOverZyvox · Mar 28, 2009

Quiksilver said:
i heard about this, anyone have the link to the article without the pharmacist's letter login? I don't remember the school's login info for that.

This is interesting because I will be doing platelet aggregation studies with clopidegrel and ASA in stroke prophylaxis next year and this may be an interesting thing to look at.

PM me your email addy. I'll send it to you.

WVUPharm2007 · Mar 28, 2009

ItsOverZyvox said:
4 cents per Protonix is not DSH nor 340B pricing. And Wyeth Protonix contract is not tied to other deals. Also 340B pricing which is the lowest pricing available can be only used for indigent patients, otherwise it's a serious fraud. Then again, 4 cents deal is something I've never seen before even in our poorest hospitals. I'm going to have our national purchasing and contracting service contact Wyeth to get the details of this contract.

Ok...I'll double check on Monday, hell, maybe I'm mistaken. I don't think I am...

But they are using it for employee scripts...and they seem to think its legal (I guess.) Should I be afraid that my hospital is going to get raided by some obscure federal agency?

WVUPharm2007 · Mar 28, 2009

Omegadramon said:
Also, I saw today in the P&T magazine that there's a formulation of amiodarone that comes pre-mixed. You think there will be any takers on it?

Is the step of "inject drug into fancy non-leeching plastic bag" really that big of a deal. You got some time after the bolus dose to get it running, no?

ItsOverZyvox · Mar 28, 2009

WVUPharm2007 said:
Ok...I'll double check on Monday, hell, maybe I'm mistaken. I don't think I am...

But they are using it for employee scripts...and they seem to think its legal. Should I be afraid that my hospital is going to get raided by some obscure federal agency?

Dood... if y'all are using 340B drugs for employee scripts, you're in deep ****.... it'll get ugly. And once your DOP and the manager get locked up in jail, then you can step right in and be the DOP!

ItsOverZyvox · Mar 28, 2009

WVUPharm2007 said:
Is the step of "inject drug into fancy non-leeching plastic bag" really that big of a deal. You got some time after the bolus dose to get it running, no?

B-Braun bag is non leeching. So you can mix Amiodarone in BBraun bag.

WVUPharm2007 · Mar 28, 2009

ItsOverZyvox said:
Dood... if y'all are using 340B drugs for employee scripts, you're in deep ****.... it'll get ugly. And once your DOP and the manager get locked up in jail, then you can step right in and be the DOP!

Sweet.

I must be mistaken then. He doesn't seem like the "federal law breaking" type. That's more like something I'd do. I'll look into it. In fact, hell, I'll call the night shift pharmacist...

WVUPharm2007 · Mar 28, 2009

ItsOverZyvox said:
B-Braun bag is non leeching. So you can mix Amiodarone in BBraun bag.

Yeah, but I was thinking that maybe his point was that if the bag was premixed, it wouldn't have to be sent up. It can be floor stock. Hell, I don't know.

ItsOverZyvox · Mar 28, 2009

WVUPharm2007 said:
Yeah, but I was thinking that maybe his point was that if the bag was premixed, it wouldn't have to be sent up. It can be floor stock. Hell, I don't know.

That's true. As long as you have "supply" cabinet instead of those drawer type pyxis cabinets.

WVUPharm2007 · Mar 28, 2009

ItsOverZyvox said:
That's true. As long as you have "supply" cabinet instead of those drawer type pyxis cabinets.

We got rid of Pyxis....went with Cerner RxStation. Dude...it is sooooo much better than Pyxis. You have no idea.

ItsOverZyvox · Mar 29, 2009

WVUPharm2007 said:
We got rid of Pyxis....went with Cerner RxStation. Dude...it is sooooo much better than Pyxis. You have no idea.

For a freaking indigent hospital, where is the money coming from to get pyxis then get rid of it for Cerner????

BTW, your employee scripts can be legal if they're considered patients of the hospital but not if their only service received is prescriptions. You should learn about 340B and DSH.

Requiem · Mar 29, 2009

Interesting area, and the CYP 2C19 enzyme is the culprit.

