Systematic review of the symptom burden, quality of life impairment and costs associated with peptic ulcer disease

Different peptic ulcer bleeding risk in chronic kidney disease and end-stage renal disease patients receiving different dialysis

BACKGROUND

End stage renal disease (ESRD) patients receiving hemodialysis (HD) have a higher risk of peptic ulcer bleeding (PUB).

AIMS

Whether ESRD patients receiving peritoneal dialysis (PD) also carries a higher risk of PUB has not been studied.

METHODS

This was a cohort study using Taiwan's National Health Insurance research database, whereby 11,408 patients, including 2,239 PD, 2,328 HD, 2,267 chronic kidney disease (CKD) and 4,574 controls with age-sex matching were recruited. The log-rank test was used to analyze differences in accumulated PUB-free survival rates between groups. Cox proportional hazard regression was performed to evaluate independent risk factors for PUB in all the enrollees.

RESULTS

During the 7-year follow-up, PD and CKD patients had a significantly higher rate of PUB than matched controls. The risk of PUB between PD and CKD was not significantly different. Moreover, patients receiving HD carried a higher risk of PUB than those receiving PD, with CKD and controls (p all <0.05, by log-rank test). Cox proportional hazard regression analysis showed that CKD (HR 3.99, 95 % CI 2.24-7.13), PD (HR 3.71, 95 % CI 2.00-6.87) and HD (HR 11.96, 95 % CI 7.04-20.31) were independently associated with an increased risk of PUB. Being elderly, male, having hypertension, diabetes, cirrhosis, and nonsteroidal anti-inflammatory drugs and steroid use were other independent risk factors of PUB in all enrollees.

CONCLUSIONS

Patients with CKD and ESRD receiving PD or HD carried a higher risk for PUB. They should be screened for risk factors for PUB and receive some protective measures to prevent PUB.

The Prevalence, Risk Factors, and Clinical Correlates of Erosive Esophagitis and Barrett's Esophagus in Iranian Patients with Reflux Symptoms

Background. Erosive esophagitis (EE) and Barrett's esophagus (BE) are the two important complications of gastroesophageal reflux disease. We aimed to investigate the prevalence of and the risk factors for EE and BE in an Iranian group of patients with reflux symptoms. We also examined the relationship between reflux symptoms and endoscopic findings. Methods. A total of 736 patients with gastroesophageal reflux disease (GERD) symptoms were enrolled and all underwent upper gastrointestinal endoscopy. Diagnosis of Barrett's esophagus was confirmed by pathologic examination and Helicobacter pylori (H. pylori) infection was demonstrated by rapid urease test. Results. Two hundred eighty-three and 34 patients were found to have EE and BE, respectively. Multivariate analysis showed that hiatal hernia (P < 0.001) and H. pylori infection (P < 0.002) were the two significantly related risk factors for esophagitis. Only age was related to BE, with BE patients being more likely to be older (P < 0.001) than others. Conclusions. Prevalence of EE and BE in Iranian reflux patients is similar to that seen in western countries. H. pylori infection and the presence of hiatal hernia may be strong risk factors for esophagitis as does older age for Barrett's esophagus. Finally, reflux symptoms have no significant relationship with endoscopic findings.

Peptic ulcer disease risk in chronic kidney disease: ten-year incidence, ulcer location, and ulcerogenic effect of medications

Objectives

We aimed at determining peptic ulcer disease (PUD) incidence among chronic kidney disease (CKD) patients during 1998–2008, compared to patients without CKD, and at examining associations between CKD and PUD.

Methods

Data for 1998–2008 were extracted from the National Health Insurance Research Database in Taiwan. The annual PUD incidence (cases per thousand persons per year) was calculated separately for patients with and without CKD. Characteristics of patients with newly diagnosed PUD (n = 16322) were compared to those of a control group without PUD (n = 32644). The 2 groups were matched for age, sex, and index year. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by logistic regression.

Results

Over the 10-year period, the PUD incidence was ∼10–12 times higher in CKD patients than in those without CKD. Its incidence in elderly CKD patients increased rapidly over time. For CKD patients, most PUD events (>95%) were managed during hospitalization. Peptic ulcer risk, adjusted for all potential confounders, was much higher in CKD patients undergoing hemodialysis (adjusted OR, 9.74; 95% CI, 7.11–13.31). Maintenance hemodialysis patients were 2 times more likely to have gastric ulcers than duodenal ulcers, while CKD patients not on dialysis had similar risks for both. There were no significant interactions between medications and CKD status on the peptic ulcer risk. Unlike CKD patients on nonsteroidal anti-inflammatory drugs and clopidogrel, those on aspirin did not have a higher peptic ulcer risk (adjusted OR, 0.88; 95% CI, 0.44–1.77).

