Risk of upper gastrointestinal ulcer bleeding associated with selective cyclo-oxygenase-2 inhibitors, traditional non-aspirin non-steroidal anti-inflammatory drugs, aspirin and combinations

BACKGROUND

The risks and benefits of coxibs, non-steroidal anti-inflammatory drugs (NSAIDs), and aspirin treatment are under intense debate.

OBJECTIVE

To determine the risk of peptic ulcer upper gastrointestinal bleeding (UGIB) associated with the use of coxibs, traditional NSAIDs, aspirin or combinations of these drugs in clinical practice.

METHODS

A hospital-based, case-control study in the general community of patients from the National Health System in Spain. The study included 2777 consecutive patients with endoscopy-proved major UGIB because of the peptic lesions and 5532 controls matched by age, hospital and month of admission. Adjusted relative risk (adj RR) of UGIB determined by conditional logistic regression analysis is provided.

RESULTS

Use of non-aspirin-NSAIDs increased the risk of UGIB (adj RR 5.3; 95% confidence interval (CI) 4.5 to 6.2). Among non-aspirin-NSAIDs, aceclofenac (adj RR 3.1; 95% CI 2.3 to 4.2) had the lowest RR, whereas ketorolac (adj RR 14.4; 95% CI 5.2 to 39.9) had the highest. Rofecoxib treatment increased the risk of UGIB (adj RR 2.1; 95% CI 1.1 to 4.0), whereas celecoxib, paracetamol or concomitant use of a proton pump inhibitor with an NSAID presented no increased risk. Non-aspirin antiplatelet treatment (clopidogrel/ticlopidine) had a similar risk of UGIB (adj RR 2.8; 95% CI 1.9 to 4.2) to cardioprotective aspirin at a dose of 100 mg/day (adj RR 2.7; 95% CI 2.0 to 3.6) or anticoagulants (adj RR 2.8; 95% CI 2.1 to 3.7). An apparent interaction was found between low-dose aspirin and use of non-aspirin-NSAIDs, coxibs or thienopyridines, which increased further the risk of UGIB in a similar way.

CONCLUSIONS

Coxib use presents a lower RR of UGIB than non-selective NSAIDs. However, when combined with low-dose aspirin, the differences between non-selective NSAIDs and coxibs tend to disappear. Treatment with either non-aspirin antiplatelet or cardioprotective aspirin has a similar risk of UGIB.

Optimising acid inhibition treatment

Acid inhibition is safe and useful in several clinical settings. Proton pump inhibitors are more effective than H2-receptor antagonists in virtually all cases. Proton pump inhibitors should be used in: the eradication of Helicobacter pylori; the treatment of non-H. pylori-related peptic ulcer healing; for the prevention and treatment of non-steroidal anti-inflammatory drug-induced upper digestive lesions; for bleeding peptic lesions; and, especially, in the short-term and long-term control of gastro-oesophageal reflux disease. The timing, the dosing and the specific drugs should be adapted to the particular patient, clinical situation and local factors. For instance, in a patient with active bleeding from a duodenal ulcer, intravenous constant infusion should be the preferred treatment. When seeking oral 'potent' acid inhibition (refractory gastro-oesophageal reflux disease, and perhaps Barrett's oesophagus), available data suggest that the pharmacological and clinical profiles of esomeprazole are slightly better.

What is potent acid inhibition, and how can it be achieved?

The clinical response to antisecretory treatment correlates directly with the degree of inhibition of acid secretion achieved. Acid inhibition able to maintain the intragastric pH at a value greater than 4 for at least 16 h/day seems to heal even the most refractory acid-related diseases. It has also been shown that the degree of inhibition of acid secretion in response to antisecretory treatment depends on the genetic characteristics of the patient and on the presence of Helicobacter pylori infection. A possible definition of potent (or profound) acid inhibition is, therefore, the achievement of the aforementioned level of control of acid secretion regardless of patient characteristics or of the presence of H. pylori infection. Antisecretory drugs differ in their ability to reach potent acid inhibition. As far as the comparative efficacy of different drugs for inhibiting acid secretion is concerned, proton pump inhibitors are more efficient in inhibiting gastric acid secretion than histamine (H2) receptor antagonists. Among the different proton pump inhibitors, esomeprazole 40 mg/day exhibits greater antisecretory potency than the others at standard doses. Rabeprazole 20 mg/day and lansoprazole 30 mg/day exhibit a more rapid onset of action than omeprazole 20 mg/day or pantoprazole 40 mg/day.

