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McCarberg BH, Cryer B. Evolving therapeutic strategies to improve nonsteroidal anti-inflammatory drug safety. Am J Ther 2016; 22:e167-78. [PMID: 25251373 DOI: 10.1097/mjt.0000000000000123] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) possess potent anti-inflammatory and analgesic properties through inhibition of cyclooxygenase enzymes (COX-1 and COX-2), which are responsible for synthesis of proinflammatory mediators. NSAIDs are frequently used for treatment of acute and chronic pain conditions. However, their use is associated with serious dose-dependent gastrointestinal (GI), cardiovascular, renal, and hepatic adverse effects, which pose a serious clinical concern for both patients and physicians. During the past 2 decades, approaches to improving the tolerability of NSAIDs were mainly directed toward discovery of COX-2 selective NSAIDs (coxibs), which were expected to minimize the risk of GI injury. Unfortunately, the results from multiple clinical studies have shown that treatment with coxibs may increase the risk for cardiovascular complications. This review summarizes current strategies used to reduce the toxicity of NSAIDs and outlines novel therapeutic approaches still in preclinical development. To minimize the risk of GI ulcerations and bleeding, combination therapies with gastroprotective agents are currently recommended. The new therapeutic agents anticipated to have similar effects include nitric oxide- and hydrogen sulfide-releasing NSAIDs. Novel manufacturing technologies enhance dissolution and absorption of NSAID products, allowing for their administration at low doses, which could lead to improved drug tolerability without diminishing the analgesic and anti-inflammatory efficacy of NSAIDs. This principle is in line with the current recommendation by the US Food and Drug Administration that NSAIDs should be used at the lowest effective dosage. Finally, NSAID formulations targeted directly to the site of inflammation are expected to reduce systemic drug exposure and thus decrease the risk of systemic adverse effects.
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Affiliation(s)
- Bill H McCarberg
- 1School of Medicine, University of California San Diego, San Diego, CA; 2The Elizabeth Hospice, Escondido, CA; 3Neighborhood Healthcare, Escondido, CA; 4UT Southwestern Medical Center, Dallas, TX; and 5Dallas VA Medical Center, Dallas, TX
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Pottegård A, Broe A, Hallas J, de Muckadell OBS, Lassen AT, Lødrup AB. Use of proton-pump inhibitors among adults: a Danish nationwide drug utilization study. Therap Adv Gastroenterol 2016; 9:671-8. [PMID: 27582879 PMCID: PMC4984329 DOI: 10.1177/1756283x16650156] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The use of proton-pump inhibitors (PPIs) has increased over the last decade. The objective of this study was to provide detailed utilization data on PPI use over time, with special emphasis on duration of PPI use and concomitant use of ulcerogenic drugs. METHODS Using the nationwide Danish Prescription Registry, we identified all Danish adults filling a PPI between 2002 and 2014. Using descriptive statistics, we reported (i) the distribution of use between single PPI entities, (ii) the development in incidence and prevalence of use over time, (iii) measures of duration and intensity of treatment, and (iv) the prevalence of use of ulcerogenic drugs among users of PPIs. RESULTS We identified 1,617,614 adults using PPIs during the study period. The prevalence of PPI use increased fourfold during the study period to 7.4% of all Danish adults in 2014. PPI use showed strong age dependency, reaching more than 20% among those aged at least 80 years. The proportion of users maintaining treatment over time increased with increasing age, with less than10% of those aged 18-39 years using PPIs 2 years after their first prescription, compared with about 40% among those aged at least 80 years. The overall use of ulcerogenic drugs among PPI users increased moderately, from 35% of users of PPI in 2002 to 45% in 2014. CONCLUSIONS The use of PPIs is extensive and increasing rapidly, especially among the elderly.
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Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark
| | - Anne Broe
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark Department of Clinical Chemistry & Pharmacology, Odense University Hospital
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Singh DP, Borse SP, Nivsarkar M. Clinical importance of nonsteroidal anti-inflammatory drug enteropathy: the relevance of tumor necrosis factor as a promising target. Transl Res 2016; 175:76-91. [PMID: 27083387 DOI: 10.1016/j.trsl.2016.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 12/13/2022]
Abstract
The pathogenesis of nonsteroidal anti-inflammatory drug (NSAID) enteropathy is still unclear, and consequently, there is no approved therapeutic strategy for ameliorating such damage. On the other hand, molecular treatment strategies targeting tumor necrosis factor (TNF) exerts beneficial effects on NSAID-induced intestinal lesions in rodents and rheumatoid arthritis patients. Thus, TNF appears to be a potential therapeutic target for both the prevention and treatment of NSAID enteropathy. However, the causative relationship between TNF and NSAID enteropathy is largely unknown. Currently approved anti-TNF agents are highly expensive and exhibit numerous side effects. Hence, in this review, the pivotal role of TNF in NSAID enteropathy has been summarized and plant-derived polyphenols have been suggested as useful alternative anti-TNF agents because of their ability to suppress TNF activated inflammatory pathways both in vitro and in vivo.
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Affiliation(s)
- Devendra Pratap Singh
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India; Registered Ph.D Scholar (External) at Institute of Pharmacy, NIRMA University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, India
| | - Swapnil P Borse
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India; Registered Ph.D Scholar (External) at Institute of Pharmacy, NIRMA University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, India
| | - Manish Nivsarkar
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India.
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Reply. J Am Coll Cardiol 2016; 68:981-2. [DOI: 10.1016/j.jacc.2016.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 06/08/2016] [Indexed: 11/23/2022]
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105
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Atay K. High Risk of Gastrointestinal Bleeding on Dual Antiplatelet Treatment. J Am Coll Cardiol 2016; 68:980-1. [DOI: 10.1016/j.jacc.2016.05.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 05/02/2016] [Accepted: 05/10/2016] [Indexed: 10/21/2022]
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Velasco-Zamora J, Gómez-Reyes E, Uscanga L. Are the clinical guideline recommendations on gastroprotection being followed? A review in patients taking nonsteroidal anti-inflammatory drugs. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2016.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Velasco-Zamora J, Gómez-Reyes E, Uscanga L. ¿Qué tanto se siguen las recomendaciones de las guías clínicas sobre gastroprotección? Una revisión en enfermos que consumen antiinflamatorios no esteroideos. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 81:121-5. [DOI: 10.1016/j.rgmx.2016.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 04/11/2016] [Accepted: 04/16/2016] [Indexed: 12/17/2022]
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Abstract
Musculoskeletal conditions are common, and there are many options for pharmacologic therapy. Unfortunately, there is not strong evidence for the use of many of these medications. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are generally first-line medications for most musculoskeletal pain, but there is more evidence these medications are not as safe as once thought. Other analgesic and antispasmodic medications can be effective for acute pain but generally are not as effective for chronic pain. Antidepressants and anticonvulsants can be more effective for chronic or neuropathic pain. Topical formulations of NSAIDs can be effective for pain with fewer side effects.
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Affiliation(s)
- Melinda S Loveless
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Box 359721, Seattle, WA 98104, USA.
| | - Adrielle L Fry
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Box 359721, Seattle, WA 98104, USA
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Abstract
Non-steroidal anti-inflammatory drug (NSAID) use increases the risk of gastrointestinal complications such as ulcers or bleeding. The presence of factors like advanced age, history of peptic ulcer, Helicobacter pylori infection and the use of anticoagulants or antiplatelet agents increase this risk further. COX-2 inhibitors and antisecretory drugs, particularly proton pump inhibitors, help to minimize the risk of gastrointestinal complications in high-risk patients. This review presents a practical approach to the prevention and treatment of NSAID-associated peptic ulcer disease and examines the new advances in the rational use of NSAIDs.
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Affiliation(s)
- Luigi Melcarne
- a Unidad de Gastroenterología, Servicio de Digestivo , Corporació Sanitària Parc Taulí , Sabadell , Spain
| | - Pilar García-Iglesias
- a Unidad de Gastroenterología, Servicio de Digestivo , Corporació Sanitària Parc Taulí , Sabadell , Spain
| | - Xavier Calvet
- a Unidad de Gastroenterología, Servicio de Digestivo , Corporació Sanitària Parc Taulí , Sabadell , Spain.,b Departament de Medicina , Universitat Autònoma de Barcelona , Sabadell , Spain.,c CIBERehd , Instituto Carlos III , Madrid , Spain
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Diagnostic and Therapeutic Yield of Endoscopy in Patients with Elevated INR and Gastrointestinal Bleeding. Am J Med 2016; 129:628-34. [PMID: 26714209 DOI: 10.1016/j.amjmed.2015.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/05/2015] [Accepted: 11/18/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Gastrointestinal bleeding is a well-known risk of systemic anticoagulation. However, bleeding in the setting of supratherapeutic anticoagulation may have a milder natural history than unprovoked bleeding. It is a common clinical gestalt that endoscopy is common, but bleeding source identification or intervention is uncommon, yet few data exist to inform this clinical impression. Consequently, we sought to examine our institutional experience with gastrointestinal bleeding in the setting of supratherapeutic international normalized ratio (INR) with the aim of identifying predictors of endoscopically identifiable lesions, interventions, and outcomes. METHODS A retrospective review was conducted at a tertiary referral academic medical center to identify patients presenting with gastrointestinal bleeding in the setting of warfarin and a supratherapeutic INR (>3.5) who underwent an endoscopic procedure. Relevant clinical covariates, endoscopic findings, need for intervention, and outcomes were collected by review of the medical record. Logistic regression adjusting for potential confounders identified predictors of endoscopically significant lesions as well as intervention and outcomes. RESULTS A total of 134 patients with INR 3.5 or greater (mean 5.5, range 3.5-17.1) presented with symptoms of gastrointestinal bleeding, most commonly as melena or symptomatic anemia. Antiplatelet agents were used by 54% of patients, and 60% of patients were on concomitant acid suppression on admission. Procedures included esophagogastroduodenoscopy (upper endoscopy; EGD) (n = 128), colonoscopy (n = 73), and video capsule endoscopy (n = 32). Active bleeding at first EGD or colonoscopy was found in only 19 patients (18%), with endoscopic intervention in only 26 patients (25%). At a critical threshold of INR 7.5 at presentation, the likelihood of finding an endoscopically significant lesion fell to <20%. On multivariate logistic regression, concomitant antiplatelet therapy (odds ratio [OR] 2.59; 95% confidence interval [CI], 1.13-5.94), timing of EGD within 12 hours of presentation (OR 3.71; 95% CI, 1.05-13.08), and INR level (OR 0.79; 95% CI, 0.64-0.98) were the only significant independent predictors of identifying a source of bleeding. A risk score incorporating these covariates performed modestly in identifying risk of significant finding on EGD (area under the curve 0.68). We found no association between identification of a significant lesion at EGD and future readmission for gastrointestinal bleeding. CONCLUSION This study demonstrates that the relationship between INR elevation and identification of a bleeding source or endoscopic intervention at EGD are indeed antiparallel. Concomitant antiplatelet therapy increases the likelihood of bleeding source identification and intervention, as does EGD within 12 hours of presentation. However, regardless of source identification or endoscopic intervention, important clinical outcomes were unchanged, suggesting that decisions about endoscopy should be made on a case-by-case basis, particularly in patients with INR > 7.5. Future prospective studies on appropriate indications and timing of endoscopy in such patients are warranted.