Conclusions

CKD patients have a substantially increased PUD risk, and the majority of CKD patients with PUD require hospital management. Further, peptic ulcer risk is affected by hemodialysis therapy, patient status (inpatient vs. outpatient), and ulcerogenic medications.

Salivary enzymes and flow rate: Markers of peptic ulcer

AIM

Peptic ulcers are among the most common and most costly diseases known to human. Its diagnosis in the early stages would have great benefit in treatment of the disease. The aim of this study was to compare alternations of enzymes activity in salivary fluid between patients with peptic ulcer disease and healthy controls.

MATERIALS AND METHODS

Two groups each composed of 26 subjects (13 male and 13 female) patients with peptic and healthy controls entered. Activities of selective salivary enzymes were assayed by a spectrophotometeric method.

RESULTS

The results showed significant increased activity of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) as well as total salivary protein (TSP) concentration in peptic ulcer patients as compared to control group. However, the enzymatic activity of alkaline phosphatase (ALP) also increased in peptic ulcer patients as compared to healthy control, but not statistically significant.

CONCLUSIONS

Based on the obtained results it was concluded that peptic ulcer may be early diagnosed by detecting activity of salivary enzymes. Therefore the saliva can be suggested as a diagnostic fluid.

Duodenum: MDCT of acute conditions

Multidetector computed tomography (MDCT) is the technique of choice for evaluating patients with acute abdominal pain. As the jejunum, ileum, and colon comprise the majority of the gastrointestinal tract, radiologists may potentially neglect the duodenum. However, the duodenum is a complex structure that can be affected by both intraperitoneal and extraperitoneal processes due to its central location and proximity to numerous upper abdominal structures. In this review, the MDCT findings of various congenital, inflammatory, traumatic, infectious, vascular, and miscellaneous conditions that affect the duodenum are discussed.

Comparison of different regimens of proton pump inhibitors for acute peptic ulcer bleeding

BACKGROUND

Treatment with proton pump inhibitors (PPIs) improves clinical outcomes in patients with peptic ulcer bleeding. However, the optimal dose and route of administration of PPIs remains controversial.

OBJECTIVES

To evaluate the efficacy of different regimens of PPIs in the management of acute peptic ulcer bleeding using evidence from direct comparison randomized controlled trials (RCTs).We specifically intended to assess the differential effect of the dose and route of administration of PPI on mortality, rebleeding, surgical intervention, further endoscopic haemostatic treatment (EHT), length of hospital stay, transfusion requirements and adverse events.

SEARCH METHODS

We searched CENTRAL (in The Cochrane Library 2010, Issue 3), MEDLINE and EMBASE (from inception to September 2010) and proceedings of major gastroenterology meetings (January 2000 to September 2010), without language restrictions. Original investigators were contacted to request missing data.

SELECTION CRITERIA

RCTs that compared at least two different regimens of the same or a different PPI in patients with acute peptic ulcer bleeding, diagnosed endoscopically.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies, extracted data and assessed risk of bias. We synthesized data using the Mantel-Haenszel random-effects method and performed multivariate meta-regression with random permutations based on Monte Carlo simulation. We measured heterogeneity with the I² statistic and Cochrane Q test and assessed publication bias with funnel plots and Egger's test. We graded the overall quality of evidence using the GRADE approach.