Some PPIs have been demonstrated in pharmacokinetic trials to inhibit the 2C19 enzyme and would thusly theoretically inhibit the conversion of clopidogrel to its active form.

This changed to in vivo evidence when there were increased rates of MI in patients concomitantly receiving PPIs. So is it all PPIs? or some?

There is evidence to show that Pantoloc (or Protonix in the states) does not inhibit 2C19 and as such is not associated with increased mortality rates.

This can not be said for Losec, or Nexium who definitely inhibit the enzyme in vitro and clinically have shown increased mortality rates.

Pariet and Prevacid are on the fence. In vitro pharmacokinetic evidence shows they may not inhibit 2C19, but there are no clinical data to show whether or not they are unsafe (as losec and nexium).

We say the 3 P's are the way to go (pantoloc prevacid pariet)... some cards are writing pantoloc no sub with their plavix prescriptions.

To further complicate matters, 2C19, as every other enzyme, is subject to various genotypes. Indeed, trials of Japanese Men (only group published) have demonstrated rapid metabolizers and slow metabolizers... so definitely some genetic variation influencing results as well.

The question I got asked by a physician as we were talking about this is: How long is the inhibition on the 2C19 enzyme and what type of inhibition is it? Could we dose the PPI in the morning and Plavix at night?

This is where I've reached a wall.

ItsOverZyvox · Mar 29, 2009

Requiem said:
Interesting area, and the CYP 2C19 enzyme is the culprit.

Some PPIs have been demonstrated in pharmacokinetic trials to inhibit the 2C19 enzyme and would thusly theoretically inhibit the conversion of clopidogrel to its active form.

This changed to in vivo evidence when there were increased rates of MI in patients concomitantly receiving PPIs. So is it all PPIs? or some?

There is evidence to show that Pantoloc (or Protonix in the states) does not inhibit 2C19 and as such is not associated with increased mortality rates.

This can not be said for Losec, or Nexium who definitely inhibit the enzyme in vitro and clinically have shown increased mortality rates.

Pariet and Prevacid are on the fence. In vitro pharmacokinetic evidence shows they may not inhibit 2C19, but there are no clinical data to show whether or not they are unsafe (as losec and nexium).

We say the 3 P's are the way to go (pantoloc prevacid pariet)... some cards are writing pantoloc no sub with their plavix prescriptions.

To further complicate matters, 2C19, as every other enzyme, is subject to various genotypes. Indeed, trials of Japanese Men (only group published) have demonstrated rapid metabolizers and slow metabolizers... so definitely some genetic variation influencing results as well.

The question I got asked by a physician as we were talking about this is: How long is the inhibition on the 2C19 enzyme and what type of inhibition is it? Could we dose the PPI in the morning and Plavix at night?

This is where I've reached a wall.

You must've had a Juurlink article journal club. You summed it up nicely but I don't agree with Juurlink's claim that pantoprazole is not an inhibitor of 2C19 as stated in the article.

As far as the genotype you mention, you're referring to the polymorphism of slow metabolizers of clopidogrel. But can you make an assumption that the those genotype subjects were only in the omeprazole + other PPIS arm vs. none in pantoprazole arm? The law of randomization leads me to believe that the genotype was probably equally distributed.

Pharmavixen · Mar 29, 2009

1. Furthermore, what's more clinically relevant: the 2C19 genotype your patient is, or the PPI?

2. Did the PPI/clopidogrel studies take into account (eg stratify) on the basis of genotypes, or not acknowledge them at all?

Requiem · Mar 29, 2009

ItsOverZyvox said:
You must've had a Juurlink article journal club. You summed it up nicely but I don't agree with Juurlink's claim that pantoprazole is not an inhibitor of 2C19 as stated in the article.

As far as the genotype you mention, you're referring to the polymorphism of slow metabolizers of clopidogrel. But can you make an assumption that the those genotype subjects were only in the omeprazole + other PPIS arm vs. none in pantoprazole arm? The law of randomization leads me to believe that the genotype was probably equally distributed.