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Lee JK, Wu CK, Juang JM, Tsai CT, Hwang JJ, Lin JL, Chiang FT. Non-Carriers of Reduced-Function CYP2C19 Alleles are Most Susceptible to Impairment of the Anti-Platelet Effect of Clopidogrel by Proton-Pump Inhibitors: A Pilot Study. ACTA CARDIOLOGICA SINICA 2016; 32:215-22. [PMID: 27122952 DOI: 10.6515/acs20160201a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The phenomenon of CYP2C19 polymorphism affects the metabolism of both clopidogrel and proton-pump inhibitors (PPI). However, concomitant use of both drugs may reduce the desired therapeutic effects. In this study, we evaluated whether individuals with different numbers of reduced-function CYP2C19 alleles were equally affected and whether PPIs with different dependencies on CYP2C19 metabolism were equally involved. METHODS Thirty healthy volunteers were recruited to a six-week regimen of clopidogrel. Three PPIs with different metabolic dependencies on CYP2C19 were included and separately administered in this order. Each PPI was given for a week, followed by a one-week washout period before the intervention of the next PPI. The anti-platelet effect was examined by Thromboelastography Platelet Mapping(TM) (TEG®) and vasodilator-stimulated phosphoprotein (VASP) assays. RESULTS Both TEG® and VASP tests showed the same general qualitative trend, but TEG® detected a statistically significant fluctuation of platelet aggregation in response to different drug interventions. The TEG® results also demonstrated that non-carriers experienced the most significant impairment of anti-platelet effect of clopidogrel after concomitant use of PPIs. This impairment was closely related to the metabolic dependence on CYP2C19 of PPI. CONCLUSIONS Our study indicated that non-carriers of reduced-function CYP2C19 alleles are most susceptible to impairment of the anti-platelet effect of clopidogrel after concomitant PPI use. Individual subjects are not equally affected, and PPIs are not equally involved. However, large-scale randomized clinical trials are needed to evaluate the clinical outcome. KEY WORDS Clopidogrel • CYP2C19 polymorphism • Platelet aggregation • Proton pump inhibitors • TEG • VASP.
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Affiliation(s)
- Jen-Kuang Lee
- Division of Cardiology, Department of Internal Medicine; ; Department of Laboratory Medicine, National Taiwan University College of Medicine and Hospital; ; Graduate Institute of Biomedical Electronics and Bioinformatics, College of Electrical Engineering and Computer Science, National Taiwan University, Taipei, Taiwan
| | - Cho-Kai Wu
- Division of Cardiology, Department of Internal Medicine
| | | | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine
| | | | - Jiuun-Lee Lin
- Division of Cardiology, Department of Internal Medicine
| | - Fu-Tien Chiang
- Division of Cardiology, Department of Internal Medicine; ; Department of Laboratory Medicine, National Taiwan University College of Medicine and Hospital
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112
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Non-Steroidal Anti-Inflammatory Drugs and Aspirin Therapy for the Treatment of Acute and Recurrent Idiopathic Pericarditis. Pharmaceuticals (Basel) 2016; 9:ph9020017. [PMID: 27023565 PMCID: PMC4932535 DOI: 10.3390/ph9020017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 03/15/2016] [Accepted: 03/16/2016] [Indexed: 01/08/2023] Open
Abstract
Aspirin (ASA) and non-steroidal anti-inflammatory drugs (NSAIDs) are a mainstay of therapy for the treatment of idiopathic pericarditis (IP). A comprehensive review consisting of pertinent clinical literature, pharmacokinetic, and pharmacodynamic considerations, has not been released in recent years. This review will facilitate the clinician's understanding of pharmacotherapeutic considerations for using ASA/NSAIDs to treat IP. Data were compiled using clinical literature consisting of case reports, cohort data, retrospective and prospective studies, and manufacturer package inserts. ASA, ibuprofen, indometacin, and ketorolac relatively have the most evidence in the treatment of IP, provide symptomatic relief of IP, and should be tapered accordingly. ASA is the drug of choice in patients with coronary artery disease (CAD), heart failure (HF), or renal disease, but should be avoided in patients with asthma and nasal polyps, who are naïve to ASA therapy. Ibuprofen is an inexpensive and relatively accessible option in patients who do not have concomitant CAD, HF, or renal disease. Indometacin is not available over-the-counter in the USA, and has a relatively higher incidence of central nervous system (CNS) adverse effects. Ketorolac is an intravenous option; however, clinicians must be mindful of the maximum dose that can be administered. While ASA/NSAIDs do not ameliorate the disease process of IP, they are part of first-line therapy (along with colchicine), for preventing recurrence of IP. ASA/NSAID choice should be dictated by comorbid conditions, tolerability, and adverse effects. Additionally, the clinician should be mindful of considerations such as tapering, high-sensitivity CRP monitoring, bleeding risk, and contraindications to ASA/NSAID therapy.
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113
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Vaduganathan M, Bhatt DL, Cryer BL, Liu Y, Hsieh WH, Doros G, Cohen M, Lanas A, Schnitzer TJ, Shook TL, Lapuerta P, Goldsmith MA, Laine L, Cannon CP. Proton-Pump Inhibitors Reduce Gastrointestinal Events Regardless of Aspirin Dose in Patients Requiring Dual Antiplatelet Therapy. J Am Coll Cardiol 2016; 67:1661-71. [PMID: 27012778 DOI: 10.1016/j.jacc.2015.12.068] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/13/2015] [Accepted: 12/22/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND The COGENT (Clopidogrel and the Optimization of Gastrointestinal Events Trial) showed that proton-pump inhibitors (PPIs) safely reduced rates of gastrointestinal (GI) events in patients requiring dual antiplatelet therapy (DAPT). However, utilization of appropriate prophylactic PPI therapy remains suboptimal, especially with low-dose aspirin. OBJECTIVES The authors investigated the safety and efficacy of PPI therapy in patients receiving DAPT in low- and high-dose aspirin subsets. METHODS Randomized patients with available aspirin dosing information in COGENT (N = 3,752) were divided into "low-dose" (≤ 100 mg) and "high-dose" (>100 mg) aspirin groups. The primary GI and cardiovascular endpoints were composite upper GI events and major adverse cardiac events, respectively. All events were adjudicated by independent, blinded gastroenterologists and cardiologists. RESULTS Median duration of follow-up was 110 days. Low-dose aspirin users (n = 2,480; 66.1%) were more likely to be older, female, and have higher rates of peripheral artery disease, prior stroke, and hypertension, whereas high-dose aspirin users (n = 1,272; 33.9%) had higher rates of hyperlipidemia, smoking, a history of percutaneous coronary intervention, and were more than twice as likely to be enrolled from sites within the United States (80.4% vs. 39.8%). High-dose aspirin was associated with similar 180-day Kaplan-Meier estimates of adjudicated composite GI events (1.7% vs. 2.1%; adjusted hazard ratio: 0.88; 95% confidence interval: 0.46 to 1.66) and major adverse cardiac events (4.8% vs. 5.5%; adjusted hazard ratio: 0.73; 95% confidence interval: 0.48 to 1.11) compared with low-dose aspirin. Randomization to PPI therapy reduced 180-day Kaplan-Meier estimates of the primary GI endpoint in low-dose (1.2% vs. 3.1%) and high-dose aspirin subsets (0.9% vs. 2.6%; p for interaction = 0.80), and did not adversely affect the primary cardiovascular endpoint in either group. CONCLUSIONS Gastroprotection with PPI therapy should be utilized in appropriately selected patients with coronary artery disease requiring DAPT, even if the patients are on low-dose aspirin. (Clopidogrel and the Optimization of Gastrointestinal Events Trial [COGENT]; NCT00557921).
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Affiliation(s)
- Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts.
| | - Byron L Cryer
- University of Texas Southwestern and Veterans Affairs North Texas Health Care System, Dallas, Texas
| | - Yuyin Liu
- Harvard Clinical Research Institute, Boston, Massachusetts; Department of Biostatistics, Boston University, Boston, Massachusetts
| | - Wen-Hua Hsieh
- Harvard Clinical Research Institute, Boston, Massachusetts
| | - Gheorghe Doros
- Harvard Clinical Research Institute, Boston, Massachusetts; Department of Biostatistics, Boston University, Boston, Massachusetts
| | - Marc Cohen
- Newark Beth Israel Medical Center, Newark, New Jersey
| | - Angel Lanas
- University of Zaragoza, Instituto de Investigación Sanitaria Aragón, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Zaragoza, Spain
| | - Thomas J Schnitzer
- Departments of Physical Medicine and Rehabilitation and Internal Medicine-Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher P Cannon
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts; Harvard Clinical Research Institute, Boston, Massachusetts
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Li YF, Gao WQ, Li YX, Feng QZ, Zhu P. Management of acute perioperative myocardial infarction: a case report of concomitant acute myocardial infarction and tumor bleeding in the transverse colon. Clin Interv Aging 2016; 11:159-66. [PMID: 26937182 PMCID: PMC4762468 DOI: 10.2147/cia.s91918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Acute myocardial infarction complicated by bleeding colon tumor is problematic with regard to management, and appropriate balance of antiplatelet or anticoagulation therapy and hemostasis or surgery is crucial for effective treatment. Here, we present a case of concomitant acute myocardial infarction and bleeding tumor in the transverse colon, and share our experience of successfully balancing anticoagulation therapy and hemostasis.
