Potassium-Competitive Acid Blocker Versus pROton-Pump Inhibitor for GastroproTECTion Strategies In Patients at High Gastro-Intestinal Bleeding Risk Receiving Antithrombotic Therapy

Prior treatment

• Any clinical contraindication to using of antithrombotic therapies (antiplatelet agents or OAC)
• Concurrent use of PPI or P-CAB within 4 weeks before randomization
• Concomitant use of clarithromycin with terfenadine, cisapride, astemizole, or pimozide for Helicobacter pylori eradication
• Systemic treatment with strong CYP 3A4 and p-glycoprotein (P-GP) inhibitors (e.g., systemic azole antimycotics, such as ketoconazole, and human immunodeficiency virus \[HIV\]-protease inhibitors, such as ritonavir)
• Patients who take atazanavir, nelfinavir, or rilpivirine-containing products (see Drug-Drug interaction section)

Other illness

• Active bleeding at the time of inclusion or a history of hereditary or acquired hemostatic disorder
• Hemodynamically unstable conditions at the time of inclusion: cardiogenic shock at the time of randomization, refractory ventricular arrhythmias, or congestive heart failure (New York Heart Association class IV).
• Severe chronic liver disease (defined as variceal haemorrhage, ascites, hepatic encephalopathy, or jaundice)
• Hypersensitivity or contraindication to PPI, P-CAB, any of the product components, or substituted benzimidazoles
• Use of clarithromycin and hypersensitivity to macrolide antibiotics for Helicobacter pylori eradication
• Any known or suspected malignancy
• Patients with non-cardiac co-morbidities with a life expectancy of less than 12 months
• Patients with active treatment for H-pylori infection
• Participation in another clinical study within 12 months. However, where at least one or more conditions are satisfied, it could be an exception according to an investigator's discretion;
  • Participated in the observational study expected no effect on the safety and/or effectiveness evaluation of this trial
  • Screening failed before any interventional factor is involved
  • Participated in academic trials like strategic or medical device comparison studies conducted under standard therapy provided that there is no additional risk or a specific procedure to a subject and no interference between this trial and other studies

Lab values

• Baseline severe anemia (Hgb \<8 g/dl at baseline) or transfusion within 4 weeks before randomization
• Baseline severe thrombocytopenia (platelet count \<50,000/mm3)
• Renal failure dependent on dialysis or severe renal insufficiency (creatinine clearance \<15 ml/min)
• Clinically significant laboratory abnormality at screening (estimated glomerular filtration rate (eGFR) \<15 mL/min or elevated liver enzyme \[AST, ALT, ALP, total bilirubin\] \> 3 times upper normal limit \[UNL\] or any other condition that, in the opinion of the Investigator, precludes participation in the study

Other

• Women who are pregnant or breastfeeding or female subjects, premenopausal who are not surgically sterile, or, if sexually active not practicing an effective method of birth control (e.g., prescription oral contraceptives, contraceptive injections, intrauterine device, double-barrier method, contraceptive patch, male partner sterilization) before entry and throughout the study; and, for those of childbearing potential, who have a positive pregnancy test at screening

• Patients 19 years of age or older with known cardiac and vascular disease who are receiving chronic use of antithrombotic drugs (either antiplatelets, oral anticoagulant (OAC), and its combinations). Specific clinical conditions that may confer a need for long-term antithrombotic therapy may include documented coronary artery disease (stable or unstable angina, acute coronary syndrome, a history of myocardial infarction, or any coronary revascularization), documented cerebrovascular disease (stroke or transient ischemic attack), known peripheral arterial disease or a history of peripheral arterial revascularization, atrial fibrillation, or valvular heart disease requiring interventions (transcatheter aortic valve replacement or transcatheter mitral-valve repair). Concomitant use of a proton pump inhibitor is strongly recommended in patients receiving aspirin monotherapy, DAPT (dual antiplatelet therapy; aspirin plus any P2Y12 inhibitors), DAT (dual antithrombotic therapy; antiplatelet drug plus OAC), TAT (triple antithrombotic therapy; DAPT plus OAC), or OAC monotherapy (warfarin or direct oral anticoagulants) who are at high risk of GI bleeding in order to reduce the risk of gastric bleed or GI events. Based on clinical guidelines, the use of P2Y12 inhibitor monotherapy (i.e. clopidogrel, ticagrelor, or prasugrel) is not considered in trial enrollment.
• On the basis of clinical guidelines and expert consensus documents, we defined a study population with an increased risk of gastrointestinal bleeding if they had a least 1 or more criteria of the following characteristics. Eligible patients for randomization must meet at least 1 characteristic of these criteria:
  • \*Definition of patients who are at high risk of gastrointestinal bleeding
  • Age ≥65 years
  • Concomitant use of OAC and any antiplatelet therapy (mono or DAPT) (i.e., DAT or TAT)
  • Long-term use of oral NSAIDs (non-steroidal anti-inflammatory drugs) or steroids or high-dose NSAID therapy even during a relatively short-term period.
  • History of prior GI bleeding events at any time
  • History of a previously complicated ulcer
  • History of peptic ulcer disease or a previously uncomplicated ulcer
  • Documented Helicobacter pylori infection
• Patients who voluntarily participated in the written agreement