Sucralfate

Sucralfate: a help during oral management in patients with epidermolysis bullosa

BACKGROUND

Epidermolysis bullosa (EB) is a group of genetic disorders that lead to blister formation at variable depths in skin and mucosa. Vesicles may arise spontaneously or be caused by friction or trauma. Oral tissue fragility and blistering is common in all EB types. The majority of patients with mild forms of EB are able to receive dental treatment. The prevention of dental caries is most challenging in subjects with severe mucosal involvement, as they are least able to routinely undergo correct preventive procedures. The aim of this study was to evaluate the effectiveness of a sucralfate suspension in reducing both pain and the number of blisters in patients with EB, and to obtain improved oral hygiene and a lower incidence of caries.

METHODS

Five patients with dystrophic EB were treated with sucralfate suspension for the prevention and management of oral blisters. Oral blisters were assessed using a quantitative scale, while pain was assessed using visual analogue scale (VAS), and hygiene was evaluated through plaque and gingival indexes.

RESULTS

The number of blisters, oral pain, and plaque decreased in all cases.

CONCLUSIONS

Oral prophylaxis with sucralfate prevented oral blisters and oral discomfort. The procedure proved to be cost effective and easy to administer. It did not show significant side effects and may be used routinely in patients with EB.

Upper Gastrointestinal Bleeding of Nonvariceal Origin in the ICU Setting

Upper gastrointestinal bleeding (UGI) is a common medical emergency in the intensive care unit (ICU). Although it can be caused by a number of gastrointestinal disorders, its management usually follows a few simple management rules. Prior to endoscopy, the key to management is to resuscitate the patient, to determine the need for airway protection, and to assess the need for transfusions according to the American Society of Gastrointestinal Endoscopy guidelines. During endoscopy, the key to management is to recognize the cause of the bleeding and to achieve hemostasis. Following endoscopy, the key to management is to determine the need for medical therapy and to determine a proper disposition for the patient given his potential risk for rebleeding. Stress-related erosions syndrome (SRES) is a disease that usually develops in the ICU setting and is known to be associated with a high degree of morbidity and mortality. Although it is approached in the same fashion as other causes of UGI bleeding, patients tend to do better if they are recognized early and treated prophylactically. Criteria for proper patient selection and the recommended prophylactic therapy are reviewed.

GI complications in patients receiving mechanical ventilation

Mechanical ventilation (MV) can be lifesaving by maintaining gas exchange until the underlying disorders are corrected, but it is associated with numerous organ-system complications, which can significantly affect the outcome of critically ill patients. Like other organ systems, GI complications may be directly attributable to MV, but most are a reflection of the severity of the underlying disease that required intensive care. The interactions of the underlying critical illness and MV with the GI tract are complex and can manifest in a variety of clinical pictures. Incorporated in this review are discussions of the most prevalent GI complications associated with MV, and current diagnosis and management of these problems.

Use of sucralfate in renal failure

OBJECTIVE

To assess the potential for the development of aluminum toxicity in patients with renal insufficiency or chronic renal failure who are taking sucralfate.

DATA SOURCES

Clinical literature accessed through MEDLINE (1966-December 1999) and International Pharmaceutical Abstracts (1970-December 1999). Key search terms included sucralfate, renal failure, renal insufficiency, and end-stage renal disease.

DATA SYNTHESIS

Urinary excretion is an important route of elimination for systemically absorbed aluminum. Accumulation of aluminum in patients with impaired renal function may lead to significant toxicity. A potential source of aluminum is the antiulcer medication sucralfate. Studies and case reports evaluating the use and toxicity of sucralfate in patients with normal renal function, as well as those with renal failure or renal insufficiency, were reviewed.

CONCLUSIONS

Aluminum accumulation and toxicity have been reported with the use of sucralfate in patients with compromised renal function. The risk of toxicity most likely represents a long-term complication of sucralfate use in this patient population. Toxicity may be enhanced by concurrent use of other aluminum-containing medications, such as phosphate binders or antidiarrheal preparations. These medications, in addition to sucralfate, should be avoided if possible in patients with end-stage renal disease. Patients with renal failure or renal insufficiency who are undergoing prolonged sucralfate therapy should be monitored for potential signs of aluminum toxicity.

Plasma aluminum levels during sucralfate prophylaxis for stress ulceration in critically ill patients on continuous venovenous hemofiltration: a randomized, controlled trial

OBJECTIVE

To investigate plasma aluminum levels in critically ill patients requiring continuous venovenous hemofiltration (CVVH), while receiving sucralfate for stress ulcer prophylaxis.

DESIGN

Randomized, controlled study.

SETTING

Cardiothoracic intensive care unit.

PATIENTS

Twenty postoperative cardiac surgical patients

INTERVENTIONS

Twenty patients requiring CVVH support for acute renal failure were randomized into two groups for concurrent stress ulcer prophylaxis. Group 1 (n = 10) received nasogastric sucralfate, and group 2 patients received intravenous ranitidine. Plasma aluminum samples were analyzed at baseline and on days 1, 4, 8, and 14.