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Affiliation(s)
- Yu-Feng Li
- The Department of Cardiology, Clinical Division of Medicine, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Wen-Qian Gao
- The Department of Cardiology, Clinical Division of Nanlou, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Yuan-Xin Li
- Navy Wangshoulu Clinics, Beijing, People's Republic of China
| | - Quan-Zhou Feng
- The Department of Cardiology, Clinical Division of Medicine, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Ping Zhu
- The Department of Cardiology, Clinical Division of Nanlou, Chinese PLA General Hospital, Beijing, People's Republic of China
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Ayub A, Parkash O, Naeem B, Murtaza D, Khan AH, Jafri W, Hamid S. Proton pump inhibitors and other disease-based factors in the recurrence of adverse cardiovascular events following percutaneous coronary angiography: A long-term cohort. Indian J Gastroenterol 2016; 35:117-22. [PMID: 27056735 DOI: 10.1007/s12664-016-0645-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/14/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Dual aspirin-clopidogrel antiplatelet therapy (DAPT) has been shown to decrease the risk of adverse cardiac events after percutaneous coronary intervention (PCI). Proton pump inhibitors (PPIs) are used in these patients to decrease the risk of gastrointestinal bleeding and several studies have reported potential interaction and conflicting clinical outcomes with their use. We aim to assess the effect of different PPIs and other factors on the recurrence of cardiovascular (CV) events in patients following PCI. METHODS We performed a retrospective cohort on patients who underwent PCI in the last 5 years and were discharged with or without PPIs. Strict inclusion criteria were adopted, outcome measures were defined, and patient follow up up to 2 years was collected. RESULTS Out of 740 patients, 453 (61.2 %) had received PPIs and 287 (38.8 %) were discharged without PPIs. Ninety-five (12.8 %) patients were readmitted due to adverse CV events. Statistically, there was no significant difference in the recurrence of CV events with the use of different PPIs (p = 0.384) and PPI use had an overall protective effect (p = 0.009, HR 0.58 (CI 0.39-0.88). Patients with history of diabetes mellitus (p = 0.048) had an increased risk of adverse CV events. CONCLUSION We conclude that pharmacokinetic interaction between PPIs and antiplatelet therapy is not associated with adverse CV events. A comprehensive, multicenter, open-label trial including all PPI subclasses and patient and disease-based factors is warranted for a fair evaluation.
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Affiliation(s)
- Adil Ayub
- Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Sindh, Pakistan
| | - Om Parkash
- Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Sindh, Pakistan.
| | - Buria Naeem
- Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Sindh, Pakistan
| | - Duraiz Murtaza
- Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Sindh, Pakistan
| | - Aamir Hameed Khan
- Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Sindh, Pakistan
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Sindh, Pakistan
| | - Saeed Hamid
- Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Sindh, Pakistan
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Puranik R, Bao S, Bonin AM, Kaur R, Weder JE, Casbolt L, Hambley TW, Lay PA, Barter PJ, Rye KA. A novel class of copper(II)- and zinc(II)-bound non-steroidal anti-inflammatory drugs that inhibits acute inflammation in vivo. Cell Biosci 2016; 6:9. [PMID: 26855766 PMCID: PMC4744413 DOI: 10.1186/s13578-016-0076-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 01/25/2016] [Indexed: 11/16/2022] Open
Abstract
Background The ability of Zn(II) and Cu(II) metal complexes of non-steroidal anti-inflammatory drugs (NSAIDs) to inhibit acute arterial inflammation in vivo has been studied.
Results When acute vascular inflammation was induced in normocholesterolemic New Zealand White rabbits by inserting a non-occlusive silastic collar around the common carotid artery, a single oral dose of Cu(II)-indomethacin (Cu(II)Indo, 3 mg/kg) administered by laparotomy achieved a 67 % (8.2 ± 1.7 vs. 2.7 ± 0.4 image units, p < 0.05) reduction in endothelial expression of vascular cell adhesion molecule-1 (VCAM-1) but did not inhibit endothelial intercellular adhesion molecule (ICAM-1) expression significantly. Treatment with Cu(II)-acemetacin (Cu(II)ACM, 3 mg/kg) led to a profound 88 % (8.2 ± 1.7 vs. 1.0 ± 0.5 image units, p < 0.01) reduction in endothelial VCAM-1 expression but did not inhibit ICAM-1 expression, while treatment with Zn(II)-acemetacin (Zn(II)ACM, 3 mg/kg) led to an 84 % (19.3 ± 1.0 vs. 3.1 ± 1.2 image units, p < 0.01) reduction in endothelial ICAM-1 expression and did not inhibit VCAM-1 expression. No adverse gastric, hepatic or renal effects were observed in treated animals.
Conclusion These findings provide the “proof of concept” that this novel class of drug, where there is complexation of NSAIDs with metal ions, has substantial anti-inflammatory effects in an animal model of acute vascular inflammation with the possibility of low rates of adverse effects.
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Affiliation(s)
- Rajesh Puranik
- The Heart Research Institute, 7, Eliza St., Sydney, NSW 2042 Australia ; Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050 Australia
| | - Shisan Bao
- The Heart Research Institute, 7, Eliza St., Sydney, NSW 2042 Australia ; Discipline of Pathology, D17, The School of Medical Sciences and Bosch Institute, The University of Sydney, Sydney, NSW 2006 Australia
| | - Antonio M Bonin
- The School of Chemistry, The University of Sydney, Sydney, NSW 2006 Australia
| | - Ravinder Kaur
- The School of Chemistry, The University of Sydney, Sydney, NSW 2006 Australia
| | - Jane E Weder
- The School of Chemistry, The University of Sydney, Sydney, NSW 2006 Australia
| | | | - Trevor W Hambley
- The School of Chemistry, The University of Sydney, Sydney, NSW 2006 Australia
| | - Peter A Lay
- The School of Chemistry, The University of Sydney, Sydney, NSW 2006 Australia
| | - Philip J Barter
- The Heart Research Institute, 7, Eliza St., Sydney, NSW 2042 Australia
| | - Kerry-Anne Rye
- The Heart Research Institute, 7, Eliza St., Sydney, NSW 2042 Australia ; Lipid Research Group, Centre for Vascular Research, The University of New South Wales, Sydney, NSW 2052 Australia
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Effects of omeprazole or pantoprazole on platelet function in non-ST-segment elevation acute coronary syndrome patients receiving clopidogrel. Mil Med Res 2016; 3:38. [PMID: 28018669 PMCID: PMC5159972 DOI: 10.1186/s40779-016-0107-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 11/26/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND This study evaluated the effect of omeprazole or pantoprazole on platelet reactivity in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients receiving clopidogrel. METHODS Consecutive patients with NSTE-ACS (n = 620) from general hospital of Shenyang Military Command were randomized to the omeprazole or pantoprazole (20 mg/d) group (1:1), and received routine dual antiplatelet treatment. Patients' reversion rate of adenosine diphosphate-induced platelet aggregation (ADP-PA) was assessed at baseline, 12 to 24 h after administration of medication, and after 72 h of percutaneous coronary intervention (PCI). The primary endpoint of the study was platelet reactivity assessed with ADP-PA at 30 days after PCI. Adverse events (AEs) were recorded for 30-day and 180-day follow-up periods. RESULTS There were no significant differences between both the groups in platelet response to clopidogrel at 12-24 h after drug administration (54.09% ± 18.90% vs 51.62% ± 19.85%, P = 0.12), 72 h after PCI (52.15% ± 19.45% vs 49.66% ± 20.05%, P = 0.18), and 30 days after PCI (50.44% ± 14.54% vs 48.52% ± 15.08%, P = 0.17). The rate of AEs did not differ significantly between groups during the 30-day (15.2% vs 14.8%, P = 0.91) and 180-day (16.5% vs 14.5%, P = 0.50) follow-up periods after PCI. CONCLUSIONS The addition of omeprazole or pantoprazole to clopidogrel did not restrict the effect of platelet aggregation by reducing the conversion of clopidogrel. Compared with clopidogrel alone, pantoprazole-clopidogrel and omeprazole-clopidogrel combinations did not increase the incidence of adverse clinical events during 30-day and 180-day follow-up periods after PCI. TRIAL REGISTRATION The study is registered in the National Institutes of Health website with identifier NCT01735227. Registered 14 November 2012.
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Lo PH, Huang YF, Chang CC, Yeh CC, Chang CY, Cherng YG, Chen TL, Liao CC. Risk and mortality of gastrointestinal hemorrhage in patients with thrombocytopenia: Two nationwide retrospective cohort studies. Eur J Intern Med 2016; 27:86-90. [PMID: 26604107 DOI: 10.1016/j.ejim.2015.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 10/08/2015] [Accepted: 10/13/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The association between thrombocytopenia (TP) and gastrointestinal hemorrhage was not completely understood. The purpose of this study is to evaluate the risk of gastrointestinal hemorrhage and post-hemorrhage mortality in patients with TP. METHODS Using the Taiwan National Health Insurance Research Database, we identified 1033 adults aged ≥18 years diagnosed with TP in 2000-2003. Non-TP cohort consisted of 10,330 adults randomly selected and matched by age and sex from the same dataset. Incident events of gastrointestinal hemorrhage occurring after TP from January 1, 2000, through December 31, 2008, were ascertained from medical claims. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of gastrointestinal hemorrhage associated with TP were calculated. Another nested cohort study consisted of 27,369 patients with hospitalization due to gastrointestinal hemorrhage between January 1, 2004, and December 31, 2010. We calculated the adjusted odds ratios (ORs) and 95% CIs of 30-day mortality after gastrointestinal hemorrhage in patients with and without TP during admission. RESULTS The incidences of gastrointestinal hemorrhage for people with and without TP were 14.5 and 5.07 per 1000 person-years, respectively (P<0.0001). Compared to people without TP, patients with TP had increased risk of gastrointestinal hemorrhage (HR, 2.61; 95% CI, 2.05-3.32). In the nested cohort study, TP was associated with post-hemorrhage mortality (OR, 1.98; 95% CI, 1.09-3.59). CONCLUSION Patients with TP showed higher risks of gastrointestinal hemorrhage and post-hemorrhage mortality. Our findings suggest the urgency of preventing and managing gastrointestinal hemorrhage by a multidisciplinary medical team for this specific population.
