A case-control study of the risk of upper gastrointestinal mucosal injuries in patients prescribed concurrent NSAIDs and antithrombotic drugs based on data from the Japanese national claims database of 13 million accumulated patients

Epidemiology and Risk Factors of Eosinophilic Esophagitis in Japan: A Population-Based Study

BACKGROUND & AIMS

Eosinophilic esophagitis (EoE) has been increasingly diagnosed globally. However, there have been few general population-based studies in Asia. The aim of this study was to investigate EoE epidemiology in the Japanese general population.

METHODS

We analyzed an employer-based health insurance claim database from January 2005 to September 2022. EoE cases were identified on the basis of the International Statistical Classification of Diseases and Health-related Problems, 10th Revision code, K20.0. We calculated the incidence and prevalence of EoE using Poisson regression and binomial distribution, respectively. Using 10 matched controls for each EoE case, a nested case-control study was performed to identify potential risk factors for EoE.

RESULTS

Of 15,200,895 individuals, 1010 EoE cases were identified. The incidence and prevalence of EoE were 2.82 (95% confidence interval [CI], 2.44-3.26) per 100,000 person-years and 10.68 (95% CI, 10.01-11.37) per 100,000 people in 2022, nearly 3 and 8 times as high as those in 2017, respectively. Smoking was associated with decreased risk of EoE (odds ratio [OR], 0.45, 0.36-0.56, P < .001), whereas alcohol consumption (OR, 1.51, 1.21-1.88, P < .001) was associated with increased risk of EoE along with several allergic conditions and psychiatric disorders. EoE was not related to either body mass index or lifestyle-related diseases such as hypertension, diabetes mellitus, hyperuricemia, and dyslipidemia.

CONCLUSIONS

The incidence and prevalence of EoE in Japan have steadily increased over the past 2 decades. Nevertheless, EoE remains less common in Japan compared with the United States and Western Europe. Factors contributing to the epidemiology of EoE on a global basis may improve our understanding of the contribution of genetic and environmental risk factors.

Association of long-term use of low-dose aspirin with Helicobacter pylori infection and effect on recurrence rate

To investigate the relationship between long-term use of low-dose aspirin and Helicobacter pylori (HP) infection, and its effect on eradication and recurrence of HP. According to the results of C14-Urea Breath Test (C14-UBT), 3256 patients with cardiovascular and cerebrovascular diseases from March 2019 to December 2020, were divided into HP infection group and non-infection group. Univariate and multivariate was used to investigate the relationship between Low-dose aspirin use and HP infection. 859 patients with hypertension combined with HP infection were divided into aspirin group, non-aspirin group and control group, the eradication rate after 2 weeks of bismuth-containing quadruple drug treatment and the recurrence rate after 1,3 year were compared. The overall infection rate of HP was 53.3%. The results of univariate analysis showed that the infection rate of female, age, BMI, LDL-C, FBG of HP infected group was higher than non-infection. The infection rate of patients who took low-dose aspirin was higher than no-aspirin [56.6% vs. 51.3%, χ2 = 8.548, P = 0.003]. Multivariate Logistic regression analysis showed that long-term aspirin use still increased the risk of infection (OR = 1.433, 95% CI 1.196-1.947, P < 0.001). The Per-Protocol analysis showed that the overall eradication rate was 87.6%, and among the eradication rates of aspirin group, non-aspirin group and control group were not statistically significantly (87.8%, 88.5%, and 86.6%, respectively), The Intention-To-Treat analysis showed that the overall eradication rate was 84.3%, and the eradication rates among the three groups were not statistically significantly. The overall 1-year recurrence rate was 1.3%, and the recurrence rates of the three groups were no statistical significance. The overall 3-years recurrence rate was 3.1%, and the recurrence rate of aspirin group was higher than non-aspirin group and control group (5.30%, 1.90% and 1.70%, respectively, χ2 = 6.118, P < 0.05). The main adverse reactions in the first month of eradication treatment were constipation and mild nausea, and there was no statistical significance between the three groups. Long-term use of low-dose aspirin increases the risk of HP infection and the recurrence rate in 3 years after eradication. It is suggested that HP should be tested and eradicated regularly in long-term users.