Actividad de la tiopurina metiltransferasa en la enfermedad inflamatoria intestinal. Un estudio en 7.046 pacientes españoles

BACKGROUND AND OBJECTIVE

Our objective was to assess the activity of thiopurine methyltransferase (TPMT) in a very large number of Spanish patients with inflammatory bowel disease (IBD), to evaluate the influence of several variables (including azathioprine or 6-mercaptopurine) on that activity, and to know the proportion of patients with low TPMT activity and therefore high risk of myelotoxicity when treated with these drugs.

PATIENTS AND METHOD

TPMT activity in red blood cells (RBCs) was measured by a radiochemical method. The association between several variables and TPMT values was assessed by multiple lineal regression.

RESULTS

7046 patients were included (mean age: 37 years; 53% males): 70% with Crohn's disease, 22% with ulcerative colitis, and 8% with indeterminate colitis. Mean TPMT value was 20 (6) U/ml RBCs (minimum 0 and maximum 46). TPMT activity distribution was as follows: low levels (< 5 U/ml), 0.5%; intermediate (5-13.7), 11.1%; and high (> or = 13.8), 88.4%. TPMT values did not follow a normal distribution (p < 0.001). In the univariate study, statistically significant differences (p < 0.001), yet of doubtly clinical significance because its minimal magnitude, were demonstrated in TPMT values depending on age, sex, type of disease, and treatment with azathioprine/6-mercaptopurine. In the multivariate study, the variables associated with TPMT activity were: sex, treatment with 5-aminosalicylates, steroids and azathioprine/6-mercaptopurine.

CONCLUSIONS

This study shows that 0.5% of the Spanish patients with IBD have low TPMT activity (< 5 U/ml RBCs), a figure similar to that reported in other countries, these patients being at higher risk of myelotoxicity when treated with azathioprine or 6-mercaptopurine. The drugs usually prescribed for the treatment of IBD, including 5-aminosalicylates and azathioprine/6-mercaptopurine, do not seem to modify in a clinically relevant manner TPMT activity.

Cirugía de una cohorte incidente de pacientes con enfermedad de Crohn en Aragón: indicaciones, tipo de cirugía y factores de riesgo asociados

INTRODUCTION

Few population-based studies have been published on predictive factors in the clinical course of Crohn's disease (CD). The only constant risk factor for postsurgical recurrence is smoking. The aim of this study is to describe surgical need, etiology and characteristics, and the distinct clinical variables that act as risk or protective factors for the indication of surgery in an incidence cohort of patients with a diagnosis of CD in Aragon.

MATERIAL AND METHODS

Based on the results of a population-based, prospective study reporting the incidence of inflammatory bowel disease in Aragon, 88 patients with a diagnosis of CD were included in the present study. The patients medical records were reviewed and data on the following clinical variables from diagnosis (1992-1995) to February 2001 were gathered: surgery, type of surgery and etiology, anatomic distribution, number of relapses, remission, clinical course, death, smoking, oral contraceptive intake, and hospitalization. Descriptive and bivariate analyses were performed to investigate the association between these variables and surgery during follow-up.

RESULTS

Eighty-eight patients with at least 6 months of follow-up were included (88/103; 85%), with a mean follow-up of 77 months (range, 6-110 months). Some kind of surgery during follow-up was required by 20.5% of our patients; in nearly 50% of these, surgery was indicated for intestinal obstruction. A second surgical intervention was required in 10.2% due to fistula and/or abscess or ileostomy for subsequent reconstruction of intestinal transit. Although ileal localization was more frequently associated with surgery, this association was not statistically significant. No association was found between surgery during follow-up and sex, age at diagnosis or oral contraceptive intake. Factors positively associated with surgery were a chronic clinical course and a greater number of hospitalizations. We found no positive or negative association with smoking, non-smoking or time free of smoking, but the total time of smoking was positively associated with surgery.