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Affiliation(s)
- Po-Han Lo
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Yu-Feng Huang
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chuen-Chau Chang
- School of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan; Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Chieh Yeh
- Department of Surgery, China Medical University Hospital, Taipei, Taiwan; Department of Surgery, University of IL, Chicago, USA
| | - Chia-Yau Chang
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yih-Giun Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ta-Liang Chen
- School of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan; Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chien-Chang Liao
- School of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan; Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan.
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Shah Z, Masoomi R, Tadros P. Managing Antiplatelet Therapy and Anticoagulants in Patients with Coronary Artery Disease and Atrial Fibrillation. J Atr Fibrillation 2015; 8:1318. [PMID: 27957230 DOI: 10.4022/jafib.1318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 09/09/2015] [Accepted: 10/27/2015] [Indexed: 01/15/2023]
Abstract
Oral anticoagulation (OAC) is essential in patients with atrial fibrillation (AF). Interestingly coronary artery disease coexists in 20-30% of these patients.[1,2] Balancing the risk of bleeding and thromboembolism is very important for the management of patients on OAC, especially than when such patients require percutaneous coronary intervention (PCI). Lack of data and clear societal guidelines for peri-procedural and post-procedural management of anticoagulated patients has resulted in diverse clinical practices among clinicians, hospitals, and countries. Furthermore with expanding number of available oral antiplatelet and anticoagulant agents, the uncertainty regarding optimal combination therapy in this growing pool of the patients with overlapping clinical indications is also growing. Given the high proportion of patients with atherothrombosis and requiring OAC for conditions particularly like AF, it is important that physicians are aware of the clinical implications and management of these overlapping syndromes. In this article we discuss; this evolving dilemma of peri-procedural and post-procedural management of anticoagulated patient's, burden of the disease, available data, risk factors that could identify high risk patients and propose a well-balanced management strategy.
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Affiliation(s)
- Zubair Shah
- Division of Cardiovascular Diseases, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS
| | - Reza Masoomi
- Division of Cardiovascular Diseases, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS
| | - Peter Tadros
- Division of Cardiovascular Diseases, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS
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Hassan A, Wahba A, Haggag H. Tramadol versus Celecoxib for reducing pain associated with outpatient hysteroscopy: a randomized double-blind placebo-controlled trial. Hum Reprod 2015; 31:60-6. [DOI: 10.1093/humrep/dev291] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/23/2015] [Indexed: 11/14/2022] Open
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Staerk L, Lip GYH, Olesen JB, Fosbøl EL, Pallisgaard JL, Bonde AN, Gundlund A, Lindhardt TB, Hansen ML, Torp-Pedersen C, Gislason GH. Stroke and recurrent haemorrhage associated with antithrombotic treatment after gastrointestinal bleeding in patients with atrial fibrillation: nationwide cohort study. BMJ 2015; 351:h5876. [PMID: 26572685 PMCID: PMC4646074 DOI: 10.1136/bmj.h5876] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY QUESTION What are the risks of all cause mortality, thromboembolism, major bleeding, and recurrent gastrointestinal bleeding associated with restarting antithrombotic treatment after gastrointestinal bleeding in patients with atrial fibrillation? METHODS This Danish cohort study (1996-2012) included all patients with atrial fibrillation discharged from hospital after gastrointestinal bleeding while receiving antithrombotic treatment. Restarted treatment regimens were single or combined antithrombotic drugs with oral anticoagulation and antiplatelets. Follow-up started 90 days after discharge to avoid confounding from use of previously prescribed drugs on discharge. Risks of all cause mortality, thromboembolism, major bleeding, and recurrent gastrointestinal bleeding were estimated with competing risks models and time dependent multiple Cox regression models. STUDY ANSWER AND LIMITATIONS 4602 patients (mean age 78 years) were included. Within two years, 39.9% (95% confidence interval 38.4% to 41.3%, n=1745) of the patients had died, 12.0% (11.0% to 13.0%, n=526) had experienced thromboembolism, 17.7% (16.5% to 18.8%, n=788) major bleeding, and 12.1% (11.1% to 13.1%, n=546) recurrent gastrointestinal bleeding. 27.1% (n=924) of patients did not resume antithrombotic treatment. Compared with non-resumption of treatment, a reduced risk of all cause mortality was found in association with restart of oral anticoagulation (hazard ratio 0.39, 95% confidence interval 0.34 to 0.46), an antiplatelet agent (0.76, 0.68 to 0.86), and oral anticoagulation plus an antiplatelet agent (0.41, 0.32 to 0.52), and a reduced risk of thromboembolism was found in association with restart of oral anticoagulation (0.41, 0.31 to 0.54), an antiplatelet agent (0.76, 0.61 to 0.95), and oral anticoagulation plus an antiplatelet agent (0.54, 0.36 to 0.82). Restarting oral anticoagulation alone was the only regimen with an increased risk of major bleeding (1.37, 1.06 to 1.77) compared with non-resumption of treatment; however, the difference in risk of recurrent gastrointestinal bleeding was not significant between patients who restarted an antithrombotic treatment regimen and those who did not resume treatment. WHAT THIS STUDY ADDS Among patients with atrial fibrillation who experience gastrointestinal bleeding while receiving antithrombotic treatment; subsequent restart of oral anticoagulation alone was associated with better outcomes for all cause mortality and thromboembolism compared with patients who did not resume treatment. This was despite an increased longitudinal associated risk of bleeding. FUNDING, COMPETING INTERESTS, DATA SHARING This study was supported by a grant from Boehringer-Ingelheim. Competing interests are available in the full paper on bmj.com. The authors have no additional data to share.
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Affiliation(s)
- Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev, and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark University of Birmingham Centre for Cardiovascular Sciences, Birmingham City Hospital, Birmingham UK
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham City Hospital, Birmingham UK
| | - Jonas B Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev, and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jannik L Pallisgaard
- Department of Cardiology, Copenhagen University Hospital Herlev, and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Anders N Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev, and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Anna Gundlund
- Department of Cardiology, Copenhagen University Hospital Herlev, and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Tommi B Lindhardt
- Department of Cardiology, Copenhagen University Hospital Herlev, and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Morten L Hansen
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev, and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark Danish Heart Foundation, Copenhagen, Denmark
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Adams MA, Scheiman JM. "Risky business": periprocedural aspirin use for colonoscopy with polypectomy. Gastrointest Endosc 2015; 82:901-3. [PMID: 26472002 DOI: 10.1016/j.gie.2015.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 05/06/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Megan A Adams
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James M Scheiman
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Nagata N, Niikura R, Aoki T, Sakurai T, Moriyasu S, Shimbo T, Sekine K, Okubo H, Watanabe K, Yokoi C, Yanase M, Akiyama J, Uemura N. Effect of proton-pump inhibitors on the risk of lower gastrointestinal bleeding associated with NSAIDs, aspirin, clopidogrel, and warfarin. J Gastroenterol 2015; 50:1079-86. [PMID: 25700638 DOI: 10.1007/s00535-015-1055-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/10/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND We investigated the effects of proton-pump inhibitors (PPIs) on lower gastrointestinal bleeding (LGIB) and of their interactions with nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin, clopidogrel, and warfarin on LGIB risk. METHODS We prospectively studied 355 patients emergently hospitalized for LGIB and 8,221 nonbleeding patients. All patients underwent colonoscopy. Smoking, alcohol drinking, drug exposure, and the Charlson comorbidity index score were assessed before colonoscopy. Adjusted odds ratios (AOR) of LGIB were estimated. RESULTS LGIB was significantly associated with older age, higher comorbidity index, and NSAID, aspirin, clopidogrel, or warfarin use. PPI use was significantly associated with older age, male sex, being a current alcohol drinker, higher comorbidity index, and NSAID, aspirin, clopidogrel, warfarin, acetaminophen, or corticosteroid use. Multivariate analysis adjusted by the confounding factors revealed LGIB was not significantly associated with PPI use (AOR 0.87; 95 % confidence interval 0.68-1.13; p = 0.311), or specifically with omeprazole (AOR 1.18; p = 0.408), esomeprazole (AOR 0.76; p = 0.432), lansoprazole (AOR 0.93; p = 0.669), or rabeprazole (AOR 0.63; p = 0.140). In the interaction model, no significant interactions were observed between PPIs and NSAIDs (AOR 1.40; p = 0.293), aspirin (AOR 1.09; p = 0.767), clopidogrel (AOR 0.99, p = 0.985), or warfarin (AOR 1.52; p = 0.398). CONCLUSIONS This large case-control study demonstrated that PPI use did not lead to an increased risk of LGIB, regardless of the type of PPI used. Further, LGIB risk was not affected by PPI use, irrespective of concomitant therapy with NSAIDs, low-dose aspirin, clopidogrel, or warfarin.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Ryota Niikura
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Tomonori Aoki
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Shiori Moriyasu
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Takuro Shimbo
- Department of Clinical Research and Informatics, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Katsunori Sekine
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Hidetaka Okubo
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Chizu Yokoi
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Mikio Yanase
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, International Clinical Research Center, Research Institute, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
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Gastrointestinal bleeding in patients receiving oral anticoagulation: Current treatment and pharmacological perspectives. Thromb Res 2015; 136:1074-81. [PMID: 26508464 DOI: 10.1016/j.thromres.2015.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 10/06/2015] [Accepted: 10/07/2015] [Indexed: 02/07/2023]
Abstract
Gastrointestinal bleeding (GIB) is a potentially fatal and avoidable medical condition that poses a burden on global health care costs. The rate of major GIB related to the use of some direct acting oral anticoagulant drugs (DOACs), is higher than that detected in warfarin users. Current strategies in the treatment of GIBs in patients receiving warfarin or DOACs (vitamin K, activated charcoal; hemodialysis; recombinant factor VIIa; [activated] prothrombin complex concentrates) including indications for the treatment of bleeding based on different degrees of severity of the episodes, is reported in this article. Potential preventive strategies to mitigate the risk of GIBs (e.g. upper endoscopy/biopsy, colon cancer screening; eradication of Helicobacter pylori prior to starting anticoagulation; use of proton-pump inhibitors, identification of risk factors for bleeding) are also reported as well as the fact that some of them have not been tested so far in patients receiving DOACs. Antidotes that experimentally reverse the anti-coagulant effect of dabigatran (Idarucizumab; BI 655075; Boehringer Ingelheim); of rivaroxaban, apixaban, or edoxaban (Andexanet alfa, r-Antidote, PRT064445; Portola Pharmaceuticals) or of all DOACs (Aripazine, PER-977, ciraparantag; Perosphere Inc.) are discussed. Likewise, population pharmacokinetics modeling related to the rate of major DOACs-related GIBs is presented. It is also emphasized that the occurrence of GIB reflects the presence of patients at the highest risk for adverse outcomes. Finally, the implications of the concept that patient characteristics and the severity of illness (i.e. comorbidities) exert a greater impact on the risk of GIB than the type of antithrombotic agent employed, are analyzed.