Drug-Associated Gastropathy: Diagnostic Criteria

Drugs are widely used to treat different diseases in modern medicine, but they are often associated with adverse events. Those located in the gastrointestinal tract are common and often mild, but they can be serious or life-threatening and determine the continuation of treatment. The stomach is often affected not only by drugs taken orally but also by those administered parenterally. Here, we review the mechanisms of damage, risk factors and specific endoscopic, histopathological and clinical features of those drugs more often involved in gastric damage, namely NSAIDs, aspirin, anticoagulants, glucocorticosteroids, anticancer drugs, oral iron preparations and proton pump inhibitors. NSAID- and aspirin-associated forms of gastric damage are widely studied and have specific features, although they are often hidden by the coexistence of Helicobacter pylori infection. However, the damaging effect of anticoagulants and corticosteroids or oral iron therapy on the gastric mucosa is controversial. At the same time, the increased use of new antineoplastic drugs, such as checkpoint inhibitors, has opened up a new area of gastrointestinal damage that will be seen more frequently in the near future. We conclude that there is a need to expand and understand drug-induced gastrointestinal damage to prevent and recognize drug-associated gastropathy in a timely manner.

Differential effects of proton pump inhibitors and vonoprazan on vascular endothelial growth factor expression in cancer cells

Proton pump inhibitors (PPIs) are potent inhibitors of gastric acid secretion, used as first-line agents in treating peptic ulcers. However, we have previously reported that PPIs may diminish the therapeutic effect of anti-vascular endothelial growth factor (VEGF) drugs in patients with cancer. In this study, we explored the effects of vonoprazan, a novel gastric acid secretion inhibitor used for the treatment of peptic ulcers, on the secretion of VEGF in cancer cells and attempted to propose it as an alternative PPI for cancer chemotherapy. The effects of PPI and vonoprazan on VEGF expression in cancer cells were compared by real-time reverse transcription-polymerase chain reaction and ELISA. The interaction of vonoprazan and PPIs with transcriptional regulators by docking simulation analysis. In various cancer cell lines, including the human colorectal cancer cell line (LS174T), PPI increased VEGF messenger RNA expression and VEGF protein secretion, while this effect was not observed with vonoprazan. Molecular docking simulation analysis showed that vonoprazan had a lower binding affinity for estrogen receptor alpha (ER-α), one of the transcriptional regulators of VEGF, compared to PPI. Although the PPI-induced increase in VEGF expression was counteracted by pharmacological ER-α inhibition, the effect of vonoprazan on VEGF expression was unchanged. Vonoprazan does not affect VEGF expression in cancer cells, which suggests that vonoprazan might be an alternative to PPIs, with no interference with the therapeutic effects of anti-VEGF cancer chemotherapy.

Co-prescription of Dual-Antiplatelet Therapy and Proton Pump Inhibitors: Current Guidelines

Dual-antiplatelet therapy (DAPT) prevents thrombotic complications associated with coronary artery disease, acute coronary syndrome, and stent thrombosis following the percutaneous coronary intervention or coronary artery bypass grafting. When initiating DAPT, the risk of thrombosis must be balanced with the increased risk of upper gastrointestinal bleed (UGIB). Proton-pump inhibitors (PPIs) are concurrently prescribed with DAPT to reduce bleeding risk. In this review, we discuss the benefits and potential complications of DAPT/PPI co-prescription. The only large international randomized control trial (RCT), Clopidogrel and the Optimization of Gastrointestinal Events Trial (COGENT), shows robust evidence that PPIs are a safe and effective method to reduce the risk of bleeding in patients on DAPT. However, more large-scale RCTs are needed to study potential long-term effects and draw a stronger conclusion on this topic.