MAIN RESULTS

Twenty two RCTs were included; risk of bias was high in 17 and unclear in 5. The main analysis included 13 studies (1716 patients) comparing "high" dose regimens (72-hour cumulative dose > 600 mg of intravenous PPI) to other doses; there was no significant heterogeneity for any clinical outcome. We found low quality evidence that did not exclude a potential reduction or increase in mortality, rebleeding, surgical interventions or endoscopic haemostatic treatment (EHT) with "high" dose regimens. For mortality, pooled risk ratio (RR) was 0.85 (95% confidence interval (CI) 0.47 to 1.54); pooled risk difference (RD) was 0 more deaths per 100 patients treated with "high" dose (95% CI from 1 fewer to 2 more deaths per 100 treated). For rebleeding, pooled RR was 1.27 (95% CI 0.96 to 1.67); pooled RD was 2 more rebleeding events per 100 patients treated with "high" dose (95% CI from 0 fewer to 5 more rebleeding events per 100 treated). For surgical interventions, pooled RR was 1.33 (95% CI 0.63 to 2.77); pooled RD was 1 more surgical intervention per 100 patients treated with "high" dose (95% CI from 1 fewer to 2 more surgical interventions per 100 treated). For further EHT, pooled RR was 1.39 (95% CI 0.88 to 2.18), pooled RD was 2 more events per 100 patients treated with "high" dose PPI (95% CI from 1 fewer to 5 more events per 100 treated). We found moderate quality evidence suggesting no important difference between the two regimens with regards to length of hospital stay (mean difference (MD) 0.26 days; 95% CI -0.08 to 0.6 days) or blood transfusion requirements (MD 0.05 units; 95% CI -0.21 to 0.3 units). There was visual and statistical evidence of "inverse" publication bias for mortality (missing small studies with favourable outcomes for "high" dose), but not for any other outcome. The results were similar for all subgroup analyses (according to risk of bias, geographical location, route of administration for non-"high" dose regimens, continuous infusion vs. bolus administration for intravenous non-"high" regimens group), sensitivity analyses (restriction to patients who had EHT for high risk stigmata, use of different dose thresholds for comparative regimens) and post hoc analyses (inclusion of all studies (N = 22) that compared at least two PPI regimens with different cumulative 72 hour doses; restriction of the previous analysis to patients who had EHT for high risk stigmata). Meta-regression analysis did not show any statistically significant associations between treatment effect (for the outcomes of mortality, rebleeding and surgical intervention) and the three study-level factors that were assessed (geographical location (Asia versus not Asia), route of PPI administration (intravenous versus oral), within-study ratio among the 72-hour cumulative doses of the two PPI regimens).

AUTHORS' CONCLUSIONS

There is insufficient evidence for concluding superiority, inferiority or equivalence of high dose PPI treatment over lower doses in peptic ulcer bleeding.

Effect of comorbidity on mortality in patients with peptic ulcer bleeding: systematic review and meta-analysis

OBJECTIVES

By systematic review and meta-analysis, we sought to assess the impact of comorbidity on short-term mortality in patients with peptic ulcer bleeding (PUB).

METHODS

We conducted systematic searches in PubMed and Embase (January 1989-January 2010). Relative risks (RRs) were pooled across selected studies and an analysis of diagnostic test accuracy was performed to validate the results further.

RESULTS

Of 1,572 identified studies, 16 were eligible for inclusion. Only three had a low risk of bias and the overall quality of evidence was low. The risk of death (30-day or in-hospital mortality) was significantly greater in PUB patients with comorbidity than in those without (RR: 4.44; 95% confidence interval (CI): 2.45-8.04). The pooled sensitivity for comorbidity predicting death in patients with PUB was 0.86 (95% CI: 0.66-0.95) and the pooled specificity was 0.53 (95% CI: 0.40-0.65). PUB patients with three or more comorbidities had a greater risk of dying than those with one or two (RR: 3.46; 95% CI: 1.34-8.89). All individual comorbidities that we assessed significantly increased the risk of death associated with PUB. However, RRs were higher for hepatic, renal, and malignant disease (range: 4.04-6.33; no significant heterogeneity) than for cardiovascular and respiratory disease and diabetes (2.39, 2.45, and 1.63, respectively; no significant heterogeneity).

CONCLUSIONS

Underlying comorbidity is consistently associated with increased mortality in patients with PUB. The number and type of comorbidities in patients with PUB should be carefully evaluated and factored into initial management strategies.

Role of gastric mucus secretion, oxinitrergic system and sulfhydryl groups on the gastroprotection elicited by Polygala cyparissias (Polygalaceae) in mice

Objectives

This study has aimed to assess the mechanisms of action for the gastroprotective effect of the acetone extract (PCAE) and methanol fraction (PCMF) of Polygala cyparissias, as well as to evaluate the activity of 1,3,6,8-tetrahydroxy-2,7-dimethoxyxanthone (1), 1,7-dihydroxy-2,3-dimethoxyxanthone (2) and astragalin (3).