CONCLUSIONS

Risk factors for surgery in patients with CD were a chronic clinical course, the number of hospitalizations and total time of smoking. Ileal localization was more frequently associated with surgery but this association was not statistically significant.

La afectación pancolónica inicial en la colitis ulcerosa predice la necesidad de colectomía: estudio poblacional basado en una cohorte incidente de pacientes en Aragón

INTRODUCTION

Population-based studies show pancolitis as the only risk factor for colectomy in patients with ulcerative colitis (UC).

AIM

To evaluate surgical need, its etiology and characteristics, and the distinct clinical variables that act as risk and/or protective factors for the indication for surgery in an incident cohort of patients with UC in Aragón.

PATIENTS AND METHOD

Based on the results of a population-based, prospective study reporting the incidence of inflammatory bowel disease in Aragón, 168 patients with a diagnosis of UC were included in the present study. The patients' medical records were reviewed and the following clinical variables were collected from the time of diagnosis (1992-1995) to February 2001: surgery, type of surgical intervention and etiology, anatomic distribution, number of relapses, remissions, clinical course, death, smoking, oral contraceptives and hospitalizations. To investigate the association between these variables and surgery during follow-up, descriptive and bivariate analyses were performed.

RESULTS

Of 204 patients diagnosed with UC, 168 (82.3%) with a follow-up of at least 6 months were included. The mean follow-up was 77 months (range: 6-110 months). Some type of surgery was required by 6.5% of our patients during follow-up and 3.6% needed a second surgical intervention. Surgery was indicated for various etiologies. Most patients underwent colectomy and ileostomy with subsequent surgical reconstruction of the intestinal tract. Pancolitis was a clear independent risk factor for colectomy in our patient cohort. No association was found between sex, age at diagnosis, and oral contraceptive intake with surgery during follow-up. Patients who underwent surgery had previously shown more than one relapse and several hospitalizations but did not necessarily show a chronic clinical course. We found no positive or negative association with any smoking-related variables: smoker, non-smoker, years of smoking or years free of smoking.

CONCLUSION

Ulcerative pancolitis at diagnosis is a predictive factor for surgery in the short term in patients with a diagnosis of UC in Aragón. We found no other significant associations with the remaining epidemiological factors studied.

[Helicobacter pylori resistance to metronidazole and clarythromicin: descriptive analysis 1997-2000]

BACKGROUND AND OBJECTIVE

We aimed to assess the resistance of H. pylori to clarithromycin and metronidazole, in patients with and without previous eradication treatment, in a geographic area from the north of Spain. We also analyzed the evolution of resistance rates and its relationships with annual antibiotic consumption.

PATIENTS AND METHOD

Retrospective study including all patients with H. pylori infection and positive culture from January 1997 to December 2000. Minimal inhibitory concentrations (MIC) determined by the E test were used to report the clarithromycin (MIC > 2 mg/l) and metronidazole (MIC > 32 mg/l) resistance.

RESULTS

A total of 537 clinical H. pylori isolates from patients without (n = 389) and with previous eradication treatment (n = 148) were studied. H. pylori resistance to clarithromycin and metronidazole was found in 8.7% (95% CI, 6.1-12) and 13.8% (95% CI, 10.4-17.3) patients without previous eradication treatment and in 39.2% (95% CI, 31.3-47.1) and 37.8% (95% CI, 30-45.7) patients with previous eradication treatment (p < 0.001), respectively. Clarithromycin resistance remained stable (1997: 9.7%; 1998: 5.7%; 1999: 11.8%; 2000: 6.2%) whereas metronidazole resistance decreased over the 4 years study period (1997: 38.7%; 1998: 15.1%; 1999: 9%; 2000: 6.9%). We did not observe any clear relationship between resistance's evolution and antibiotic annual consumption.

CONCLUSIONS

In our geographic area, primary resistance rates for clarithromycin remained stable whereas resistance for metronidazole decreased over the 4 years period.

Granulocyteaphaeresis in steroid-dependent inflammatory bowel disease: a prospective, open, pilot study

BACKGROUND

Uncontrolled studies suggest that granulocyteaphaeresis might be useful in the management of active ulcerative colitis.