Yeah, I certainly believe they would have been equally distributed. I think the issue with genotypes is that: a) Are there differences in the severity of this interaction with the different genotypes and b) attempting to identify these genotypes, to accurately study whether the interaction holds true for every polpmorphism, is extremely time and cost intensive.

So we're in the dark with that. Also as I mentioned - what is this inhibition? is it irreversible, reversible? How long are the PPIs irreversibly, or reversibly, bound to the enzyme? PPIs have a very short half life, is this a factor?

Dosing plavix qhs and ppis qam may work, or it may not. But it'd be good to have some info.

ItsOverZyvox · Mar 29, 2009

Pharmavixen said:
1. Furthermore, what's more clinically relevant: the 2C19 genotype your patient is, or the PPI?

2. Did the PPI/clopidogrel studies take into account (eg stratify) on the basis of genotypes, or not acknowledge them at all?

I still stay 3A4 is more involved in clopidogrel metabolism. As WVU stated previously, clopidogrel is a prodrug which must be converted to an active metabolite. 2C19's role is not as prominent...I would say less than 10% of the total? Somebody go pull a study.

But to address your question, they're both clinically relevant. For a high risk patient on clopidogrel and ASA, PPI is been shown to prevent GI ADR. For those polymorphic patients, it's even more crucial because not only are they not getting the full benefit of anti-plalete effect of clopidogrel, it has an additive effect by an addition of PPI.

Your 2nd concern, again, it was an observational study which did not account for the genotype. Yet, that is not the relevant point. It's about Pantoprazole vs. Non Pantoprazole (omeprazole and the rest) and if we were to go back and stratify the subject, I would think they were equally distributed in both arms.

ItsOverZyvox · Mar 29, 2009

Requiem said:
Yeah, I certainly believe they would have been equally distributed. I think the issue with genotypes is that: a) Are there differences in the severity of this interaction with the different genotypes and b) attempting to identify these genotypes, to accurately study whether the interaction holds true for every polpmorphism, is extremely time and cost intensive.

So we're in the dark with that. Also as I mentioned - what is this inhibition? is it irreversible, reversible? How long are the PPIs irreversibly, or reversibly, bound to the enzyme? PPIs have a very short half life, is this a factor?

Dosing plavix qhs and ppis qam may work, or it may not. But it'd be good to have some info.

Sí, creo ciertamente que habrían sido distribuidos igualmente. Pienso que la edición con genotipos es ésa: a) Hay las diferencias en la severidad de esta interacción con los diversos genotipos y b) el intentar identificar estos genotipos, para estudiar exactamente si la interacción es verdad para cada polpmorphism, es extremadamente tiempo y de alto coste. Tan we' re en la obscuridad con eso. ¿También como mencioné - cuál es esta inhibición? ¿es irreversible, reversible? ¿Cuanto tiempo está el PPIs irreversible, o reversible, límite a la enzima? ¿PPIs tiene un período muy corto, es éste un factor? La dosificación del qam de los qhs y de los ppis del plavix puede trabajar, o no puede. Pero it' d sea buena tener cierto Info ????

ItsOverZyvox · Mar 29, 2009

Requiem said:
So we're in the dark with that. Also as I mentioned - what is this inhibition? is it irreversible, reversible? How long are the PPIs irreversibly, or reversibly, bound to the enzyme? PPIs have a very short half life, is this a factor?

Dosing plavix qhs and ppis qam may work, or it may not. But it'd be good to have some info.

Great point..and I don't know the answer. But you could write up an awesome paper on that topic. I'm sure there are PK data to show the duration of inhibition. Heck it might even involve Michaelis Menten saturation.

WVUPharm2007 · Mar 29, 2009

Huh....check that out. Nice summary. I suppose Aciphex isn't even an inhibitor of 2c19. I always forget that damned drug even exists. Nobody ever uses it.

ItsOverZyvox · Mar 29, 2009

WVUPharm2007 said:
Huh....check that out. Nice summary. I suppose Aciphex isn't even an inhibitor of 2c19. I always forget that damned drug even exists. Nobody ever uses it.