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Tran-Duy A, Vanmolkot FH, Joore MA, Hoes AW, Stehouwer CDA. Should patients prescribed long-term low-dose aspirin receive proton pump inhibitors? A systematic review and meta-analysis. Int J Clin Pract 2015; 69:1088-111. [PMID: 25846476 DOI: 10.1111/ijcp.12634] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Several clinical guidelines recommend the use of proton pump inhibitors (PPIs) in patients taking low-dose aspirin but report no or limited supporting data. We conducted a systematic review and meta-analysis to examine the effects of co-administration of PPIs in patients taking low-dose aspirin on the risks of adverse gastrointestinal (GI) and cardiovascular (CV) events, and on patient adherence to aspirin. METHODS We searched PUBMED, EMBASE and Cochrane Central Register of Controlled Trials databases for relevant articles published through November 2013. We included randomised controlled trials (RCTs) and observational studies in patients taking low-dose aspirin with and without PPIs. Risk of bias was assessed using the Cochrane Collaboration's tool (for RCTs) and the Newcastle-Ottawa Scale (for observational studies). Pooled risk ratios (RRs) were computed using a random-effects model. RESULTS We included 13 studies, of which 12 (2 RCTs and 10 observational studies) reported on GI events, and one (cohort study) on both GI bleeding and CV events. No study reported on adherence to aspirin. Co-administration of PPIs in patients receiving low-dose aspirin was associated with risk reductions of 73% (RR 0.27, 95% CI 0.17-0.42) and 50% (RR 0.50, 95% CI 0.32-0.80) in the occurrence of peptic ulcer and GI bleeding respectively. There was evidence of bias in publications reporting on the GI events. CONCLUSIONS The practice of co-prescribing PPIs in patients taking low-dose aspirin is supported by some data, but the evidence is rather weak. It currently remains unclear whether the benefits of co-administration of PPIs in users of low-dose aspirin outweigh their potential harms.
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Affiliation(s)
- A Tran-Duy
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F H Vanmolkot
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C D A Stehouwer
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht UMC+, Maastricht, the Netherlands
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Pelliccia F, Rollini F, Marazzi G, Greco C, Gaudio C, Angiolillo DJ. Drug–drug interactions between clopidogrel and novel cardiovascular drugs. Eur J Pharmacol 2015; 765:332-6. [DOI: 10.1016/j.ejphar.2015.08.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 08/24/2015] [Accepted: 08/31/2015] [Indexed: 11/24/2022]
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Abstract
Ischemic heart disease and stroke are major causes of death and morbidity worldwide. Coronary and cerebrovascular events are a consequence of thrombus formation caused by atherosclerotic plaque rupture or embolism, both of which result from platelet activation and aggregation and thrombin-mediated fibrin generation via the coagulation cascade. Current and emerging antiplatelet and anticoagulant agents are evolving rapidly. The use of aspirin for primary prevention continues to be controversial, as are the doses appropriate for secondary prevention. Development of new oral and intravenous adenosine diphosphate P2Y12 inhibitors and novel antiplatelet agents continues to transform the landscape of antiplatelet therapy. Oral anticoagulation has advanced with the use of direct thrombin and factor Xa inhibitors that do not require therapeutic monitoring. In this review, we discuss the pharmacology and growing clinical evidence for traditional and new antiplatelet and anticoagulant therapies.
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Affiliation(s)
- Jeremiah P Depta
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts 02115;
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Hsieh CF, Huang WF, Chiang YT, Chen CY. Effects of Clopidogrel and Proton Pump Inhibitors on Cardiovascular Events in Patients with Type 2 Diabetes Mellitus after Drug-Eluting Stent Implantation: A Nationwide Cohort Study. PLoS One 2015; 10:e0135915. [PMID: 26313000 PMCID: PMC4552429 DOI: 10.1371/journal.pone.0135915] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 07/28/2015] [Indexed: 12/14/2022] Open
Abstract
Objective To investigate whether there is an increased risk of cardiac events in diabetic patients with a combined therapy of clopidogrel (CLO) and proton pump inhibitors (PPIs) after drug-eluting stent (DES) deployment. Methods By using National Health Insurance Research Database, all patients who received CLO with or without PPI therapy within 90 days after undergoing DES (limus-eluting or paclitaxel-eluting stents) deployment were enrolled. Endpoints were acute coronary syndrome (ACS) and readmission for revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) after 3, 6, and 12 months. Results A total of 6,603 diabetic patients received LESs (5,933 in the CLO subgroup and 670 in the CLO plus PPIs subgroup), and 3,202 patients received PESs (2,923 in the CLO subgroup and 279 in the CLO plus PPIs subgroup). The patients who received CLO plus PPIs were at higher risk of ACS than those receiving CLO within 1 year after DES deployment (LESs: 6-month hazard ratio [HR] = 1.63, and 1-year HR = 1.37; PESs: 3-month HR = 1.72). Patients with a history of ACS who received CLO plus PPIs were at higher risk of ACS after LES implantation (HR = 1.55) than those in the CLO group. Conclusion In “real-world” diabetic patients with LES deployment, the combination of PPIs and CLO is associated with higher rates of ACS after 6 months and 1 year. Even after correction for confounding factors, concomitant PPI use remained an independent predictor of cardiac events, emphasizing the clinical importance of this drug—drug interaction.
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Affiliation(s)
- Chi-Feng Hsieh
- Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan
| | - Weng-Foung Huang
- Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Ting Chiang
- Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan
| | - Chun-Yen Chen
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- * E-mail:
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129
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Cardoso RN, Benjo AM, DiNicolantonio JJ, Garcia DC, Macedo FYB, El-Hayek G, Nadkarni GN, Gili S, Iannaccone M, Konstantinidis I, Reilly JP. Incidence of cardiovascular events and gastrointestinal bleeding in patients receiving clopidogrel with and without proton pump inhibitors: an updated meta-analysis. Open Heart 2015. [PMID: 26196021 PMCID: PMC4488889 DOI: 10.1136/openhrt-2015-000248] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Dual antiplatelet therapy is the standard of care after coronary stent placement but increases the bleeding risk. The effects of proton pump inhibitors (PPIs) on clopidogrel metabolism have been described, but the clinical significance is not yet definitive. We aimed to do an updated meta-analysis comparing outcomes in patients receiving clopidogrel with and without PPIs. Methods We systematically searched PubMed, Scopus and the Cochrane Central Register of Controlled Trials for randomised controlled trials (RCTs) and controlled observational studies in patients taking clopidogrel stratified by concomitant PPI use. Heterogeneity was examined with the Cochran Q test and I2 statistics; p values inferior to 0.10 and I2 >25% were considered significant for heterogeneity. Results We included 39 studies with a total of 214 851 patients, of whom 73 731 (34.3%) received the combination of clopidogrel and a PPI. In pooled analysis, all-cause mortality, myocardial infarction, stent thrombosis and cerebrovascular accidents were more common in patients receiving both drugs. However, among 23 552 patients from eight RCTs and propensity-matched studies, there were no significant differences in mortality or ischaemic events between groups. The use of PPIs in patients taking clopidogrel was associated with a significant reduction in the risk of gastrointestinal bleeding. Conclusions The results of our meta-analysis suggest that PPIs are a marker of increased cardiovascular risk in patients taking clopidogrel, rather than a direct cause of worse outcomes. The pharmacodynamic interaction between PPIs and clopidogrel most likely has no clinical significance. Furthermore, PPIs have the potential to decrease gastrointestinal bleeding in clopidogrel users.