MEASUREMENTS AND MAIN RESULTS

In both the sucralfate and ranitidine groups, clinical characteristics, number of days the patients were on CVVH support (median, 5.5 [range, 2-32] days, and median, 3 [range, 2-18] days, respectively) and duration of prophylaxis (median, 12 [range, 4-42] days, and median, 16 [range, 3-62] days, respectively) were similar. There were no significant differences in the baseline aluminum concentrations (median, 0.37 [range, 0.15-1.63] micromol/L, vs. median, 0.32 [range, 0.11-1.0] micromol/L; p =.79). On initiation of therapy, aluminum levels in the sucralfate group increased dramatically on day 1 (median, 0.87 [range, 0.26-4.4] micromol/L) and peaked on day 4 (median, 2.84 [range, 1.52-4.44] micromol/L) with seven of the ten patients exhibiting levels of >2 micromol/L. In the ranitidine group, there were no significant elevations in aluminum levels above baseline. Analysis of the two groups at the four time points revealed that aluminum levels in the sucralfate group were up to 14 times higher, with the confidence intervals suggesting that the true value may be 2-27 times higher (p <.0001). On cessation of CVVH, a rapid decline in aluminum levels was observed. No clinical manifestations of these potentially toxic levels were observed.

CONCLUSIONS

The use of sucralfate for stress ulcer prophylaxis in patients requiring CVVH results in toxic elevations in plasma aluminum levels. Alternative agents should be considered for prophylaxis in these patients.

Prevention of NSAID-related ulcers

The use of NSAIDs constitutes a significant risk for gastrointestinal bleeding and other ulcer complications. However, if they prove clinically effective in relieving arthritic symptoms, the new COX-2 selectively inhibiting NSAIDs may ultimately solve the problem of gastrointestinal toxicity with NSAIDs.

Nonsteroidal anti-inflammatory drugs

NSAID-associated dyspeptic symptoms are common and can be managed empirically with an H2-receptor antagonist or a proton-pump inhibitor. Treatment of established gastroduodenal ulcers is accomplished best by withholding the offending drugs. Proton-pump inhibitors appear to heal ulcers at the same rate whether or not NSAID therapy is continued. After the ulcer is healed and if NSAID therapy must be continued, prophylaxis is accomplished best by the concomitant use of proton-pump inhibitors, misoprostol (at least 200 micrograms 3 times a day), or a NSAID that preferentially inhibits COX-2. The future development of newer, safer NSAID preparations, including highly selective COX-2 inhibitors and nitric oxide-releasing NSAIDs, should provide better treatment options for the increasing number of individuals requiring anti-inflammatory agents.

Acute gastrointestinal bleeding in the intensive care unit. The gastroenterologist's perspective

Although SRES-associated hemorrhage previously constituted a significant cause of bleeding in the ICU, improvements in ICU management and the institution of prophylactic measures in high-risk patients have significantly reduced SRES-associated hemorrhage since the 1980s. Antacids, H2-receptor antagonists, and sucralfate have been shown to be effective in preventing clinically significant bleeding resulting from SRES, particularly when the intragastric pH is maintained at greater than 4. A selective approach should be adopted in SRES prophylaxis: Patients on mechanical ventilation, with coagulopathy, or with two of the other known risk factors should receive prophylaxis. Although the drug of choice depends to some extent on local preferences, an H2-receptor antagonist by continuous intravenous infusion may represent the best option. No pharmacologic therapy is of proven value once hemorrhage begins, but the current interventional techniques are effective in controlling hemorrhage. Gastrointestinal bleeding from NOMV has become less common with improvements in the hemodynamic monitoring of critically ill patients, but this disease must always be considered when lower gastrointestinal bleeding occurs in the context of relative hypoperfusion. For SRES and NOMV, treatment of the underlying disease or diseases is the optimal route to prevention.

Iatrogenic esophagitis

A variety of medications have been reported to cause esophageal injury. Nearly 1000 cases have probably been described in the past 30 years, and this is a vast under-representation. Pill-induced esophageal injury is also associated with many underlying esophageal diseases. This review addresses the etiology, diagnosis, and clinical features of pill-induced esophageal injury as well as the specific medications that have been reported to cause it. Ways to prevent esophageal injury, including better instructions to patients who are prescribed such medications, are also discussed.

Diagnosis and treatment of nonsteroidal anti-inflammatory drug-associated upper gastrointestinal toxicity

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in the United States to treat pain and reduce inflammation from chronic inflammatory disorders such as rheumatoid arthritis and osteoarthritis. Approximately 40% of older Americans take NSAIDs. Chronic NSAID use carries a risk of peptic ulcer and other gastrointestinal disturbances. This article reviews the diagnosis of medication-induced ulcers based on clinical presentation, laboratory tests, and endoscopic findings to assist the clinician in early diagnosis and appropriate therapy. Risk factors for NSAID-induced ulcers include old age, poor medical status, prior ulcer, alcoholism, smoking, high NSAID dosage, prolonged NSAID use, and concomitant use of other drugs that are gastric irritants, such as alendronate, a bone resorption inhibitor prescribed for osteoporosis. Appropriate treatment options for patients with medication-induced ulcers include dosage reduction, medication substitution, medication withdrawal, antiulcer therapy, and discontinuation of other gastrotoxic drugs.

Injurious effect of Helicobacter pylori culture fluid to gastroduodenal mucosa, and its detoxification by sucralfate in the rat

BACKGROUND

Helicobacter pylori plays an important role in the pathogenesis of peptic ulcer. Although several cytotoxins related to H. pylori have been reported, their effects on gastroduodenal mucosa have not been well evaluated in vivo.

AIM

To investigate the effects of the combination of acid and toxic substances derived from H. pylori on gastroduodenal mucosa, and to observe the effect of sucralfate on such factors in the rat.

METHODS

Male Sprague-Dawley rats were fasted overnight and anaesthetized. The pylorus was ligated, and a double-lumen cannula was inserted into the forestomach for gastric luminal perfusion. In other animals, a cannula was inserted to perfuse the proximal duodenum. 51Cr-EDTA was administered intravenously and mucosal integrity was monitored by measuring the blood-to-lumen 51Cr-EDTA clearance. After 72 h of culture of H. pylori (NCTC11637 and Sydney strain 1), Brucella broth containing 3% FBS was filtered to remove the bacteria (supernate of H. pylori culture fluid; HPsup). HPsup was acidified (pH=2.0) with HCl, and tested for its injurious action on gastric or duodenal mucosa by luminal perfusion. HPsup was incubated with sucralfate for 30 min. The supernate was collected by centrifugation and the pH was readjusted to 2.0. This sucralfate-treated HPsup was used to test the effect of sucralfate against H. pylori-related mucosal injurious factors.