Efficacy and Safety of Tongxinluo Capsule as Adjunctive Treatment for Unstable Angina Pectoris: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Tongxinluo capsule (TXLC) is a commonly used Chinese medicine for unstable angina pectoris (UA). This article aimed to clarify the safety and efficacy of TXLC as an adjunctive treatment for UA. Two reviewers searched 7 databases from inception to August 2021, and performed literature screening and information extraction independently. The meta-analysis was implemented after evaluating the methodological quality of each randomized controlled trial (RCT) by the Cochrane Risk of Bias tool. Sensitivity analyses were conducted for testing the stability of the results, and the Begg and Egger tests were performed for any potential publication bias. After eligibility assessment, 42 RCTs with a total of 5,421 participants were included. Evidence showed that TXLC reduced the rate of cardiovascular events [RR = 0.29, 95% CI (0.19, 0.45), p < 0.00001, I ² = 0%] {including cardiovascular mortality [RR = 0.16, 95% CI (0.03, 0.88), p = 0.03, I ² = 20%], the incidence of acute myocardial infarction [RR = 0.27, 95% CI (0.13, 0.57), p = 0.0006, I ² = 0%] and the occurrence of revascularization [RR = 0.28, 95% CI (0.15,0.54), p = 0.0001, I ² = 0%]}, all-cause mortality [RR = 0.25, 95% CI (0.06, 0.99), p = 0.05, I ² = 19%], recurrence of angina [RR = 0.25, 95% CI (0.11, 0.61), p = 0.002, I ² = 0%], the number of ST-segment depression [MD = -0.45, 95% CI (-0.69, -0.20), p = 0.0005, I ² = 0%], the summation of ST-segment depression [MD = -0.70, 95% CI (-1.08, -0.32), p = 0.0003, I ² = 70%] and the hypersensitive C-reactive protein level [MD = -2.86, 95% CI (-3.73, -1.99), p < 0.00001, I ² = 86%], increased the nitric oxide level [MD = 11.67, 95% CI (8.33, 15.02), p < 0.00001, I ² = 33%], improved the electrocardiogram change [RR = 1.23, 95% CI (1.16, 1.30), p < 0.00001, I ² = 0%] and the clinical efficacy in UA [RR = 1.26, 95% CI (1.21, 1.32), p < 0.00001, I ² = 24%], and relieved the symptoms of angina pectoris {including chest pain or tightness [RR = 1.13, 95% CI (0.97, 1.32), p = 0.12, I ² = 30%], palpitations [RR = 1.47, 95% CI (1.18, 1.84), p = 0.0007, I ² = 0%], shortness of breath [RR = 1.53, 95% CI (1.24, 1.88), p < 0.0001, I ² = 0%], and asthenia [RR = 1.69, 95% CI (0.83, 3.43), p = 0.15, I ² = 90%]}. The most common adverse effect was gastrointestinal symptoms which could be relieved and eliminated through dose reduction, medication time adjustment and symptomatic remedy. Collectively, TXLC was effective and considerably safe for UA. However, due to the unavoidable risk of bias, these results must be interpreted with caution and further verified by large-scale and high-quality RCTs. Systematic Review Registration: www.crd.york.ac.uk/PROSPERO/, identifier CRD42021232771.

Advances in prevention and treatment of digestive tract damage induced by antithrombotic therapy with traditional Chinese and Western medicine

The incidence of cardiovascular diseases has increased due to the aging of the population. Therefore, antithrombotic therapy is increasingly prescribed for cardiovascular prevention. However, long-term use of antithrombotic drugs can cause damage to the digestive tract. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antithrombotic therapy. In order to minimize the digestive tract damage induced by antithrombotic drugs, there are several strategies available, including reducing modifiable risk factors, using the most optimal antithrombotic regimen to ensure gastrointestinal risk-cardiovascular benefit balance, and using gastroprotective agents. In recent years, researchers are attempting to find new solutions from traditional Chinese medicine. Studies have shown that traditional Chinese medicine has its own characteristics and clinical advantages in preventing and treating diseases. In this review, we provide a summary of recent updates regarding gastrointestinal damage induced by antithrombotic therapy as well as its prevention and treatment with both traditional Chinese and Western medicine.

Potent Acid Suppression With Vonoprazan vs Proton Pump Inhibitors Does Not Have Higher Association With Clostridioides difficile Infection

INTRODUCTION

Proton pump inhibitors (PPIs) are associated with the onset of Clostridioides difficile infection (CDI). Although a new potassium-competitive acid blocker, vonoprazan, consistently shows a more potent acid inhibitory effect in comparison to PPIs, the risk of CDI in vonoprazan-treated patients relative to those treated with PPIs is unknown. In this retrospective case-control study, using a nationwide hospital-based administrative database in Japan, we investigated the association of the onset of CDI in patients treated with vonoprazan.

METHODS

A CDI case was defined as a case in which a patient was diagnosed and treated for CDI. For each CDI case, 3 non-CDI patients were extracted as controls. Information on the usage of acid suppressants in the 2 months before the onset of CDI and other confounding factors was collected. Relative associations of gastric acid suppressants with the onset of CDI were estimated.

