Co-prescription of H2 receptor blockers and proton pump inhibitors with warfarin in general practice

Acid-suppressing drugs and anticoagulants are used increasingly in general practice. Warfarin is potentiated by some acid-suppressing drugs, notably cimetidine and omeprazole, through interference of the cytochrome P450 system. This study aimed to ascertain the extent of co-prescribing of warfarin and acid-suppressing drugs in general practice. We conducted a retrospective survey of the records of all patients prescribed acid-suppressing drugs over a 2-year period to ascertain those who had also taken warfarin; we also made a cross-sectional survey of all patients on warfarin to ascertain those who had taken acid-suppressing drugs. From a general practice population of 45 574 patients in northern England, 3423 (7.5%) had been prescribed acid-suppressing drugs during the previous 24 months. Of 274 patients who had been on warfarin, 44 (16.1%) had also taken acid-suppressing drugs (26 H2 receptor blockers and 18 proton-pump inhibitors). The commonest reasons for anticoagulation were thrombo-embolic disease (40.9%), atrial fibrillation (36.4%), valvular heart disease (18.2%), and surgical prophylaxis (4.5%). The indications for concurrent acid-suppressing drugs were: `dyspepsia' 38.6%, reflux 22.7%, oesophagitis 13.6%, duodenal ulcer 13.6%, gastric ulcer 4.5%, unknown 6.8%. There have been no studies from primary care to evaluate the possible clinical effects of the concomitant use of acid-suppressing drugs and warfarin; some fluctuations in coagulation control, particularly in patients taking the combinations intermittently, may be due to this. Keywords: H2 receptor blockers; acid-suppressing drugs; warfarin; proton pump inhibitors