That is well written and I agree with their recommendation.

ItsOverZyvox · Mar 29, 2009

And this topic will be a moot point once Prasugrel is approved. But it'll resurface once plavix goes generic for the 2nd time.

WVUPharm2007 · Mar 29, 2009

Those damned Canadians...always one step ahead of us. I looked through that site's home page...it looks like a pretty awesome resource, actually. Like if the Pharmacist Letter was actually useful.

ItsOverZyvox · Mar 29, 2009

WVUPharm2007 said:
Those damned Canadians...always one step ahead of us. I looked through that site's home page...it looks like a pretty awesome resource, actually. Like if the Pharmacist Letter was actually useful.

ehhh...they were paid off by Eli Lily!!! Dang socialists!!

Aren't Requiem and Vixen both Canadian?

WVUPharm2007 · Mar 29, 2009

ItsOverZyvox said:
Aren't Requiem and Vixen both Canadian?

See, that's why they know so much about it. The Canadian version of the pharmacist's letter has them one step ahead. Hey, maybe that's what you should do, Z. Publish a newsletter of relevant crap like this "RxFiles" thing. It can't be that hard of a job.

ItsOverZyvox · Mar 29, 2009

WVUPharm2007 said:
See, that's why they know so much about it. The Canadian version of the pharmacist's letter has them one step ahead. Hey, maybe that's what you should do, Z. Publish a newsletter of relevant crap like this "RxFiles" thing. It can't be that hard of a job.

eh.. we actually do. But it's proprietary yo. I do the peer review but I hate being the one doing the writing. So I try to stay away...

WVUPharm2007 · Mar 29, 2009

ItsOverZyvox said:
eh.. we actually do. But it's proprietary yo. I do the peer review but I hate being the one doing the writing. So I try to stay away...

Haha. You're handcuffed via intellectual copyright agreement.

ItsOverZyvox · Mar 29, 2009

WVUPharm2007 said:
Haha. You're handcuffed via intellectual copyright agreement.

Welcome to the world of for profit.

WVUPharm2007 · Mar 29, 2009

ItsOverZyvox said:
Welcome to the world of for profit.

Haha. You work for "the man."

ItsOverZyvox · Mar 29, 2009

WVUPharm2007 said:
Haha. You work for "the man."

The "man" is gracious enough to divide up the pie for some of us worker bees too. So we work a little harder.

Requiem · Mar 29, 2009

My bad on the spam. Not once did the post actually work, then an hour later 5 posts appear.

To Z, I actually didn't have the journal club article on it - it was all research on my end as our team asked us about it and we had to present the topic.

The RxFiles article we did have access to, and it is a good reference.

The print version is dirt cheap, like $40, but incredibly difficult to read. They use different size font, colors, bold, italics etc., to mean different things.

To Vixen -> they did not do multivariate analysis on genotype.... and honestly it will probably not be done for a long time. The only studies on genotype of 2c19 are in japanese, young healthy men, and its like n=20.

Quiksilver · Mar 29, 2009

ItsOverZyvox said:
PM me your email addy. I'll send it to you.

pm sent!

Plavix vs. PPI Drug Interaction

Retired

Full Member

imagine sisyphus happy

Retired

Senior Member

Retired

Senior Member

imagine sisyphus happy

Retired

Retired

Secundum Artem PharmD

imagine sisyphus happy

Retired

Retired

imagine sisyphus happy

imagine sisyphus happy

Full Member

Retired

Retired

Retired

imagine sisyphus happy

imagine sisyphus happy

Retired

Retired

imagine sisyphus happy

imagine sisyphus happy

Retired

imagine sisyphus happy

Retired

Senior Member

Retired

foxy pharmacist

Senior Member

Retired

Retired

Retired

imagine sisyphus happy

Retired

Retired

imagine sisyphus happy

Retired

imagine sisyphus happy

Retired

imagine sisyphus happy

Retired

imagine sisyphus happy

Retired

Senior Member

Secundum Artem PharmD

Similar threads