RESULTS

A total of 4,466 CDI cases and 13,220 of non-CDI controls were extracted. A multivariate conditional regression analysis revealed that PPI or vonoprazan use was modestly, but significantly associated with CDI (odds ratio [95% confidence interval]: PPI, 1.3 [1.2-1.4]; vonoprazan, 1.4 [1.2-1.7]). With PPI users as a reference, vonoprazan did not show a stronger association with CDI (odds ratio [95% confidence interval]: 1.07 [0.91-1.26]).

DISCUSSION

We found a significant positive association between vonoprazan use and CDI; however, the magnitude of the association was not beyond that in PPI users. This is the first report on any potential adverse effects of vonoprazan.

ZINC40099027 Promotes Gastric Mucosal Repair in Ongoing Aspirin-Associated Gastric Injury by Activating Focal Adhesion Kinase

Nonsteroidal anti-inflammatory drugs cause gastric ulcers and gastritis. No drug that treats GI injury directly stimulates mucosal healing. ZINC40099027 (ZN27) activates focal adhesion kinase (FAK) and heals acute indomethacin-induced small bowel injury. We investigated the efficacy of ZN27 in rat and human gastric epithelial cells and ongoing aspirin-associated gastric injury. ZN27 (10 nM) stimulated FAK activation and wound closure in rat and human gastric cell lines. C57BL/6J mice were treated with 300 mg/kg/day aspirin for five days to induce ongoing gastric injury. One day after the initial injury, mice received 900 µg/kg/6 h ZN27, 10 mg/kg/day omeprazole, or 900 µg/kg/6 h ZN27 plus 10 mg/kg/day omeprazole. Like omeprazole, ZN27 reduced gastric injury vs. vehicle controls. ZN27-treated mice displayed better gastric architecture, with thicker mucosa and less hyperemia, inflammation, and submucosal edema, and lost less weight than vehicle controls. Gastric pH, serum creatinine, serum alanine aminotransferase (ALT), and renal and hepatic histology were unaffected by ZN27. Blinded scoring of pFAK-Y-397 immunoreactivity at the edge of ZN27-treated lesions demonstrated increased FAK activation, compared to vehicle-treated lesions, confirming target activation in vivo. These results suggest that ZN27 ameliorates ongoing aspirin-associated gastric mucosal injury by a pathway involving FAK activation. ZN27-derivatives may be useful to promote gastric mucosal repair.

Low-dose aspirin and the severity of ıschemic colitis: A single-center retrospective study

BACKGROUND/AIMS

This retrospective study aimed to evaluate the effect of low-dose aspirin (50-150 mg/d) on the severity of ischemic colitis.

MATERIALS AND METHODS

A total of 244 patients admitted to our hospital for ischemic colitis between 2013 and 2018 were included in the study. Patients were divided into two groups-aspirin and non-aspirin groups-based on their recent history of aspirin use before the onset of ischemic colitis. Clinical performance, biochemical indices, and endoscopic findings were compared.

RESULTS

The average age and the proportion of underlying disease, including hypertension, cerebral infarction, and coronary heart disease in the aspirin group was significantly higher than those in the non-aspirin group (p<0.05). In terms of clinical symptoms, the proportion of diarrhea in the aspirin group was significantly higher than that in the non-aspirin group, while the proportion of abdominal pain was significantly lower in the aspirin group compared with the non-aspirin group. Colonoscopy results showed that the incidence of ulceration was significantly higher in the aspirin group than in the non-aspirin group (p<0.05).

CONCLUSION

The use of low-dose aspirin may aggravate the severity and mask the symptoms of abdominal pain in ischemic colitis.

[An Introduction to Real-world Data and Tips for Analysing It]

Medical big data, also referred to as 'real-world data' (RWD) is defined as "data related to patient health status and/or health care delivery collected routinely from a variety of sources". This includes data from disease and drug registries, electronic health records, claims and billing data and census data collected from clinicians, hospitals, and payers. Observational studies using RWD collected during general clinical practice are considered complementary to randomized control trials. However, since this design does not allow the random assignment of patients, causal inference analyses are required. Researchers should study the protocol properly before considering the combination of study design, the characteristics of data source, calculation of the appropriate sample size and the validity of outcomes. Data definition using data code should also be considered. Furthermore, the reliability of the source studies must be considered and discussed when the article is written. This review aims to outline the methods for performing reliable observational studies using RWD.

