Objective
Proton pump inhibitors (PPI) are the most widely preferred drugs to prevent the gastrointestinal bleeding especially in coronary care units. Since the cardiologists feel obliged to initiate this class of drug to prevent our patients from any gastrointestinal hemorrhage due to highly potent anti-aggregating and anticoagulant drugs such as acetylsalicylic acid derivatives, clopidogrel, and heparin, and etc. However, this class of drugs should be used cautiously in patients with acute coronary syndrome by several ways. Since those drugs may have some rare but potentially serious adverse reactions.
Method
We present a 72-year-old female patient who was diagnosed subacute anterior myocardial infarction and developed anemia in a few days due to pantoprazole 40 mg intravenously. She was taking clopidogrel 75 mg/day, acetylsalicylic acid 100 mg/day, atorvastatin 20 mg/day orally, enoxaparin 0.6 cc bid subcutaneously and pantoprazole 40 mg/day intravenously. Blood urea was 77 mg/dL and creatinine was 2.1 mg/dL. Hemoglobin and hematocrite levels were 13.2 g/dL and %42 in complete blood count (CBC), respectively. During the follow up in coronary care unit, Hb values reduced to 9,8 g/dL and 7,9 g/dL on the third and fourth days with normal MCV and LDH levels. Pantoprazole dosage was increased 40 mg intravenously two times a day against the probability of gastrointestinal hemorrhage. In order to increase hemoglobin level, two units of erythrocyte suspension were transfused to the patient in different times. Hemoglobin level was increased from 7.9 g/dL to 9.7 mg/dL on the 4th day. However it was reduced to 7.8 g/dL on the 5th day again. Meanwhile upper or lower gastrointestinal hemorrhage was excluded by normal physical examination of her abdomen with normal bowel sounds, triplicate negative tests for occult blood on stool, and normal colored stool. Coombs tests were also negative. Upon the searching for the etiology of anemia, we found that the PPIs were reported to be associated with anemia due to several reasons and pantoprazole could be rarely associated with anemia. After pantoprazole discontinuation, anemia which persisted or required erythrocyte replacement did not occur. By several mechanisms, PPIs can produce anemia. Initially long term use of PPIs can produce B12 vitamin deficiency and macrocytic anemia. However we observed that anemia developed in a few days and persisted when we increased the parenteral dose of pantoprazole.
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