RESULTS

Non-acidified and acidified HPsup did not cause any detectable injury to the gastric mucosa. Non-acidified HPsup did not cause injury in the duodenal mucosa. However, acidified HPsup induced a significantly greater increase in 51Cr-EDTA clearance and greater histological damage than in controls. Sucralfate completely reversed this.

CONCLUSION

These results suggest that an H. pylori-related toxic substance may aggravate duodenal acid injury by acting on luminal surfaces, and that the detoxification of this substance by sucralfate may contribute to its anti-ulcer action.

Upper gastrointestinal tract bleeding in critically ill pediatric patients

Similar to adults, children under physiologic stress can develop an imbalance in defensive (mucosal layer, motility) and aggressive (gastric acid, bile salts, enzymes) factors responsible for maintaining a healthy gastrointestinal tract. Hypoxia in the gastrointestinal tract likely disrupts the defensive factors, thereby permitting damage by aggressive factors to upper gastrointestinal epithelium that may progress to stress ulceration and acute upper gastrointestinal tract bleeding (UGIB). The basic pathophysiology may be similar in children and adults; however, differences in the time to developing ulceration, ulcer location, and number of ulcers have been reported. Functional development of the gastrointestinal tract is influenced by disease, gestational and postnatal age, and exposure to and type of enteral feedings, thereby confounding the development and prophylaxis of UGIB in neonates and infants. In addition, pharmacotherapy decisions are often complicated by drug administration issues and adverse effects.

Risk reduction in the intensive care unit

Many potentially preventable complications occur in patients who receive intensive care. We have reviewed the epidemiology of three important complications (venous thromboembolism, stress-related upper gastrointestinal bleeding, and vascular catheter-related infection) and evaluated common preventive treatments to provide evidence-based recommendations for prevention. We used English language articles located by MEDLINE or cross-citation, giving preference to articles published in the last 10 years, meta-analyses, and clinical trials that were randomized, double-blinded, and used intention-to-treat analysis. We recommend prophylaxis against venous thromboembolism in most patients, whereas those without respiratory failure or coagulopathy may not require prophylaxis against stress-related upper gastrointestinal hemorrhage. Chlorhexidine gluconate is the preferred antiseptic for disinfecting the skin prior to and during intravascular catheterization. Central venous catheters impregnated with antibacterial or antiseptic agents should be considered in patients at high risk for vascular catheter-related infection. Finally, central venous, pulmonary arterial, and systemic arterial catheters should be changed only when clinically indicated.

[Bronchial lobar obstruction from a sucralfate tablet: a rare cause of acute respiratory insufficiency]

We report two cases of patients with chronic respiratory disease who experienced an asphyxia after aspirating a sucralfate tablet that occluded a lobar bronchus. In adults, a foreign body is a rare cause of acute respiratory failure from tracheobronchial occlusion. The sucralfate tablet has the physical property of expanding rapidly when wet (contact with mucosa). After aspiration, the tablet expands to a larger size and can occlude a lobar bronchus, causing acute respiratory failure. In patients at risk of aspiration, we recommend the use of sucralfate in liquid or suspension form.

Ventilator-associated pneumonia

Mechanically ventilated patients are at a substantially higher risk for developing nosocomial pneumonia. Overall, there is a relatively constant 1&!TN!150;3% risk per day of developing pneumonia while receiving mechanical ventilation. The sensitivity and specificity of clinical criteria alone for diagnosis of ventilator-associated pneumonias (VAP) is low. Several techniques have been developed to sample and quantitate the lower respiratory tract to improve the diagnostic yield. Gram-negative bacillary pneumonias account for the majority of the VAP. Strategies for prevention of VAP such as use of sucralfate for stress ulcer prophylaxis and selective decontamination of the digestive tract have been the focus of many clinical studies. Cost-effective preventive measures are needed to combat the increasing antimicrobial resistance, growing population of immunocompromised patients and increasing number of mechanically ventilated patients.

Review article: the management of acute liver failure

Acute liver failure (ALF) is a relatively uncommon but dramatic clinical syndrome with high mortality rates, in which a previously normal liver fails within days or weeks. Paracetamol overdose remains the major cause of ALF in the UK, while viral hepatitis is the commonest cause world-wide. Cerebral oedema is the leading cause of death in patients with ALF. Despite advances in intensive care and the development of new treatment modalities, ALF remains a condition of high mortality best managed in specialist centres. Orthotopic liver transplantation is the only new treatment modality that has made a significant impact in improving outcome. Bioartificial liver support systems and hepatocyte transplantation are new promising treatment options that may change the management of ALF in the future.

Gastric and duodenal ulcers during pregnancy

The frequency, symptoms, and complication rate of peptic ulcer disease appear to decrease during pregnancy significantly. Clinicians, however, often have to treat dyspepsia or pyrosis of undetermined cause because the frequency of pyrosis increases during pregnancy. Physicians are reluctant to perform esophagogastroduodenoscopy (EGD) during pregnancy for pyrosis to reliably differentiate gastroesophageal reflux from peptic ulcer disease. Dyspepsia or pyrosis during pregnancy first should be treated with dietary and lifestyle changes, together with antacids or sucralfate. When symptoms persist, H2 receptor-antagonists are recommended. If symptoms continue and are severe despite these interventions, the patient should be evaluated for possible EGD or proton pump inhibitor therapy during the second or third trimester.