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Affiliation(s)
- Rhanderson N Cardoso
- Department of Internal Medicine , University of Miami/Jackson Memorial Hospital , Miami, Florida , USA
| | - Alexandre M Benjo
- Department of Cardiology , Ochsner Medical Center , New Orleans, Louisiana , USA
| | | | - Daniel C Garcia
- Department of Internal Medicine , University of Miami/Jackson Memorial Hospital , Miami, Florida , USA
| | - Francisco Y B Macedo
- Department of Cardiology , Baylor College of Medicine and Michael E. DeBakey VA Medical Center , Houston, Texas , USA
| | | | - Girish N Nadkarni
- Nephrology Department , Mount Sinai Hospital , New York, New York , USA
| | - Sebastiano Gili
- Department of Cardiology , University of Turin , Turin , Italy
| | | | | | - John P Reilly
- Department of Cardiology , Ochsner Medical Center , New Orleans, Louisiana , USA
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130
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Management of low-dose aspirin and clopidogrel in clinical practice: a gastrointestinal perspective. J Gastroenterol 2015; 50:626-37. [PMID: 25595209 DOI: 10.1007/s00535-015-1038-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 12/26/2014] [Indexed: 02/04/2023]
Abstract
Low-dose aspirin, alone or combined with other antiplatelet agents, is increasingly prescribed for cardiovascular prevention. However, the cardiovascular benefits should be evaluated together with the gastrointestinal risks. Low-dose aspirin is associated with upper and lower gastrointestinal injury, although lower gastrointestinal effects are poorly characterized. This gastrointestinal risk differs among antiplatelets drugs users. The most important risk factors are history of peptic ulcer, older age, and concomitant use of non-steroidal anti-inflammatory drugs or dual antiplatelet therapy. Effective upper gastrointestinal prevention strategies are available and should be used in at-risk patients taking low-dose aspirin or clopidogrel. Proton pump inhibitors seem to be the best gastroprotective agents, whereas the benefits of Helicobacter pylori eradication are still unclear. Low-dose aspirin has additional effects in the gastrointestinal tract. A large body of evidence indicates that it can protect against different cancers, in particular colorectal cancer. This effect could modify the future indications for use of low-dose aspirin and the risk-benefit balance.
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131
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Sostres C, Carrera-Lasfuentes P, Benito R, Roncales P, Arruebo M, Arroyo MT, Bujanda L, García-Rodríguez LA, Lanas A. Peptic Ulcer Bleeding Risk. The Role of Helicobacter Pylori Infection in NSAID/Low-Dose Aspirin Users. Am J Gastroenterol 2015; 110:684-9. [PMID: 25895518 DOI: 10.1038/ajg.2015.98] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 02/01/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Helicobacter pylori (H. pylori) infection and NSAID/low-dose aspirin (ASA) use are associated with peptic ulcer disease. The risk of peptic ulcer bleeding (PUB) associated with the interaction of these factors remains unclear. The objective of this study was to determine the risk of PUB associated with the interaction between H. pylori infection and current nonsteroidal anti-inflammatory drugs (NSAIDs) or low-dose ASA use. METHODS This was a case-control study of consecutive patients hospitalized because of PUB. Controls were matched by age, sex, and month of admission. H. pylori infection status was determined in all cases and controls by serology. Drug use was determined by structured questionnaire. Adjusted relative risk (RR) associated with different factors, and the interaction between NSAID/ASA and H. pylori infection was estimated by logistic regression analysis. RESULTS The study included 666 cases of PUB and 666 controls; 74.3% cases and 54.8% controls (RR: 2.6; 95% confidence interval (CI): 2.0-3.3) tested positive for H. pylori infection; 34.5% of cases had current NSAID use compared with 13.4% of controls (RR: 4.0; 95% CI: 3.0-5.4). Respective proportions for low-dose ASA use were 15.8 and 12%, respectively (RR: 1.9; 95% CI: 1.3-2.7). The RR of PUB for concomitant NSAID use and H. pylori infection suggested an additive effect (RR: 8.0; 95% CI: 5.0-12.8), whereas no interaction was observed with ASA use (RR: 3.5; 95% CI: 2.0-6.1). CONCLUSIONS NSAID, low-dose ASA use, and H. pylori infection are three independent risk factors for the development of PUB, but there were differences in the interaction effect between low-dose ASA (no interaction) or NSAID (addition) use and H. pylori infection, which may have implications for clinical practice in prevention strategies.
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Affiliation(s)
- C Sostres
- Universitary Hospital Lozano Blesa, Gastroenterology Unit, Zaragoza, Spain
| | | | - R Benito
- Universitary Hospital Lozano Blesa, Microbiology Unit, Zaragoza, Spain
| | - P Roncales
- Health Science Institute of Aragon, Zaragoza, Spain
| | - M Arruebo
- Health Science Institute of Aragon, Zaragoza, Spain
| | - M T Arroyo
- Universitary Hospital Lozano Blesa, Gastroenterology Unit, Zaragoza, Spain
| | - L Bujanda
- Universitary Hospital of Donostia, San Sebastian, Spain
| | | | - A Lanas
- 1] Universitary Hospital Lozano Blesa, Gastroenterology Unit, Zaragoza, Spain [2] CIBERehd, Madrid, Spain [3] Health Science Institute of Aragon, Zaragoza, Spain
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133
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Usman MW, Luo F, Cheng H, Zhao JJ, Liu P. Chemopreventive effects of aspirin at a glance. Biochim Biophys Acta Rev Cancer 2015; 1855:254-63. [PMID: 25842298 DOI: 10.1016/j.bbcan.2015.03.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 03/05/2015] [Accepted: 03/21/2015] [Indexed: 12/15/2022]
Abstract
Experimental, epidemiological, and clinical data from the last two decades have each supported the hypothesis that aspirin possesses anticancer properties, and that its use may also reduce the lifetime probability of developing or dying from a number of cancers. Aspirin's ability to act on multiple key metabolic and signaling pathways via inhibition of the cyclooxygenase (COX) enzyme, as well as through COX-independent mechanisms, makes it particularly relevant in the fight against cancer. A growing body of evidence indicates that aspirin may not only reduce cancer risk, but also prevent metastasis and angiogenesis while slowing the rate of mutation-inducing DNA damage. These emerging benefits of aspirin are offset to some extent by the known risks of treatment, such as cardiovascular events and gastrointestinal bleeding. However, it has been shown that pre-treatment risk assessment of individual patients and the use of proton pump inhibitors or Helicobacter pylori eradication therapy concomitantly with aspirin treatment can reduce these potential risks. Thus, the significant benefits of aspirin treatment, coupled with recent data concerning its risks, may prove to tip the balance in favor of aspirin use in cancer prevention.
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Affiliation(s)
- Muhammad Waqas Usman
- Cancer Institute, Second Affiliated Hospital, Dalian Medical University, Dalian, Liaoning, China; Institute of Cancer Stem Cell, Dalian Medical University, Dalian, Liaoning, China
| | - Fuwen Luo
- Department of Acute Abdomen Surgery, Second Affiliated Hospital, Dalian Medical University, Dalian, Liaoning, China
| | - Hailing Cheng
- Cancer Institute, Second Affiliated Hospital, Dalian Medical University, Dalian, Liaoning, China; Department of Cancer Biology, Dana-Farber Cancer Institute Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA.
| | - Jean J Zhao
- Department of Cancer Biology, Dana-Farber Cancer Institute Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA; Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA, USA.
| | - Pixu Liu
- Cancer Institute, Second Affiliated Hospital, Dalian Medical University, Dalian, Liaoning, China; Institute of Cancer Stem Cell, Dalian Medical University, Dalian, Liaoning, China; Department of Cancer Biology, Dana-Farber Cancer Institute Harvard Medical School, Boston, MA, USA.
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134
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Di Minno A, Spadarella G, Prisco D, Scalera A, Ricciardi E, Di Minno G. Antithrombotic drugs, patient characteristics, and gastrointestinal bleeding: Clinical translation and areas of research. Blood Rev 2015; 29:335-43. [PMID: 25866382 DOI: 10.1016/j.blre.2015.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/04/2015] [Indexed: 02/07/2023]
Abstract
Gastrointestinal bleeding (GIB) is a potentially fatal and avoidable medical condition that poses a burden on global health care costs. Current understanding of the roles of platelet activation and thrombin generation/activity in vascular medicine has led to the development of effective antithrombotic treatments. However, in parallel with a sustained coronary and cerebral flow patency, the increasingly intensive treatment with warfarin; direct oral anticoagulant drugs [DOACs], and/or with aspirin ± clopidogrel (or ± prasugrel or ± ticagrelor), has increased the burden of GIBs related to the use of antithrombotic agents. Compelling evidence concerning this issue is accumulating to indicate that: 1) the risk of GIB related to the use of antithrombotic drugs dramatically differs in different clinical settings; and 2) the characteristics of patients (e.g., severity of illness, comorbidities) in whom it is used exert a greater impact on the risk of GIB than the type of antithrombotic agent employed. The latter concept argues for the occurrence of GIB as reflecting the presence of patients at the highest risk for adverse outcomes. The HAS-BLED score identifies subjects at risk of bleeding among those untreated and those treated with warfarin, DOACs and/or low-dose aspirin. Its use within the frame of a severity score (e.g., the CHA2DS2-VASc score in patients with atrial fibrillation) helps balance the benefits and the risks of an antithrombotic treatment and identify those patients in whom the absolute gain (vascular events prevented) outweighs the risk of GIB. Potential implications of the latter information in settings other than atrial fibrillation is thoroughly discussed.
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Affiliation(s)
- Alessandro Di Minno
- Department of Farmacia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Gaia Spadarella
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Domenico Prisco
- Department of Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Largo Brambilla 3, 50134 Firenze, Italy
| | - Antonella Scalera
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Elena Ricciardi
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giovanni Di Minno
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy.
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135
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Budzyński J, Wiśniewska J, Ciecierski M, Kędzia A. Association between Bacterial Infection and Peripheral Vascular Disease: A Review. Int J Angiol 2015; 25:3-13. [PMID: 26900306 DOI: 10.1055/s-0035-1547385] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
There are an increasing number of data showing a clinically important association between bacterial infection and peripheral artery disease (PAD). Bacteria suspected of being involved in PAD pathogenesis are: periodontal bacteria, gut microbiota, Helicobacter pylori, and Chlamydia pneumoniae. Infectious agents may be involved in the pathogenesis of atherosclerosis via activation of a systemic or local host immunological response to contamination of extravascular tissues or the vascular wall, respectively. A systemic immunological reaction may damage vascular walls in the course of autoimmunological cross-reactions between anti-pathogen antibodies and host vascular antigens (immunological mimicry), pathogen burden mechanisms (nonspecific activation of inflammatory processes in the vascular wall), and neuroendocrine-immune cross-talk. Besides activating the inflammatory pathway, bacterial infection may trigger PAD progression or exacerbation by enhancement of platelet reactivity, by a stimulatory effect on von Willebrand factor binding, factor VIII, fibrinogen, P-selectin activation, disturbances in plasma lipids, increase in oxidative stress, and resistance to insulin. Local inflammatory host reaction and induction of atherosclerotic plaque progression and/or instability result mainly from atherosclerotic plaque colonization by microorganisms. Despite these premises, the role of bacterial infection in PAD pathogenesis should still be recognized as controversial, and randomized, controlled trials are required to evaluate the outcome of periodontal or gut bacteria modification (through diet, prebiotics, and probiotics) or eradication (using antibiotics) in hard and surrogate cardiovascular endpoints.