Methods

Gastric secretion and mucus content were determined by pylorus ligation in mice. Nitric oxide (NO) and sulfhydryl group participation were observed by the pretreatment of mice with L-NAME or NEM. Acute ulcer was induced by ethanol/HCl and chronic ulcer by acetic acid. Anti-Helicobacter pylori activity was evaluated by the agar solid dilution assay.

Key findings

Neither PCAE nor PCMF had the ability to reduce H+ concentration. However, both of them enhanced mucus secretion. PCAE demonstrated its gastroprotection in a NO-dependent manner, while PCMF exerted the activity depending on the sulfhydryl group. In chronic ulcer, the curative ratios for the PCAE and PCMF were 67.5 and 58.4%, respectively. No effect over H. pylori was detected. Compounds 1, 2 and 3 were able to reduce lesions in the order of 79.6, 73.8 and 67.6%, respectively.

Conclusions

The data suggested that PCAE and PCMF displayed antiulcer activity due to different mechanisms and with the participation of phenolic compounds obtained from the plant.

Systematic review: symptom assessment using patient-reported outcomes in gastroesophageal reflux disease and dyspepsia

OBJECTIVE

The importance of symptom assessment using patient-reported outcomes (PROs) is becoming increasingly recognized in the management of upper gastrointestinal (GI) disease. The authors aimed to review systematically the methodological aspects of PRO instrument development and use in the GERD or dyspepsia literature, and to assess these instruments' properties in light of the Food and Drug Administration's (FDA) guidance.

MATERIAL AND METHODS

Systematic PubMed and Embase searches (using terms based on the FDA guidance) identified studies that reported methodological aspects in developing or using PRO instruments for GERD or dyspepsia symptom measurement.

RESULTS

Ten studies were identified (six systematically and four from citation lists). Studies reported the development or use of a relevant PRO instrument, with a focus on methodological aspects that the FDA guidance describes as important for patient understanding. Studies demonstrated heterogeneity of recall periods, symptoms and response options. Two studies demonstrated that a lack of consistent vocabulary may contribute to discrepancy in symptom reporting between investigators and patients. Two studies indicated that symptoms must be described in a manner that is relevant to patients. One study described the development of a PRO instrument separately in two languages, acknowledging linguistic and cultural differences between populations. One study demonstrated changes in symptom severity based on the recall period.

CONCLUSIONS

There is considerable heterogeneity in the methodology used to develop PRO instruments for upper GI disease. Adherence to best practices in PRO development and validation may improve the quality and utility of these measures, leading to improved communication in clinical practice.

Why do mortality rates for nonvariceal upper gastrointestinal bleeding differ around the world? A systematic review of cohort studies

BACKGROUND

Discrepancies exist in reported mortality rates of nonvariceal upper gastrointestinal bleeding (NVUGIB).

OBJECTIVE

To perform a systematic review assessing possible reasons for these disparate findings and to more reliably compare them.

METHODS

The MEDLINE, EMBASE and ISI Web of Knowledge databases were searched for studies reporting mortality rates in NVUGIB involving adults and published in English. To ensure robust and contemporary estimates, studies spanning 1996 to January 2011 that included more than 1000 patients were selected.

RESULTS

Eighteen of 3077 studies were selected. Ten studies used administrative databases and the remaining eight used registries. The mortality rates reported in these studies ranged from 1.1% in Japan to 11% in Denmark. There were variations in reported mortality rates among countries and also within countries. Reasons for these disparities included a spectrum of quality in reporting as well as heterogeneous definitions of case ascertainment, differing patient populations with regard to severity of presentation and associated comorbidities, varying durations of follow-up and different health care system-related practices.

CONCLUSIONS

Wide differences in reported NVUGIB mortality rates are attributable to differences in adopted methodologies and populations studied. More uniform standards in reporting are needed; only then can true observed variations enable a better understanding of causes of death and pave the way to improved patient outcomes.

Effect of intravenous proton pump inhibitor regimens and timing of endoscopy on clinical outcomes of peptic ulcer bleeding

BACKGROUND AND AIM

The most effective schedule of proton pump inhibitor (PPI) administration and the optimal timing of endoscopy in acute peptic ulcer bleeding remain uncertain. The aim of this study was to determine the most efficient PPI regimen and optimal timing of endoscopy.