Gastrointestinal drugs

Various drugs are commonly used for the many gastrointestinal problems that are routinely seen in dogs and cats. Many of these drugs are briefly reviewed in this article. Anecdotal as well as documented findings are provided that will hopefully allow the clinician to use them wisely and effectively in the many clinical situations that arise daily. Emetics, although not used for gastrointestinal problems, are also reviewed because of their obvious connection with the gastrointestinal tract.

Effect of sucralfate granules in suspension on endoscopic variceal sclerotherapy induced ulcer: analysis of the factors determining ulcer healing

Oesophageal ulcers commonly occur after endoscopic variceal sclerotherapy and usually cause complications and a delay in further sclerotherapy. The aims of this study are to investigate the effect of sucralfate granules in suspension on the treatment of endoscopic variceal sclerotherapy induced ulcer and analyse the factors determining the ulcer healing. Fifty-two patients with oesophageal variceal bleeding received elective endoscopic variceal sclerotherapy. After endoscopically proved oesophageal ulcers, they were randomized to receive either sucralfate granules in suspension (n = 22) or antacid (n = 23). Follow-up endoscopy was performed weekly. Ulcer healing rates were compared between the groups using the log-rank test. Forty-one ulcers receiving sucralfate and 48 ulcers receiving antacid treatment were evaluated. The clinical characteristics of the ulcers were similar in both groups. The ulcers in patients receiving sucralfate healed faster than those receiving antacid (P<0.02). On analysis of factors affecting ulcer healing, ulcers smaller than 1 cm2 (n = 59) appeared to heal faster than those larger than 1 cm2 (n = 30; P= 0.059) and shallow ulcers (n = 46) healed faster than deep ulcers (n = 43; P<0.001). On multifactorial analysis, ulcer depth was the only factor determining ulcer healing. The ulcer healing effects of sucralfate became more prominent when the ulcer was larger than 1.0cm2 (1.7+/-0.6 weeks vs 2.3+/-0.6 weeks, P= 0.011) and deep (1.7+/-0.7 weeks vs 2.5+/-1.0 weeks, P= 0.013) when compared with those receiving antacid. Sucralfate granules in suspension speed the healing of endoscopic variceal sclerotherapy induced ulcer, especially deep and large ulcers.

Impacting cost and appropriateness of stress ulcer prophylaxis at a university medical center

OBJECTIVE

To determine the appropriateness and medication cost of stress ulcer prophylaxis before and after a targeted educational intervention.

DESIGN

In the preintervention cohort (phase 1), 264 patients were evaluated over 2 months, using stress ulcer prophylaxis guidelines developed by a comprehensive literature search. Targeted educational programs were subsequently used to inform trauma housestaff on appropriate usage of stress ulcer prophylaxis medications with emphasis on using sucralfate. The postintervention cohort (phase 2) involved concurrent evaluation of 279 patients. Length of inappropriate stress ulcer prophylaxis (i.e., did not meet approved guidelines) between phases was compared using a Student's t-test for independent samples (alpha = .05).

SETTING

A 365-bed university medical center.

PATIENTS

Patients admitted to any of the intensive care units and all patients who were placed on histamine-2-antagonists or sucralfate for stress ulcer prophylaxis.

INTERVENTIONS

Educational intervention regarding appropriate stress ulcer prophylaxis directed at the trauma service.

MEASUREMENTS AND MAIN RESULTS

Patient demographics in the two phases were similar and there was no difference in the number of patient risk factors for stress-induced bleeding. The mean length of inappropriate stress ulcer prophylaxis was 5.78 +/- 4.36 days in phase 1 and 4.66 +/- 3.10 days in phase 2 (p < .05). Eighty-nine patients in phase 1 received inappropriate stress ulcer prophylaxis for a drug cost of $2,272.00 (mean $25.53 +/- 25.52) compared with 90 patients in phase 2 with a drug cost of $1,417.00 (mean $15.75 +/- 13.06). Three patients in each phase had clinically important bleeding (hemodynamic compromise or transfusion); all were receiving ranitidine. The mean total cost (fixed and variable) of hospitalization was $69,288.00 and $74,709.00 for the three patients who bled in each phase compared with $19,850.00 and $15,812.00 for all patients admitted to the intensive care unit in phases 1 and 2, respectively. The mean length of hospital stay was 30.00 days and 29.33 days for the three patients who bled in each phase compared with 11.54 days and 10.27 days for all patients admitted to the intensive care unit in phases 1 and 2, respectively.

CONCLUSIONS

Cost savings are associated with more appropriate stress ulcer prophylaxis. Clinically important bleeding is uncommon but results in prolonged hospital stays and increased costs.

Self-medication of dyspepsia: how appropriate is it?

BACKGROUND

The scope of self-medication is increasing in many countries, and drugs for dyspepsia are a popular group for deregulative activities. This study investigated what kind of upper gastrointestinal symptoms people self-medicate and how appropriate this self-medication is.

METHODS

An anonymous questionnaire was give to 50 consecutive customers buying antacids, alginates, or sucralfates in 10 pharmacies in the capital area in Finland in 1995. In half of the pharmacies the questionnaire was returned by mail, and in the other half the questionnaire was filled out at the pharmacy. The response rate was 53% (n = 292).

RESULTS

The commonest reasons for self-medication were heartburn (88%), gastrointestinal pain (31%), and acid regurgitation (32%). Seventy-five per cent of respondents had used dyspepsia drugs for more than a year. The commonest way to self-medicate was to interchange regular and occasional use. Knowledge about the proper use of dyspepsia drugs was poor, and 6% of respondents had symptoms contraindicating self-medication but had not visited a physician during the past year. Patients more than 60 years old were especially at risk of potential inappropriate use.