AIM

To assess the efficacy of granulocyteaphaeresis treatment in active steroid-dependent inflammatory bowel disease.

METHODS

We conducted a multicentre, prospective, open, pilot study in patients with steroid-dependent inflammatory bowel disease. All patients were started on 60 mg/day of prednisone; after 1 week, a five-session programme of granulocyteaphaeresis (once per week) was started. The steroid dose was tapered weekly if there was clinical improvement. Remission was defined as an inactive clinical activity index together with complete withdrawal of steroids at week 6. The patients were followed up for at least 6 months or until disease relapse.

RESULTS

Twenty-six patients (14 ulcerative colitis, 12 Crohn's disease) were included. More than a half had been previously treated with immunomodulators. Remission was achieved in 62 and 70% of ulcerative colitis and Crohn's disease, respectively. During a median follow-up of 12.6 months, six of eight ulcerative colitis patients maintained their clinical remission; however, only one Crohn's disease patient remained in remission after the first 6 months of follow-up.

CONCLUSIONS

Granulocyteaphaeresis is a safe treatment option in inflammatory bowel disease. A five-session programme of granulocyteaphaeresis seems to be efficient in the treatment of steroid-dependent ulcerative colitis, but not in Crohn's disease.

Breath test is very reliable for diagnosis of Helicobacter pylori infection in real clinical practice

AIMS

To determine the accuracy of the most common available tests for the diagnosis of Helicobacter pylori infection in an unselected and untreated population of patients.

PATIENTS AND METHODS

Prospective study including 314 unselected patients from a population of 814 patients referred for upper endoscopy at one hospital. H. pylori infection was diagnosed by rapid urease test (RUT), histology, culture and 13C-urea-breath test (UBT) and serum IgG (EIA). H. pylori infection was defined as positive if culture or at least two of the other tests were positive.

RESULTS

The prevalence of H. pylori infection in this population was 72%. The diagnostic test with the greatest combination of sensitivity (97%) and specificity (100%) was the UBT. EIA had a good sensitivity (96%), but it was the test with the least specificity (71%). RUT, histology and culture showed a high specificity (>98%) but a sensitivity lower than 90%. In elderly patients (>65 years old, n=120), UBT was also the test with the greatest combination of sensitivity (94%) and specificity (100%).

CONCLUSIONS

In conditions of real clinical practice the 13C-urea-breath test is a reliable test for H. pylori diagnosis, both in young and elderly patients.

Low frequency of upper gastrointestinal complications in a cohort of high-risk patients taking low-dose aspirin or NSAIDS and omeprazole

BACKGROUND

There is very little information available on the incidence of complications and on the best prevention therapy in high-risk patients taking non-steroidal anti-inflammatory drugs (NSAIDs) and/or aspirin. Randomized-controlled trials in such patients are rare for ethical reasons. We studied the incidence of gastrointestinal complications in high-risk patients taking long-term low-dose aspirin or non-aspirin-NSAIDs combined with omeprazole in a real-life clinical setting.

METHODS

This was a multicentre, prospective and observational study including 247 consecutive high-risk patients who had a clinical indication for long-term treatment with either low-dose aspirin or non-aspirin NSAIDs and omeprazole therapy. The occurrence of gastrointestinal complications was measured.

RESULTS

In addition to a recent history of peptic ulcer bleeding, all patients had at least 1 other risk factor and 112 (45.3%) had 3 or more risk factors; 78.9% were taking low-dose aspirin and the remainder non-aspirin NSAIDs. Mean follow-up was 14.6 +/- 10.38 months. Three patients taking low-dose aspirin developed upper gastrointestinal bleeding (1.2%; 95% CI 0.3-3.5; 1.0 event/100 patients/year). This was similar to the rate observed in studies involving non-high-risk patients taking low-dose aspirin and higher than that observed in patients not taking low-dose aspirin. Two additional patients developed a lower gastrointestinal bleeding event (0.81% (0.04%-3.12%); 0.67 events/100 patients/year), which was within the range expected in NSAID users.