METHODS

  Consecutive patients with suspected bleeding peptic ulcers were enrolled and randomized to receive either a standard regimen or a high-dose intensive intravenous regimen. Only patients with bleeding peptic ulcers diagnosed at initial endoscopy continued the study. High-risk patients received endoscopic hemostasis. The primary outcome measure of recurrent bleeding was compared between the two dosage regimens and between early and late endoscopy. Secondary outcome measures compared included need for endoscopic treatment, blood transfusion, hospital stay, surgery and mortality.

RESULTS

A total of 875 patients completed the study. Recurrent bleeding occurred in 11.0% in the standard regimen group, statistically higher than that in the intensive regimen group (6.4%, P=0.02). Mean units of blood transfused and duration of hospital stay were also higher in the standard regimen group (P<0.001 for each compared to intensive regimen group). However, no significant differences were noted between the two groups in the need for endoscopic hemostasis, need for surgery, and mortality. Recurrence of bleeding was similar between the early and late endoscopy groups. Units of blood transfused and length of hospital stay were both significantly reduced with early endoscopy.

CONCLUSION

High-dose PPI infusion is more efficacious in reducing rebleeding rate, blood transfusion requirements and hospital stay. Early endoscopy is safe and more effective than late endoscopy.

[Association between dyspepsia and upper endoscopic findings]

BACKGROUND/AIMS

We aimed to estimate the proportion of significant endoscopic findings and their association with dyspeptic symptoms and to evaluate the predictors for significant endoscopic findings.

METHODS

Total of 3,872 subjects (58.3% men, mean age 43.6±9.3 years) who had undergone endoscopy were enrolled at the health promotion center. Each subject completed validated questionnaires, including data on gastrointestinal symptoms, socio-demographic history and medical history. Significant endoscopic findings were included peptic ulcer disease, reflux esophagitis, gastric cancer, Barrett's esophagus and gastro-duodenal erosions. Multiple logistic regression models were used to assess the predictors for significant endoscopic findings.

RESULTS

The proportion of significant endoscopic findings was 39.1%. There was no significant difference of endoscopic findings between the dyspepsia and asymptomatic group (41.0% vs. 37.4%, p>0.05). There was no difference of the incidence of reflux esophagitis or peptic ulcer between subjects with and without dyspepsia. Peptic ulcer was more frequently present in subjects with reflux symptoms than asymptomatic subjects (12.3% vs. 9.0%, p=0.03). Male gender (odds ratio [OR], 3.91; 95% confidence interval [CI], 3.18-4.81) increased the risk for having endoscopic abnormality and having symptoms of functional dyspepsia according to Rome III criteria (OR, 0.75; 95% CI, 0.57-0.97) significantly decreased this risk.

CONCLUSIONS

About 40% of subjects with dyspepsia had abnormal endoscopic findings, and the dyspepsia symptoms may not predict the significant endoscopic findings. Diagnostic criteria of functional dyspepsia by Rome III may be useful to predict not having significant upper endoscopic findings.

Incidence of peptic ulcer bleeding in the US pediatric population

OBJECTIVES

The aim of the present study was to determine the incidence of peptic ulcer bleeding (PUB) in pediatric patients.

METHODS

A hospital inpatient database, Premier Perspective, and an insurance claims database, MarketScan, were analyzed to estimate upper and lower limits for the annual incidence of PUB in the US pediatric population.

RESULTS

Using data from the Premier Perspective database and database-specific projection methodology, the total number of cases of hospitalization of pediatric patients for PUB in the United States in 2008 was estimated to be between 378 and 652. This translated to an incidence of 0.5 to 0.9/100,000 individuals in the pediatric population. Using data from the MarketScan database, the incidence of PUB in the insured pediatric population was estimated to be 4.4/100,000 individuals. Overall, 17.4% of insured pediatric patients diagnosed as having any upper gastrointestinal ulcer in 2008 were reported to have developed PUB.

CONCLUSIONS

The estimated incidence of PUB in the US pediatric population in 2008 ranged from 0.5 to 4.4/100,000 individuals. The total number of cases of PUB in pediatric patients in the United States each year was thus estimated to be between 378 and 3250. Such estimates provide a likely lower and upper limit for the total number of cases of the condition annually.

Helicobacter pylori infection is strongly associated with gastric and duodenal ulcers in a large prospective study

BACKGROUND & AIMS

Infection with Helicobacter pylori (H pylori) is a risk factor for peptic ulcer disease (PUD), but there are limited longitudinal data on the associations between infection and incident gastric or duodenal ulcers.