CONCLUSIONS

Over-the-counter (OTC) drugs for dyspepsia are likely to be used improperly. A physician's advice on the use of OTC dyspepsia drugs, in addition to detailed printed information about drug action and proper administration, would be important means to guarantee appropriate use of these drugs.

A review of stress ulcer prophylaxis in the neurosurgical intensive care unit

STRESS ULCERS OCCUR frequently in intensive care unit patients who have intracranial disease. After major physiological stress, endoscopic evidence of mucosal lesions of the gastrointestinal tract appears within 24 hours of injury; 17% of these erosions progress to clinically significant bleeding. Gastrointestinal hemorrhage has been associated with mortality rates of up to 50%. The pathogenesis of stress ulcers may not be completely understood, but gastric acid and pepsin appear to play significant roles. Antacids, H2 antagonists, and sucralfate are effective prophylactic agents in the medical/surgical intensive care unit. Appropriate therapy for neurosurgical patients remains unclear, however. This review summarizes the current literature regarding the pathogenesis and therapy of stress ulcers in neurosurgical patients.

Sucralfate cream in the management of moist desquamation during radiotherapy

Randomized trials have shown that sucralfate is effective in the management of acute radiation reactions such as oesophagitis, mucositis and proctitis. However, at the time of commencement of the present trial, it had never been used in the management of moist desquamation of the skin. The purpose of the present study was to assess the value of sucralfate cream in the management of moist desquamation during radiotherapy. Patients who developed moist desquamation during radiation were eligible. Patients were stratified by site of radiotherapy into three groups: (i) the head and neck; (ii) the breast; and (iii) other sites. Patients were randomized to receive 10% sucralfate in sorbolene cream or sorbolene alone. Patients' pain and skin healing were assessed by using linear analogue self-assessment (LASA) scales and by serial measurement of the desquamated area. Due to poor patient accrual, the trial was terminated after 2 years and 39 patients. No statistically significant difference was found between the two arms in either time from randomization to healing or improvement in pain score. Twenty patients in the sucralfate arm took a geometric mean of 14.8 days to heal whereas 19 patients receiving sorbolene alone took a geometric mean of 14.2 days. The ratio of mean times of healing, 1.043, is not statistically different from 1 (P = 0.86; 95% CI = 0.65, 1.67). A total of 75% of the patients reported pain relief on application of either cream. Mean LASA scores for pain for each day after randomization were compared by treatment arm and there was no statistically significant difference (P = 0.32). The present trial was unable to show a difference in terms of time to healing or pain relief in the treatment of moist desquamation. The small number of patients in the trial gave a wide confidence interval for treatment difference, implying that an important effect of sucralfate has not been excluded. Given the poor accrual in the present, single-institution study, future studies may need to be multi-institutional and we encourage other centres to perform randomized trials in the management of moist desquamation.

Concurrent use of antiulcerative agents

Many physicians prescribe more than one antiulcerative agent (AUA) simultaneously to the same patient, although there is little evidence to support this practice. The purposes of this study were to (a) determine patient factors associated with the concurrent use of these agents and (b) estimate the excess costs generated by the prescription of multiple rather than a single agent. We conducted a case-control study of concurrent AUA users among New Jersey Medicaid enrollees age 65 years and older. To evaluate the excess cost generated by the ongoing prescription of an additional AUA, we measured the additional drug expenditures associated with each regimen of concurrent use. Nearly 1 in 15 AUA users (6.6%) met our conservative definition of concurrent AUA use. In a multiple logistic regression model, previous gastrointestinal procedure, use of a nonsteroidal anti-inflammatory drugs, nursing home residency, and recent hospitalization for more than 20 days were all predictors of concurrent use of more than one AUA. No association was found with age, sex, or number of pharmacies used. The upper bound estimate of the cost generated by the concurrent prescription of a second AUA was $210 (range: $2-$942) over the 180-day study period, with a lower bound of $151 (range: $1-$449). Annually, such excess cost would range from $301 to $420 per patient. This would account for between $457 million and $637 million per year for the nation's elderly if these patterns are generalizable. Despite the lack of evidence of therapeutic benefit from multiple concurrent AUA use in most patients, this practice is fairly common. Besides introducing the risk of additional costs and side effects in the absence of additional efficacy, the costs of such duplicative prescribing are substantial.

Randomized, controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit

OBJECTIVE

To evaluate the efficacy of two regimens of selective decontamination of the digestive tract in mechanically ventilated patients.

DESIGN

Prospective, randomized, concurrent trial.

SETTING

Multidisciplinary intensive care unit (ICU) in a 1,800-bed university hospital.

PATIENTS

Consecutive patients (n = 660) who were likely to require mechanical ventilation for at least 48 hrs were randomized to one of three groups: conventional antibiotic regimen (control group A); oral and enteral ofloxacin-amphotericin B (group B); and oral and enteral polymyxin E-tobramycin-amphotericin B (group C). Both treatment groups received systemic antibiotics for 4 days (ofloxacin in group B and cefotaxime in group C).

INTERVENTIONS

Patients were randomized to receive standard treatment (control group A, n = 220), selective decontamination regimen B (group B, n = 220), and selective decontamination regimen C (group C, n = 220). After early deaths and exclusions from the study, 185 controls (group A) and 193 (group B)/200 (group C) selective decontamination regimen patients were available for analysis.