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Affiliation(s)
- Jacek Budzyński
- Chair of Vascular and Internal Diseases, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland; Department of Vascular and Internal Diseases, Jan Biziel Hospital No. 2, Bydgoszcz, Poland
| | - Joanna Wiśniewska
- Department of Vascular and Internal Diseases, Jan Biziel Hospital No. 2, Bydgoszcz, Poland
| | - Marek Ciecierski
- Department of Vascular and Internal Diseases, Jan Biziel Hospital No. 2, Bydgoszcz, Poland
| | - Anna Kędzia
- Department of Oral Microbiology, Chair of Microbiology, Medical University, Gdańsk, Poland
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Yeomans ND. Consensus about managing gastrointestinal and cardiovascular risks of nonsteroidal anti-inflammatory drugs? BMC Med 2015; 13:56. [PMID: 25858463 PMCID: PMC4365530 DOI: 10.1186/s12916-015-0291-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 02/11/2015] [Indexed: 02/06/2023] Open
Abstract
In a recently published article in BMC Medicine, Scarpignato and colleagues present the results of a consensus conference that addressed several aspects of the management of pain in patients with osteoarthritis. The main areas covered include the relative safety in regard to gastrointestinal and cardiovascular adverse events of non-selective 'traditional' non-steroidal anti-inflammatory drugs (NSAIDs) versus cyclooxygenase-2 selective NSAIDs. The role of co-therapy with proton pump inhibitors in enhancing gastrointestinal safety is also reviewed. This commentary focuses on two areas that the consensus conference addressed, i) the whole length of gastrointestinal tract risk profile of the various NSAIDs (not just the ulcer risks in stomach and duodenum); ii) more recent information, but still some uncertainties, about the cardiovascular risks associated with the two classes of NSAID in general, and naproxen in particular. Please see related article: http://dx.doi.org/10.1186/s12916-015-0285-8.
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137
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Peura DA, Wilcox CM. Aspirin and Proton Pump Inhibitor Combination Therapy for Prevention of Cardiovascular Disease and Barrett's Esophagus. Postgrad Med 2015; 126:87-96. [DOI: 10.3810/pgm.2014.01.2728] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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138
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Kikkert WJ, Hassell MECJ, Delewi R, van der Laan MH, Baan J, Vis MM, Koch KT, de Winter RJ, Piek JJ, Tijssen JGP, Henriques JPS. Predictors and prognostic consequence of gastrointestinal bleeding in patients with ST-segment elevation myocardial infarction. Int J Cardiol 2015; 184:128-134. [PMID: 25703420 DOI: 10.1016/j.ijcard.2015.01.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 01/07/2015] [Accepted: 01/25/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Limited data are available on the predictors and implications of gastrointestinal (GI) bleeding in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) and dual antiplatelet therapy. METHODS AND RESULTS Predictors of and clinical outcome after GI bleeding were assessed in 2002 STEMI patients undergoing PPCI between 1-1-2003 and 31-07-2008. 139 patients suffered GI bleeding during a median follow-up of 4.9 years. Predictors of GI bleeding were age, history of bleeding, anemia, baseline thrombocytopenia, previous coronary artery bypass grafting, cardiogenic shock, anterior infarction and the use of GP IIb/IIIa inhibitor. By multivariable analysis, a first occurrence of GI bleeding was associated with a twofold increase in risk of subsequent GI bleeding (hazard ratio (HR) 2.19; 95% confidence interval (CI) 1.15-4.17). GI bleeding was not significantly associated with subsequent major adverse cardiac events (HR 1.33; 95% CI 0.98-1.79), cardiac (HR 1.40; 95% CI 0.97-2.02) and all-cause mortality (HR 1.34; 95% CI 0.96-1.85), recurrent MI (HR 0.97; 95% CI 0.58-1.63), stroke (HR 1.26; 95% CI 0.57-2.79) or stent thrombosis (HR 0.71; 95% CI 0.33-1.69). CONCLUSION Among STEMI patients undergoing PPCI, the risk of GI bleeding is related to a number of risk factors, including advanced age, previous (GI) bleeding, GP IIB/IIIA inhibitors, anterior infarction and anemia. GI bleeding does not substantially increase the risk of subsequent recurrent ischemic events in STEMI patients undergoing PPCI, whereas the risk of GI bleeding after a first occurrence is more than doubled.
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Affiliation(s)
- Wouter J Kikkert
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Mariëlla E C J Hassell
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Mariet H van der Laan
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan Baan
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marije M Vis
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Karel T Koch
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan G P Tijssen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - José P S Henriques
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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139
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Management of osteoarthritis. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00181-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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140
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Lu Y, Chen YI, Barkun A. Endoscopic management of acute peptic ulcer bleeding. Gastroenterol Clin North Am 2014; 43:677-705. [PMID: 25440919 DOI: 10.1016/j.gtc.2014.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This review discusses the indications, technical aspects, and comparative effectiveness of the endoscopic treatment of upper gastrointestinal bleeding caused by peptic ulcer. Pre-endoscopic considerations, such as the use of prokinetics and timing of endoscopy, are reviewed. In addition, this article examines aspects of postendoscopic care such as the effectiveness, dosing, and duration of postendoscopic proton-pump inhibitors, Helicobacter pylori testing, and benefits of treatment in terms of preventing rebleeding; and the use of nonsteroidal anti-inflammatory drugs, antiplatelet agents, and oral anticoagulants, including direct thrombin and Xa inhibitors, following acute peptic ulcer bleeding.
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Affiliation(s)
- Yidan Lu
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada
| | - Yen-I Chen
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada; Division of Clinical Epidemiology, McGill University Health Center, McGill University, 687 Pine Avenue West, Montréal H3A 1A1, Canada.
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141
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Akram F, Huang Y, Lim V, Huggan PJ, Merchant RA. Proton pump inhibitors: Are we still prescribing them without valid indications? Australas Med J 2014; 7:465-70. [PMID: 25550719 DOI: 10.4066/amj.2014.2093] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Evidence from several Western studies has shown an alarmingly high and inappropriate rate of prescription of proton pump inhibitors (PPIs), which may be associated with increased healthcare costs and adverse outcomes. PPI prescribing patterns remain largely unknown in well-developed healthcare systems in Southeast Asia. AIMS We aimed to determine the prevalence of inappropriate prescription of PPI among elderly patients without documentation of valid indications, in a tertiary teaching hospital in Singapore. METHOD We carried out a retrospective clinical records review of 150 elderly patients aged ≥65 years that had been admitted to two internal medicine wards between 25 May 2011 and 28 June 2011 to determine the appropriateness of indications for PPIs prescribed at hospital discharge. PPI indications were categorised as "valid", "likely invalid", and "probable" based on current clinical literature. Pre-admission and discharge prescriptions were reviewed to determine continuation of pre-admission and new PPI prescriptions at discharge. Data on clinical characteristics and concurrent use of ulcerogenic medications were collected. RESULTS From a total of 150 patients, 80 (53 per cent) received prescriptions for PPIs. Of these, 65 (81.2 per cent) had no valid documented indications (i.e., the indication was classed as "likely invalid"); 10 (12.5 per cent) had valid indications; and in five cases (6.2 per cent) the indication was "probable". The most common "likely invalid" indication was primary gastrointestinal bleeding prophylaxis (GIP) among low-dose aspirin users in 28 patients (43 per cent) of invalid PPI prescriptions. CONCLUSION Inappropriate prescribing of PPIs without documented valid indications was prevalent among elderly patients at our tertiary teaching hospital in Singapore, providing evidence that shows a similar trend to PPI prescribing to data from Western countries.
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Affiliation(s)
- Farooq Akram
- University Medicine Cluster, National University Health System, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore
| | - Yufang Huang
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Valencia Lim
- Yong Loo Lin School of Medicine, National University of Singapore
| | - Paul J Huggan
- Waikato District Health Board, Hamilton, New Zealand
| | - Reshma A Merchant
- University Medicine Cluster, National University Health System, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore
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Duffy D, Rooney B, Adams S, Whellan DJ. PA32540 for the secondary prevention of cardiovascular disease in patients at risk for aspirin-associated gastric ulcers. Expert Rev Cardiovasc Ther 2014; 12:1251-60. [PMID: 25300316 PMCID: PMC4743601 DOI: 10.1586/14779072.2014.967214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prescribed in patients with a history of myocardial infarction, stroke, transient ischemic attack, coronary intervention or bypass surgery, aspirin is one of the medications most commonly used in the secondary prevention of cardiovascular diseases. It has become a mainstay of therapy after years of solid evidence supporting its efficacy in clinical trials. However, a number of risks and side effects accompany its benefits, including the notable risk of bleeding and gastrointestinal side effects. Numerous mechanisms have been proposed to attenuate these effects to promote adherence and to expand the population for which aspirin is a reasonable treatment option. A polypill or combination formulation that includes a proton pump inhibitor, a drug commonly prescribed alongside aspirin, is one potential avenue of therapy. One such combination pill, PA32540, has undergone Phase I and Phase III trials and shows promising safety and efficacy results in these preliminary trials.