METHODS

Information on potential risk factors, lifetime history of PUD, and serologic measurements of H pylori infection were obtained from a German cohort of 9953 adults, 50 to 74 years old at baseline (2000-2002). The incidence of ulcers was determined by questionnaires sent to study participants and general practitioners 2 and 5 years later, and was validated by medical records.

RESULTS

A lifetime history of PUD was reported by 1030 participants, and during the follow-up period 48 had a first gastric and 22 had a first duodenal ulcer. Infection with H pylori strains that express cytotoxin-associated gene A (cagA) was significantly associated with a lifetime history of PUD (odds ratio, 1.75; 95% confidence interval [CI], 1.50-2.04). Based on longitudinal analyses with physician-validated end points, the adjusted hazard ratios for incident gastric and duodenal ulcer disease were 2.9 (95% CI, 1.5-5.5) and 18.4 (95% CI, 4.2-79.9), respectively, among patients infected with cagA-positive strains of H pylori.

CONCLUSIONS

In cross-sectional analysis, infection with cagA-positive strains of H pylori was associated with a 1.75-fold increased risk of peptic ulcer disease. Longitudinal analyses revealed an 18.4- and 2.9-fold increased risk for duodenal ulcer and gastric ulcer, respectively. The proportion of PUD that is attributable to H pylori infection might be larger than previously believed.

Chronic obstructive pulmonary disease: an independent risk factor for peptic ulcer bleeding: a nationwide population-based study

BACKGROUND

Peptic ulcer bleeding remains a major healthcare problem despite decreasing prevalence of peptic ulcer disease. The role of chronic obstructive pulmonary disease (COPD) in the risk of peptic ulcer bleeding has not yet been established.

AIM

To determine if COPD patients have a higher risk of peptic ulcer bleeding than the general population and to identify the risk factors of peptic ulcer bleeding in COPD patients.

METHODS

From Taiwan's National Health Insurance research database, 62,876 patients, including 32,682 COPD and 30,194 age-gender-matched non-COPD controls, were recruited. Cox proportional hazard regression was performed to evaluate independent risk factors for ulcer bleeding in all patients and to identify risk factors in COPD patients.

RESULTS

During the 8-year follow-up, COPD patients had a significant higher rate of peptic ulcer bleeding than the control group (P < 0.001, by log-rank test). By Cox proportional hazard regression analysis, COPD [hazard ratio (HR) 1.93, 95% CI 1.73-2.17] was an independent risk factor after adjusting for age, gender, underlying comorbidities and ulcerogenic medication. Age > 65 years, male, comorbidities of hypertension, diabetes, heart failure, history of peptic ulcer disease, and chronic renal disease and use of nonsteroidal anti-inflammatory drugs were risk factors of ulcer bleeding in COPD patients.

CONCLUSION

Patients with chronic obstructive pulmonary disease have a higher risk of peptic ulcer bleeding after adjustments for possible confounding factors like underlying comorbidities and ulcerogenic medication.

Peptic ulcer disease

Peptic ulcer disease (PUD) is due mostly to the widespread use of low-dose aspirin and nonsteroidal anti-inflammator drugs. It occurs mostly in older patients and those with comorbidities. Pain awakening the patient from sleep between 12 and 3 a.m. affects two-thirds of duodenal ulcer patients and one-third of gastric ulcer patients. Older adults (>80 years old) with PUD often do not present with abdominal pain; instead, epigastric pain, nausea and vomiting are among their most common presenting symptoms.

The interaction between proton pump inhibitors and clopidogrel and upper gastrointestinal bleeding

There is increasing concern regarding a possible adverse interaction between proton pump inhibitors (PPIs) and clopidogrel that could lead to reduced cardiovascular protection by clopidogrel. We performed a literature search for relevant original studies and systematic reviews. PPIs likely affect the antiplatelet activity of clopidogrel as measured in vitro, and this may be a class effect. We conclude that the pharmacodynamic effect has not been translated into any clinically meaningful adverse effect. PPI cotherapy reduces the incidence of recurrent peptic ulcer and of upper gastrointestinal bleeding among patients on clopidogrel.