MEASUREMENTS AND MAIN RESULTS

Measurements included colonization and primary/secondary infection rate, ICU mortality rate, emergence of antibiotic resistance, length of ICU stay, and antimicrobial agent costs. The study duration was 19 months. The patient groups were fully comparable for age, diagnostic category, and severity of illness. One third of patients in each group suffered a nosocomial infection at the time of admission. There was a significant difference between treatment group B and control group A in the number of infected patients (odds ratio of 0.42, 95% confidence interval of 0.27 to 0.64), secondary lower respiratory tract infection (odds ratio of 0.47, 95% confidence interval of 0.26 to 0.82), and urinary tract infection (odds ratio of 0.47, 95% confidence interval of 0.27 to 0.81). Significantly more Gram-positive bacteremias occurred in treatment group C vs. group A (odds ratio of 1.22, 95% confidence interval 0.72 to 2.08). Infection at the time of admission proved to be the most significant risk factor for subsequent infection in control and both treatment groups. ICU mortality rate was almost identical (group A 16.8%, group B 17.6%, and group C 15.5%) and was not significantly related to primary or secondary infection. Increased antimicrobial resistance was recorded in both treatment groups: tobramycin-resistant enterobacteriaceae (group C 48% vs. group A 14%, p < .01), ofloxacin-resistant enterobacteriaceae (group B 50% vs. group A 11%, p < .02), ofloxacin-resistant nonfermenters (group B 81% vs. group A 52%, p < .02), and methicillin-resistant Staphylococcus aureus (group C 83% vs. group A 55%, p < .05). Antimicrobial agent costs were comparable in control and group C patients; one third less was spent for group B patients.

CONCLUSIONS

In cases of high colonization and infection rates at the time of ICU admission, the preventive benefit of selective decontamination is highly debatable. Emergence of multiple antibiotic-resistant microorganisms creates a clinical problem and a definite change in the ecology of environmental, colonizing, and infecting bacteria. The selection of multiple antibiotic-resistant Gram-positive cocci is particularly hazardous. No beneficial effect on survival is observed. Moreover, selective decontamination adds substantially to the cost of ICU care.

Iron overload and liver fibrosis

The pathogenesis of liver fibrosis in genetic haemochromatosis and other iron overload states remains enigmatic. Recent advances in the cellular and molecular pathogenesis of liver fibrosis have determined a central role for hepatic stellate cells. These become activated to a myofibroblastic phenotype following most forms of liver injury and are the major cellular source of collagens and other matrix proteins laid down in fibrotic liver. Similar changes have now been reported in the liver in genetic haemochromatosis, with activation of stellate cells becoming more prominent with increasing hepatic iron concentration. In contrast to other liver diseases, this apparently occurs in the absence of significant necroinflammatory change. Unravelling the mechanism of liver fibrogenesis in iron overload states may, therefore, provide important general insights into the pathogenesis of liver fibrosis. The present article reviews current knowledge of this field with emphasis on the role of lipid peroxidation, sideronecrosis of hepatocytes and spillover of iron to Kupffer cells. An attempt is made to draw these observations together with previous studies of the mechanisms of stellate cell activation in other models and diseases. A unifying hypothesis emerges that helps to define some of the next research questions in the pathogenic mechanisms of liver fibrosis in iron overload.

Stimulatory effects of sucralfate on secretion and synthesis of mucus by rabbit gastric mucosal cells. Involvement of phospholipase C

We examined the effects of sucralfate on the secretion and synthesis of mucus by cultured rabbit gastric mucosal cells, and the underlying intracellular mechanism. Treatment of mucosal cells with sucralfate (>0.5 mg/ml) for 4 and 8 hr caused a significant increase in the inositol triphosphate (IP3) content in the cells. Neomycin (a phospholipase C inhibitor) at 1 mM markedly inhibited the sucralfate-induced increases in both the IP3 content and mucus secretion and synthesis. Neither 10 nM staurosporine, 1 mM H-7 (protein kinase C inhibitors), nor 5 microM indomethacin (a cyclooxygenase inhibitor) affected the stimulatory effects of sucralfate on mucus secretion and synthesis, but 10 microM TMB-8 (an antagonist of intracellular Ca2+ mobilization)abolished its effects. Taken together, these results demonstrate that sucralfate acts directly an gastric mucosal cells, inducing increases in mucus secretion and synthesis, and that sucralfate causes an increase in the IP3 content, probably through activation of phospholipase C, and the subsequent IP3-elicited Ca2+ mobilization may be involved in the stimulatory effects of sucralfate.

Prophylaxis for stress-related gastrointestinal hemorrhage: a cost effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to the intensive care unit.

DESIGN

Decision model of the cost and efficacy of sucralfate and cimetidine, two commonly used drugs for prophylaxis of stress-related hemorrhage. Outcome estimates were based on data from published studies. Cost data were based on cost of medications and costs of treatment protocols at our institutions.

MEASUREMENTS AND MAIN RESULTS

The marginal cost-effectiveness of prophylaxis, as compare with no prophylaxis, was calculated separately for sucralfate and cimetidine and expressed as cost per bleeding episode averted. An incremental cost-effectiveness analysis was subsequently employed to compare the two agents. Sensitivity analyses of the effects of the major clinical outcomes on the cost per bleeding episode averted were performed. At the base-case assumptions of 6% risk of developing stress-related hemorrhage and 50% risk-reduction due to prophylaxis, the cost of sucralfate was $1,144 per bleeding episode averted. The cost per bleeding episode averted was highly dependent on the risk of hemorrhage and, to a lesser degree, on the efficacy of sucralfate prophylaxis, ranging from a cost per bleeding episode averted of $103,725 for low-risk patients to cost savings for very high-risk patients. The cost per bleeding episode averted increased significantly if the risk of nosocomial pneumonia was included in the analysis. The effect of pneumonia was greater for populations at low risk of hemorrhage. Assuming equal efficacy, the cost per bleeding episode averted of cimetidine was 6.5-fold greater than the cost per bleeding episode averted of sucralfate.