CONCLUSIONS

The use of omeprazole in the high-risk patient taking low-dose aspirin or NSAIDs seems to be a safe therapeutic approach in this population and is associated with a low frequency of upper gastrointestinal complications.

[Comparison between two 13C-urea breath tests for the diagnosis of Helicobacter pylori infection: isotope ratio mass spectrometer versus infrared spectrometer]

OBJECTIVES

To compare the accuracy of the breath test using the isotope ratio mass spectrometer (IRMS) versus the nondispersive isotope-selective infrared spectrometer (NDIRS) in the diagnosis of Helicobacter pylori infection.

METHOD

Multicenter study in 4 Spanish hospitals. One group of dyspeptic patients who had not undergone prior eradication therapy and another group of patients with gastric ulcer or gastrointestinal bleeding due to gastroduodenal ulcer receiving H. pylori eradication therapy were included in the study. A reference standard based on histology and the rapid urease test was used. The breast test (TAU-KIT, Isomed S.L., Madrid, Spain) was performed with citric acid and 100 mg of 13C-urea. Samples of expired air were collected in tubes and bags for reading with the IRMS (ABCA, PDZ, Crewe, Manchester, England) and the NDIRS (UBiT-IR200, Otsuka Electronics, Co, Osaka, Japan), respectively. The endoscopist, pathologist and person responsible for reading the urease test and both breath tests were blinded to the results of the other diagnostic methods.

RESULTS

Forty-one patients were included. The prevalence of H. pylori was 26%. No differences were found on comparing the mean values obtained with the IRMS and the NDIRS: 13 (standard deviation) (24) and 14 (25) delta units, respectively. The area under the ROC curve for the IRMS and the NDIRS was 0.96. The diagnostic accuracy for the best cut-off point with the IRMS and the NDIRS was, respectively: sensitivity (90 and 100%), specificity (96 and 89%), positive predictive value (90 and 77%), negative predictive value (96 and 100%), + likelihaod ratio (25 and 9.3) and (0.1 and 0). A close correlation was found between the values of the IRMS and those of the NDIRS (lineal regression equation, Y = 1.1 + 1.004. X; r = 0.97).

CONCLUSION

Both the spectrometers used to evaluate the breath test, the IRMS and the NDIRS, offer a high degree of accuracy in the diagnosis of H. pylori infection.

Validation of the 13c-urea breath test for the initial diagnosis of helicobacter pylori infection and to confirm eradication after treatment

OBJECTIVES

the breath test with 13C-urea (UBT) is a method widely used in Spain, but its diagnostic accuracy has not been evaluated in a clinical trial until now. Our objective was to validate the UBT (TAU-KIT) both as an initial diagnostic method for the detection of H. pylori infection and as a method to confirm eradication.

METHODS

a multi-centre study in 7 Spanish hospitals was performed. A group of dyspeptic patients who had not previously received eradication treatment was included, and a second group of patients with gastric ulcer or upper gastrointestinal bleeding due to peptic ulcer was also included (eradication of H. pylori was confirmed 6 to 8 weeks after treatment completion with omeprazole, clarithromycin and amoxycillin). In both groups an endoscopy was performed with biopsies for histology and rapid urease test. Patients were considered infected if both tests yielded positive results, and not infected when both tests were negative. The UBT 13C-urea (TAU-KIT, Isomed S.L., Madrid, Spain) was performed with citric acid and 100 mg of 13C-urea. The pathologist and persons responsible for endoscopy, urease test and UBT were all unaware of the results from the other diagnostic methods.

RESULTS

in the pre-treatment group (36 patients) the prevalence of H. pylori was 72%, the area under the ROC curve for the diagnosis of infection with the UBT was 0.99, and the best cut-off point was 5 units, with the following results: sensitivity= 96% (95% CI = 81-99%), specificity= 100% (69-100%), positive predictive value (PPV) = 100% (87-100%), negative predictive value (NPV) = 92% (59-100%), likelihood ratio (LR) + = infinity, and LR- = 0.04. In the post-treatment group (85 patients) the prevalence of H. pylori was 16%, the area under the ROC curve was 0.99, and the best cut point was 4.6, with the following results: sensitivity= 100% (77-100%), specificity = 97% (90-99%), PPV = 88% (62-98%), NPV = 100% (95-100%), LR+ = 35, and LR- = 0.