Mast cells are critical for protection against peptic ulcers induced by the NSAID piroxicam

Many commonly used non-steroidal anti-inflammatory drugs (NSAIDs) also cause gastrointestinal toxicity, including the development of life-threatening peptic ulcers. We report that mast cell-deficient mice have an extremely high incidence of severe peptic ulceration when exposed to the NSAID piroxicam. This enhanced ulcer susceptibility can be reversed by reconstitution with mast cells. Furthermore, wild type mice treated with diphenhydramine hydrochloride, a commonly used antihistamine that blocks histamine H1 receptors, develop a similarly high incidence of peptic ulcers following piroxicam exposure. The protective effect of mast cells is independent of TNF, blockade of H2 receptors, or acid secretion. These data indicate a critical role for mast cells and the histamine that they produce in prevention and/or repair of piroxicam-induced gastric mucosal injury. Additional studies will be required to determine whether this represents a NSAID class effect that can be exploited to develop novel therapeutic strategies to limit the incidence of NSAID-induced side effects in humans.

Treating Bugs with Bugs: The Role of Probiotics as Adjunctive Therapy for Helicobacter pylori

Objective:

To review the literature on the role of probiotics as adjunctive therapy in the treatment of Helicobacter pylori infections.

Data Sources:

Literature was accessed through MEDLINE (1966-March 2011) using the terms H. pylori, probiotic, Lactobacillus, Bifidobacterium, Saccharomyces, Bacillus clausii, and Propionibacterium. Article references were hand-searched for additional relevant articles and abstracts.

Study Selection and Data Extraction:

All English-language articles published in full were evaluated. Randomized, double-blind, placebo-controlled trials assessing the use of probiotics combined with standard eradication therapy of H. pylori infection in adults were included in the review.

Data Synthesis:

Various probiotics, including Lactobacillus spp., Saccharomyces spp., Bifidobacterium spp., and B. clausii, reduce adverse effects such as nausea, taste disturbance, diarrhea, and epigastric pain, and increase tolerability of H. pylori eradication therapy. Based on the studies reviewed, probiotics do not affect H. pylori eradication rates.

Conclusions:

Probiotics may be beneficial in reducing adverse effects and increasing tolerability of H. pylori eradication regimens. They may especially be helpful in patients with recurrent H. pylori infection and a history of gastrointestinal adverse effects with antibiotics. Pharmacists can play an important role in educating patients regarding probiotic use during H. pylori eradication therapy.

Intravenous esomeprazole: a pharmacoeconomic profile of its use in the prevention of recurrent peptic ulcer bleeding

Intravenous esomeprazole (Nexium®) is approved in Europe for the prevention of rebleeding following therapeutic endoscopy for acute bleeding gastric or duodenal ulcers. In a pivotal clinical trial, patients with peptic ulcer bleeding and high-risk stigmata who received intravenous esomeprazole for 72 hours following endoscopic haemostatic therapy were significantly less likely than those receiving intravenous placebo to experience recurrent peptic ulcer bleeding at days 3, 7 and 30. In addition, the need for repeat endoscopic haemostatic therapy, the total amount of blood transfused and the number of additional hospital days required because of rebleeding were significantly lower in intravenous esomeprazole recipients than in intravenous placebo recipients. All patients received oral esomeprazole for 27 days following intravenous study drug administration. Intravenous esomeprazole was generally well tolerated in the pivotal trial, with infusion-site reactions being among the most commonly reported adverse events. Two pharmacoeconomic analyses conducted from a healthcare payer perspective used decision-tree models with 30-day time horizons to examine the cost effectiveness and cost utility of intravenous esomeprazole in patients with bleeding peptic ulcers who had undergone endoscopic haemostatic therapy. With regard to the incremental cost per bleed averted, intravenous esomeprazole was predicted to be dominant in Spain and cost effective in Sweden and the US compared with no intravenous esomeprazole. Efficacy results and resource utilization data from the pivotal clinical trial were inputted into this model, and the results of the analysis were generally robust to plausible variations in key variables. In the cost-utility analysis, which was conducted in the UK and is available as an abstract and poster, esomeprazole was considered to be the most cost-effective treatment alternative, compared with omeprazole or pantoprazole. For this analysis, clinical outcomes data were obtained from a systematic review and mixed treatment comparison (given the absence of head-to-head trial data), and utility values were proxied from the literature. In conclusion, intravenous esomeprazole prevents peptic ulcer rebleeding in patients who have undergone endoscopic haemostatic therapy. Pharmacoeconomic analyses support the use of intravenous esomeprazole following endoscopic haemostatic therapy in patients with peptic ulcer bleeding and high-risk stigmata.