CONCLUSIONS

The cost of prophylaxis in patients at low risk of stress-related hemorrhage is substantial, and may be prohibitive. Further research is needed to identify patient populations that are at high risk of developing stress-related hemorrhage, and to determine whether prophylaxis increases the risk of nosocomial pneumonia.

Comparative role of omeprazole in the treatment of gastroesophageal reflux disease

OBJECTIVE

To review gastroesophageal reflux disease (GERD) and its treatment, with emphasis on the use and place of omeprazole, a proton pump inhibitor.

DATA SOURCES

A compilation prepared by the National Library of Medicine's Interactive Retrieval Services (Medlars II) for the period 1987 to 1994 was used as the data source.

STUDY SELECTION

Focus was placed on human comparative clinical studies with well-accepted measures of esophageal healing (endoscopy) and symptom resolution. Safety data were compiled from the clinical trials literature and large postmarketing data studies. Pharmacoeconomic studies selected were judged to meet the criteria of good design, presence of sensitivity testing, and statement of perspective.

DATA EXTRACTION

Data were obtained from double-blind, controlled clinical studies. Other data were extracted from pertinent literature of good design and significant results.

DATA SYNTHESIS

Overall, the clinical trials of omeprazole for the treatment of patients with erosive GERD demonstrate that omeprazole provides superior therapy in terms of esophageal healing symptom resolution and patient compliance when compared with histamine2-receptor antagonists (H2RAs) and antacids. In addition, studies also indicate that omeprazole is the most effective agent for the treatment of patients with GERD refractory to other treatments. Dosage adjustment is not necessary in patients with impaired renal or hepatic function or in the elderly. Finally, although the acquisition drug cost for daily treatment of patients with GERD is highest with the use of omeprazole, pharmacoeconomic studies indicate that treatment is more cost-effective with the use of omeprazole than with H2RA or antacid treatment alone or combined with nonpharmacologic approaches.

CONCLUSIONS

Based on efficacy, safety, and cost-effectiveness, omeprazole is the drug of choice for the treatment of patients with endoscopically confirmed erosive GERD.

Cigarette smoking and clinically significant drug interactions

OBJECTIVE

To review clinically significant drug interactions associated with cigarette smoking.

DATA SOURCES

Data from scientific literature were identified by using a MEDLINE search. Data were extracted, evaluated, and summarized for this review.

STUDY SELECTION

Findings and experiences were selected from clinical, epidemiologic, and pharmacokinetic studies; review articles; case studies; abstracts; letters to the editor, and proceedings.

DATA EXTRACTION

Data from human studies published in English were evaluated. Only interactions deemed clinically significant are included in this review. Conclusions derived from review articles on the subject of smoking and drug interactions also were used.

DATA SYNTHESIS

Cigarette smoking can affect drug therapy via pharmacokinetic and pharmacodynamic mechanisms. Pharmacokinetic drug interactions are presented for theophylline, tacrine, insulin, flecainide, propoxyphene, propranolol, diazepam, and chlordiazepoxide. Pharmacodynamic interactions are described for antihypertensive and antianginal agents, antilipidemics, oral contraceptives, and histamine2-receptor antagonists.

CONCLUSIONS

Cigarette smoking can reduce the efficacy of certain drugs or make drug therapy more unpredictable. Pharmacokinetic interactions may cause smokers to require a larger dosage of certain drugs through an increase in plasma clearance, a decrease in absorption, an induction of cytochrome P450 enzymes, or a combination of these factors. Pharmacodynamic interactions may increase the risk of adverse events in smokers with cardiovascular or peptic ulcer disease, and in women who smoke and use oral contraceptives. Healthcare professionals should pay special attention to patients with these profiles and should try to prevent cigarette smoking or encourage patients to discontinue this addictive habit.

Is there a role for selective decontamination of the digestive tract in primarily infected patients in the ICU?

The role of selective decontamination of the digestive tract (SDD) for the prevention of nosocomial infection in critically ill patients remains controversial, and the efficacy of this technique in patients who are already infected on presentation to the intensive care unit has not previously been assessed. We performed a double-blind randomized placebo controlled trial of SDD (parenteral cefotaxime, six-hourly oral and enteral polymyxin E, tobramycin, and amphotericin B vs placebo) for all infected patients presenting to the ICU requiring mechanical ventilation for more than 48 hours and ICU stay of more than 5 days. Daily clinical and microbiological monitoring for secondary infection was undertaken until hospital discharge. In all, 59 selective decontamination and 76 placebo fully comparable patients fulfilled criteria for enrollment and analysis (APACHE II 15.2 vs 15.1). The number of patients receiving SDD who developed nosocomial infections was significantly reduced (P = 0.048), and there were no infections caused by the enterobacteriaceae or Candida spp in this group. No difference in ICU (17.5 vs 18.8 days) or hospital stay (32.7 vs 34.2 days) or mortality (17% vs 22.3%) was shown. Critically ill, primarily infected patients are protected from nosocomial infection by the use of SDD.