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Affiliation(s)
- Danielle Duffy
- Thomas Jefferson University, Philadelphia, PA 19107, USA
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Rubboli A, Faxon DP, Juhani Airaksinen KE, Schlitt A, Marín F, Bhatt DL, Lip GYH. The optimal management of patients on oral anticoagulation undergoing coronary artery stenting. The 10th Anniversary Overview. Thromb Haemost 2014; 112:1080-7. [PMID: 25298351 DOI: 10.1160/th14-08-0681] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 09/30/2014] [Indexed: 01/02/2023]
Abstract
Even 10 years after the first appearance in the literature of articles reporting on the management of patients on oral anticoagulation (OAC) undergoing percutaneous coronary intervention with stent (PCI-S), this issue is still controversial. Nonetheless, some guidance for the everyday management of this patient subset, accounting for about 5-8 % of all patients referred for PCI-S, has been developed. In general, a period of triple therapy (TT) of OAC, with either vitamin K-antagonists (VKA) or non-vitamin K-antagonist oral anticoagulants (NOAC), aspirin, and clopidogrel is warranted, followed by the combination of OAC, and a single antiplatelet agent for up to 12 months, and then OAC alone. The duration of the initial period of TT is dependent on the individual risk of thromboembolism, and bleeding, as well as the clinical context in which PCI-S is performed (elective vs acute coronary syndrome), and the type of stent implanted (bare-metal vs drug-eluting). In this article, we aim to provide a comprehensive, at-a-glance, overview of the management strategies, which are currently suggested for the peri-procedural, medium-term, and long-term periods following PCI-S in OAC patients. While acknowledging that most of the evidence has been obtained from patients on OAC because of atrial fibrillation, and with warfarin being the most frequently used VKA, we refer in this overview to the whole population of OAC patients undergoing PCI-S. We refer to the whole population of patients on OAC undergoing PCI-S also when OAC is carried out with NOAC rather than VKA, pointing out, when appropriate, the particular management issues.
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Affiliation(s)
- A Rubboli
- Dr. Andrea Rubboli, FESC, Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Largo Nigrisoli 2, 40133 Bologna, Italy, Tel.: +39 0516478976, Fax: +39 0516478635, E-mail
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Fardet L, Fève B. Systemic Glucocorticoid Therapy: a Review of its Metabolic and Cardiovascular Adverse Events. Drugs 2014; 74:1731-45. [DOI: 10.1007/s40265-014-0282-9] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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145
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Ahn DG, Kim BJ, Kim JW, Kim JG. [Clinical impact of dual antiplatelet therapy on peptic ulcer disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 64:81-6. [PMID: 25168049 DOI: 10.4166/kjg.2014.64.2.81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS Increased incidence of coronary artery disease has led to the increased use of dual antiplatelet therapy composed of aspirin and clopidogrel. We investigated the incidence of gastrointestinal complications in patients who received single or dual antiplatelet therapy and analyzed their clinical characteristics in order to predict the prognostic factors. METHODS Between January 2009 and December 2011, we retrospectively reviewed the medical records of patients who underwent coronary angiography at Chung-Ang University Hospital (Seoul, Korea). One hundred and ninety-four patients were classified into two groups: aspirin alone group and dual antiplatelet group. Clinical characteristics, past medical history, and presence of peptic ulcer were analyzed. RESULTS During the follow-up period, 11 patients had duodenal ulcer; the event rate was 2.02% in the aspirin alone group and 9.47% in the dual antiplatelet group (hazard ratio [HR] 5.24, 95% CI 1.03-26.55, p<0.05). There was no significant difference in the rate of significant upper gastrointestinal bleeding: 0% vs. 4.2% (p=0.78). In patients who received proton pump inhibitor (PPI), 24 patients had gastric ulcer; the event rate was significantly different between the two groups: 4.87% vs. 22.98% (HR 3.40, 95% CI 1.02-11.27, p<0.05). CONCLUSIONS Dual antiplatelet groups had a higher incidence of duodenal ulcers without significant bleeding compared with the aspirin alone group. In patients who received PPI, the dual antiplatelet therapy group had a higher incidence of gastric ulcers without significant bleeding compared with the aspirin alone group. Therefore, physicians must pay attention to high risk groups who receive dual antiplatelet therapy and aggressive diagnostic endoscopy should also be considered.
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Affiliation(s)
- Dae Geon Ahn
- Department of Internal Medicine, Chung-Ang University College of Medicine, 84 Heukseok-ro, Dongjak-gu, Seoul 156-861, Korea
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Impact of blood type, functional polymorphism (T-1676C) of the COX-1 gene promoter and clinical factors on the development of peptic ulcer during cardiovascular prophylaxis with low-dose aspirin. BIOMED RESEARCH INTERNATIONAL 2014; 2014:616018. [PMID: 25243161 PMCID: PMC4163467 DOI: 10.1155/2014/616018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 07/09/2014] [Indexed: 12/23/2022]
Abstract
Aims. To investigate the impact of blood type, functional polymorphism (T-1676C) of the COX-1 gene promoter, and clinical factors on the development of peptic ulcer during cardiovascular prophylaxis with low-dose aspirin. Methods. In a case-control study including 111 low-dose aspirin users with peptic ulcers and 109 controls (asymptomatic aspirin users), the polymorphism (T-1676C) of the COX-1 gene promoter was genotyped, and blood type, H pylori status, and clinical factors were assessed. Results. Univariate analysis showed no significant differences in genotype frequencies of the COX-1 gene at position -1676 between the peptic ulcer group and control group. Multivariate analysis revealed that blood type O, advanced age, history of peptic ulcer, and concomitant use of NSAID were the independent risk factors for the development of peptic ulcer with the odds ratios of the 2.1, 3.1, 27.6, and 2.9, respectively. Conclusion. The C-1676T polymorphism in the COX-1 gene promoter is not a risk factor for ulcer formation during treatment with low-dose aspirin. Blood type O, advanced age, history of peptic ulcer, and concomitant use of NSAID are of independent significance in predicting peptic ulcer development during treatment with low-dose aspirin.
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Boyapati R, Ong SY, Ye B, Kruavit A, Lee N, Vaughan R, Nandurkar S, Gibson P, Garg M. One fifth of hospitalizations for peptic ulcer-related bleeding are potentially preventable. World J Gastroenterol 2014; 20:10504-10511. [PMID: 25132768 PMCID: PMC4130859 DOI: 10.3748/wjg.v20.i30.10504] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 02/28/2014] [Accepted: 04/23/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To calculate the proportion of potentially preventable hospitalizations due to peptic ulcer disease (PUD), erosive gastritis (EG) or duodenitis (ED).
METHODS: Retrospective cohort study using ICD-10 codes to identify all patients with upper gastrointestinal hemorrhage secondary to endoscopically proven PUD, EG or ED during the period from March 2007 to October 2010 in three major metropolitan hospitals in Melbourne, Australia. Patients were divided into “high risk” (those who would benefit from gastroprotection) and “not high risk” groups as defined by established guidelines. Mean Rockall score, transfusion requirement, length of stay, rebleeding rates, need for surgery and in-hospital mortality was compared between “high risk” and “not high risk” groups. Within the “high risk” group, those on gastroprotection and those with no gastroprotection were also compared.
RESULTS: Five hundred and seven patients were included for analysis of which 174 were classified as high risk. Median values of complete Rockall Score (5 vs 4, P = 0.002) and length of stay (5 d vs 4 d, P = 0.04) were higher in the high risk group but in-hospital mortality was lower (0.6% vs 3.9%, P = 0.03). 130 out of the 174 patients in the high risk group were not taking recommended gastroprotective therapy prior to hospitalization. Past history of PUD (OR = 3.7, P = 0.006) and clopidogrel use (OR = 3.2, P = 0.007) significantly predicted prescription of gastroprotective therapy. Using proton pump inhibitor protection rates of 50%-85% from published studies, an estimation of 13% to 22% of the total number of the hospitalizations due to PUD or EG/ED related bleeding may have been preventable.
CONCLUSION: Up to one fifth of all hospitalizations for bleeding secondary to PUD or EG/ED are potentially preventable.
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Kim JJ, Kim N. [Does dual antiplatelet therapy increase the risk of peptic ulcer disease?]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2014; 64:67-69. [PMID: 25318124 DOI: 10.4166/kjg.2014.64.2.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Lanas A, Sostres C. PPI therapy. The small bowel, low-dose aspirin and PPIs--should we be concerned? Nat Rev Gastroenterol Hepatol 2014; 11:458-60. [PMID: 25001974 DOI: 10.1038/nrgastro.2014.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A new study suggests that co-prescription of low-dose aspirin and PPIs increases the incidence of small-bowel mucosal breaks. Should we be concerned about the potential negative interactions of these drugs? Or is the balance of evidence still substantially tipped towards the need for PPIs to protect against aspirin-induced upper gastrointestinal damage?
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Affiliation(s)
- Angel Lanas
- University Clinic Hospital, University of Zaragoza, CIBERehd, IIS Aragón, Calle de San Juan Bosco 15, 5009 Zaragoza, Spain
| | - Carlos Sostres
- University Clinic Hospital, University of Zaragoza, CIBERehd, IIS Aragón, Calle de San Juan Bosco 15, 5009 Zaragoza, Spain
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Sostres C, Gargallo CJ, Lanas A. Interaction between Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs and/or low-dose aspirin use: Old question new insights. World J Gastroenterol 2014; 20:9439-9450. [PMID: 25071338 PMCID: PMC4110575 DOI: 10.3748/wjg.v20.i28.9439] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 01/15/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Previous reports clearly demonstrated that Helicobacter pylori (H. pylori) infection, nonsteroidal anti-inflammatory drugs (NSAID) or low dose aspirin (ASA) use significantly and independently increased the risk for the development of peptic ulcer disease. Today, the presence of H. pylori infection associated with low dose ASA and/or NSAID use in the same patient is becoming more frequent and therefore the potential interaction between these factors and the consequences of it has important implications. Whether NSAID intake in the presence of H. pylori infection may further increase the risk of peptic ulcer carried by the presence of only one risk factor is still a matter of debate. Studies on the interaction between the two risk factors yielded conflicting data and no consensus has been reached in the last years. In addition, the interaction between H. pylori infection and low-dose ASA remains even more controversial. In real clinical practice, we can find different clinical scenarios involving these three factors associated with the presence of different gastrointestinal and cardiovascular risk factors. These huge variety of possible combinations greatly hinder the decision making process of physicians.
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