CONCLUSION

UBT provides excellent accuracy both for the initial diagnosis of H. pylori infection and to confirm eradication after treatment.

[Is the breath test reliable in primary care diagnosis of Helicobacter pylori infection?]

OBJECTIVE

To evaluate the reliability of the breath test urea 13C in the primary care for the diagnosis of Helicobacter pylori (Hp) infection.

DESIGN

Descriptive, prospective and multicentric.Location. Urban area belonging to the Health Center Actur Sur of Zaragoza with participation of Miguel Servet Hospital.

PARTICIPANTS

87 patients with clinical diagnosis of functional dispepsia. In all of them was made a breath test with 13C urea as well as a gastroscopy with taking of samples for histology and ureasa fast test.

MAIN MEASUREMENTS

Age, sex and the presence of positivity or negativity of infection by Hp were valued in the histology, ureasa test and in the breath test, considering the histology and the ureasa test like gold tests for this measurement, reason why it was demanded that the positive or outside negative result in both considering it nonambiguous.

RESULTS

Two cases were excluded by ambiguous results. The 77.6% (66/85) were positive by histology and ureasa test, and these, 92.4% (61/66) were positives to the breath test. The sensitivity of this test was 92% and the specificity 100%.

CONCLUSIONS

The breath test in primary care has a high value diagnosis of Hp infection, being able to avoid, in some cases, another invasives techniques like gastroscopy.

[Helicobacter pylori eradication in patients with peptic ulcer after two treatment failures: a prospective culture-guided study]

AIM

To determine the effectiveness of a third, culture-guided, treatment of H. pylori infection after two unsuccessful attempts.

PATIENTS AND METHODS

Forty-two consecutive patients with a diagnosis of peptic ulcer were included in an open prospective and multicenter study. After two unsuccessful attempts at eradication (demonstrated by positive urea breath test), all patients underwent endoscopy and H. pylori infection was confirmed by urease test, histology and culture (Pylori-Agar, Bio Merieux, France). Antibiotic susceptibility to metronidazole, amoxicillin, tetracycline and clarithromycin was defined by E-test. Thirty-nine patients received a two-week quadruple culture-guided therapy defined by the protocol, which considered sensitivity data and previous allergies to antibiotics (one culture was contaminated, one patient refused treatment and one was allergic to tetracycline and amoxicillin and was resistant to metronidazole and clarithromycin). Compliance was monitored by pill counting and eradication was defined as a negative urea breath test six weeks after the end of treatment.

RESULTS

Sensitivity data were obtained in 41 patients. Intention-to-treat analysis revealed that overall eradication was achieved in 60% (24/40). Eighteen strains (43.9%) were resistant to metronidazole, 21 (51.2%) were resistant to clarithromycin and 8 (19.5%) were resistant to both drugs. None of the strains were resistant to amoxicillin or tetracycline. We used mainly two kinds of quadruple therapy in the 39 patients. Despite good compliance with treatment based on omeprazole (20 mg/12 h), bismuth subcitrate (120 mg/6 h), tetracycline (500 mg/4 h) and clarithromycin (500 mg/ 12 h) (OBTC) eradication was achieved in only 9 of 19 patients (47.4%; CI: 24.4-71.1) (one patient failed to attend the urea breath test). Nineteen clarithromycin-resistant patients received amoxicillin (1,000 mg/12 h) instead of clarithromycin (OBTA) and this treatment was effective in 14 (73.7%; CI: 48.8-90.9). Eradication was achieved in one patient who was allergic to amoxicillin and resistant to clarithromycin and metronidazole and who received ciprofloxacin (500 mg/8 h) instead of clarithromycin (OBTCipro). No clinical factors associated with eradication failure were found.

CONCLUSIONS

Despite the use of two-week, high-dose, quadruple and culture-guided combinations of drugs, a third treatment was frequently unsuccessful. The lowest eradication rate was obtained in patients with H. pylori strains sensitive to all antibiotics; therefore, we believe that other factors could influence eradication rates. New prospective and randomized studies are needed in this subgroup of patients to find effective treatments.