Protection by almagate of ethanol-induced gastric mucosal damage in rats

The study was designed to analyse the protective effects of almagate on a model of gastric injury, ethanol-induced mucosal damage, in which acid plays little, if any, role. Pretreatment with almagate dose-dependently reduced the level of gastric damage induced by oral administration of 1 mL 100% ethanol. Administration of 12 mumol kg-1 alamagate 30 min before ethanol significantly reduced the area of mucosal damage by 65 +/- 10%, and the maximum level of inhibition (74 +/- 11%) was obtained with 150 mumol kg-1 almagate. Administration of higher doses of almagate (200-250 mumol kg-1) did not result in any further increase in the level of protection against ethanol-induced gastric damage. Administration of 1 mL 100% ethanol induces substantial damage to the gastric mucosa, with nearly 40% of the length of the section evaluated exhibiting deep necrotic and haemorrhagic damage. Pretreatment with almagate caused a significant diminution in all parameters of histological damage, whereas damage to the epithelial cell layer was only significantly reduced by pretreatment with the highest doses evaluated (25, 50 and 150 mumol kg-1). Administration of aluminium hydroxide did not modify ethanol-induced mucosal damage, even at doses containing concentrations of aluminium higher than those present in gastroprotective doses of almagate. Pretreatment with sucralfate, another aluminium containing compound, at doses of 250 mumol kg-1 protected the mucosa, although lower doses did not. The present study has shown that almagate prevents ethanol-induced gastric mucosal damage.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of sucralfate coating by sequential scintigraphic imaging in radiation-induced esophageal lesions

The value of mucosal protection with sucralfate in cases of gastric ulceration is well documented. Although sucralfate is advocated as treatment of esophageal lesions, we found it to be of limited value in the management of radiation-induced esophagitis; in a pilot study of 10 cases, minor relief of symptoms, with analgetics still required, was noted in 4 patients, and no improvement was seen at endoscopy after 6 weeks of treatment in any patient. To see if this might be the result of inadequate mucosal coating, we administered sucralfate labeled with technetium 99m to 26 patients with endoscopically proven esophagitis secondary to irradiation for esophageal carcinoma. The degree of coating was evaluated according to persistence of the radionuclide in the affected esophageal segment. Scans were performed at regular intervals for 120 minutes after administration of 150 MBq 99mTc-sucralfate. Although scans were positive for radioactivity in 24 of 26 (92%) patients, only 8 (31%) of these represented selective binding of sucralfate to tissue. In the other 16 cases, scans were positive for sucralfate and albumin, indicating nonspecific retention most likely caused by concomitant esophageal stenosis. Residual radioactivity was observed for 30 minutes or more in 11 (42%) patients, but scans were positive for radioactivity after 1 to 2 hours in only 4 (15%). The duration and intensity of tracer accumulation were similar in both acute lesions an chronic radiation damage. These findings suggest that the inability of sucralfate to alleviate irradiation-induced odynophagia may be related to insufficient duration of adherence of this compound to damaged esophageal mucosa.

Treatment of peptic ulcers from now to the millennium

The present strategies for the management of peptic ulceration are well tolerated and clinically effective. Histamine H2-receptor antagonists can be used for mild to moderate disease, and proton pump inhibitors are of particular benefit for patients with severe peptic ulceration and the Zollinger-Ellison syndrome. However, none of these treatments provides protection against recurrent ulceration, except when taken as long-term continuous treatment. Long-term exposure to pharmacological agents raises problems of safety, particularly relating to a lack of intragastric acidity. In addition, the accelerated development of atrophic gastritis in patients receiving omeprazole requires investigation and assessment. It is unlikely that there will be any major development in the area of control of gastric acid secretion, except perhaps the introduction of specific immunization against gastrin. However, the clinical benefit of this strategy awaits assessment. The main area for development must be the introduction of convenient and effective regimens for the eradication of Helicobacter pylori infection. Existing regimens are either simpler and relatively ineffective, or too complicated for widespread application. Bearing in mind the long gestation period of any new drug, it seems likely that the only innovative drug that will be introduced for the management of peptic ulceration before the millennium will be ranitidine bismuth citrate, an antisecretory anti-H. pylori drug that will usually be used in combination with an antibiotic.

Sucralfate causes malabsorption of L-thyroxine

PURPOSE

To determine if sucralfate causes malabsorption of L-thyroxine.

PATIENTS AND METHODS

Five healthy volunteers ingested L-thyroxine, 1,000 micrograms, administered orally (1) without sucralfate, (2) with sucralfate, 1 g, and (3) 8 hours after sucralfate, 2 g. The amount of L-thyroxine absorbed was calculated from the peak increase in serum T4 levels within 6 hours of hormone ingestion multiplied by the volume of distribution for the hormone.

RESULTS

Peak absorption of L-thyroxine in the absence of sucralfate was 796 micrograms (95% confidence interval (CI): 515-1,074 micrograms). Coadministration of sucralfate, 1 g, with L-thyroxine reduced thyroid hormone absorption to 225 micrograms (95% CI: 151-299 micrograms) (P = 0.0029 compared with control). Peak hormone absorption was delayed 2 hours by simultaneous sucralfate ingestion. Separation of administered L-thyroxine and sucralfate doses by 8 hours returned hormone absorption to control values. Maximum T3 levels did not differ, regardless of drug regimen, but suppression of thyroid-stimulating hormone (TSH) by L-thyroxine was reduced by coadministration of sucralfate.

CONCLUSIONS

Sucralfate causes malabsorption of L-thyroxine, presumably by intraluminal binding of hormone.

Acute occlusion of a mainstem bronchus by a rapidly expanding foreign body

We report a case of an 85-year-old woman who presented with acute respiratory failure, caused by aspirating a sucralfate tablet that totally occluded her left main-stem bronchus. Acute respiratory failure resolved after bronchoscopic removal of the markedly expanded tablet. To our knowledge, the acute obstruction of a main-stem bronchus by an aspirated foreign body has not been previously described in adults. We believe that the unusual properties of sucralfate tablets (rapid expansion and mucosal binding) were contributing factors in this patient.