# Situation: A 41-year-old man with long-standing gastroesophageal reflux disease (GERD) and a large sliding hiatal hernia is being prepared for laparoscopic fundoplication. A coronary stent was placed 5 months ago. His medication list is: clopidogrel 75 mg daily; aspirin 80 mg daily; atorvastatin 40 mg at night; omeprazole 40 mg before breakfast. Which drug combination should the nurse bring to the prescriber's attention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630470  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 41-year-old man with long-standing gastroesophageal reflux disease (GERD) and a large sliding hiatal hernia is being prepared for laparoscopic fundoplication. A coronary stent was placed 5 months ago.

His medication list is: clopidogrel 75 mg daily; aspirin 80 mg daily; atorvastatin 40 mg at night; omeprazole 40 mg before breakfast. Which drug combination should the nurse bring to the prescriber's attention?

## 보기

1. Omeprazole with clopidogrel **✔ 정답**
2. Aspirin with clopidogrel
3. Atorvastatin with clopidogrel
4. Omeprazole with aspirin

**정답: 1**

## 해설

Omeprazole and esomeprazole reduce the activation of clopidogrel, which can weaken its antiplatelet effect in a client with a recent stent. When acid suppression is still needed with clopidogrel, pantoprazole is preferred. Aspirin with clopidogrel after a recent stent is intended dual antiplatelet therapy, and a proton pump inhibitor protects the stomach of a client taking aspirin.

## 심화 해설

The interaction to report
The client takes clopidogrel and aspirin after a coronary stent placed 5 months ago, plus atorvastatin and omeprazole. Omeprazole and esomeprazole reduce the activation of clopidogrel, which can weaken its antiplatelet effect in a client with a recent stent. The nurse brings this combination to the prescriber's attention. When acid suppression is still needed with clopidogrel, pantoprazole is preferred.

Why omeprazole weakens clopidogrel
Clopidogrel is a prodrug: it has no antiplatelet effect until the liver converts it to its active form, mainly through the enzyme CYP2C19. Omeprazole and esomeprazole inhibit CYP2C19, so less active drug is formed and platelets are less inhibited. In a client with a coronary stent, reduced platelet inhibition raises the risk of stent thrombosis and heart attack. Pantoprazole has much less effect on CYP2C19 and is therefore preferred when a PPI is needed.

| Combination | Effect | Action |
| --- | --- | --- |
| Omeprazole with clopidogrel | Reduced clopidogrel activation | Report; pantoprazole preferred |
| Aspirin with clopidogrel | Intended dual antiplatelet therapy after a stent | Continue as prescribed |
| Atorvastatin with clopidogrel | No clinically important effect at usual doses | Continue |
| Omeprazole with aspirin | PPI protects the stomach from aspirin | Helpful |

Why the other combinations are appropriate
Aspirin plus clopidogrel after a recent stent is dual antiplatelet therapy, intended to prevent stent thrombosis, and is continued for the period set by the cardiologist. Atorvastatin at usual doses has no clinically important effect on clopidogrel. A PPI given with aspirin protects the stomach from aspirin-related bleeding, which is a reason to keep acid suppression, just with a different PPI.

Watch out! Combining two antiplatelet drugs may look like a duplication error, but after a coronary stent it is deliberate. Do not report intended therapy as the problem.

Perioperative note
Because this client is preparing for fundoplication, his antiplatelet therapy also needs careful planning: stopping it early after a stent can cause stent thrombosis, so any change must be decided by the surgeon and cardiologist together. Key point! Omeprazole reduces activation of clopidogrel through CYP2C19; report the pairing, as pantoprazole is preferred when a PPI is needed with clopidogrel.

## 임상 시나리오

Omeprazole and ClopidogrelCoronary stent 5 months ago
Clopidogrel is a prodrug activated by CYP2C19; omeprazole inhibits this enzyme and weakens the antiplatelet effect.

Reduced platelet inhibition raises the risk of stent thrombosis. When a PPI is needed with clopidogrel, pantoprazole is preferred.

Aspirin with clopidogrel is intended dual antiplatelet therapy; a PPI with aspirin protects the stomach.

CautionNever stop antiplatelet therapy after a recent stent without the cardiologist; early discontinuation can cause stent thrombosis.

## 핵심 개념

- **Clopidogrel** — An antiplatelet prodrug that blocks the platelet P2Y12 receptor after activation in the liver.
- **CYP2C19** — A liver enzyme that converts clopidogrel to its active form and is inhibited by omeprazole.
- **Dual antiplatelet therapy** — Combined use of aspirin and a P2Y12 inhibitor to prevent thrombosis after a coronary stent.
- **Stent thrombosis** — Clot formation within a coronary stent, which can cause a heart attack.

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