Decline incidence in upper gastrointestinal bleeding in several recent years: data of the Japan claims database of 13 million accumulated patients

This study was to examine the recent trends in upper gastrointestinal bleeding in Japan using a large-scale real-world database. The incidence of upper gastrointestinal bleeding was evaluated in the Japan Medical Data Center claims database of 13,019,713 patients aged 20 to 74 years with traceability for 3 months from 2009 to 2014. The incidence was compared with peptic ulcers and gastroesophageal reflux disease. The prescription of medications was also evaluated. The incidence of bleeding was 0.137%, 0.121%, 0.113%, 0.106%, 0.099%, and 0.105% during 2009 to 2014 with a time-dependent decline (p<0.001). Peptic ulcers (>10 times higher than the incidence of bleeding) decreased with time (p<0.001), whereas gastroesophageal reflux disease increased (p = 0.006). Upper gastrointestinal bleeding was higher in male patients and older patients (60–74 years old) (p<0.001 respectively). The prescription rate of antithrombotic medications and proton pump inhibitors increased from 2009 to 2014 (p<0.001 respectively). The incidence of upper gastrointestinal bleeding decreased from 2009 to 2014 in this relatively large-scale real-world database in Japan, concomitant with the decrease in peptic ulcers. The decreased incidence might have been due to changes in the disease structure and therapeutic strategies over time.

Gastroesophageal reflux disease and esophagitis associated with the use of drugs: the modern state of the problem

From the standpoint of evidence - based medicine, the ability of various drugs to induce the development of gastroesophageal reflux disease and esophagitis is considered. Thus, all known drugs can be divided into 3 groups: drugs that have the ability to reduce pressure in the lower esophageal sphincter, for example, β-adrenoreceptor agonists, α-adrenoreceptor antagonists, anticholinergics, calcium channel blockers, nitrates, benzodiazepines (diazepam), estrogen, progesterone, aminophylline (theophylline), tricyclic antidepressants, selective serotonin reuptake inhibitors, glucocorticosteroids; means providing a direct damaging effect on the esophageal mucosa, as well as lowering its resistance reflyuktatu, e.g., bisphosphonates, acetylsalicylic acid / non - steroidal anti - inflammatory agents, anticoagulants, antiplatelet drugs, iron preparations, ascorbic acid, potassium chloride, quinidine, phenytoin, calcium dobesilate, 131I sodium iodide, antibiotics (tetracycline, doxycycline, clindamycin, ciprofloxacin, ornidazole, clindamycin, rifampicin), antitumor agents; drugs that impede gastric emptying: calcium channel blockers, anticholinergics. These data can be used in practice in the choice of treatment tactics, especially in individuals with a diagnosis of gastroesophageal reflux disease or heartburn.

Correlation of Barrett's esophagus with colorectal polyps in Japanese patients: A retrospective chart review

BACKGROUND AND AIM

Barrett's esophagus and colorectal polyps have several overlapping risk factors. Whereas several reports in Western countries have indicated a close relationship between Barrett's esophagus and colorectal polyps, the relationship between these two diseases remains unclear in Japan. This study was performed to determine whether the prevalence of Barrett's esophagus is related to that of colorectal polyps in Japanese patients.

METHODS

The present retrospective chart review included 1582 Japanese patients who underwent both total colonoscopy and esophagogastroduodenoscopy from January 2010 to December 2016. The data on colorectal polyps and Barrett's esophagus were obtained from the endoscopic findings. The medical record of each patient was checked for age, sex, body mass index, smoking, alcohol drinking, use of acid suppression agents, and comorbidities including a history of diabetes, ischemic heart disease, gastroesophageal reflux disease, hiatal hernia, and Helicobacter pylori infection.

RESULTS

Colorectal polyps were detected in 789 of the 1582 patients (49.9%). Barrett's esophagus was detected in 233 patients (14.7%), and most cases of Barrett's esophagus (n = 229) were classified as short-segment Barrett's esophagus. Colorectal polyps were more frequent in patients with than without Barrett's esophagus (odds ratio, 1.79; 95% confidence interval, 1.31-2.46; P < 0.001). In addition to Barrett's esophagus, the data indicated that old age, male sex, obesity, smoking, alcohol drinking, diabetes mellitus, and ischemic heart disease were independent risk factors for colorectal polyps.

CONCLUSIONS

The present study revealed the correlation between the prevalence of Barrett's esophagus and colorectal polyps in Japanese patients.