Drug-related damage of the ageing gastrointestinal tract

The Relieving Effects of a Polyherb-Based Dietary Supplement ColonVita on Gastrointestinal Quality of Life Index (GIQLI) in Older Adults with Chronic Gastrointestinal Symptoms Are Influenced by Age and Cardiovascular Disease: A 12-Week Randomized Placebo-Controlled Trial

Chronic gastrointestinal symptoms (CGS) negatively affect the quality of life in about 15–30% of the population without effective drugs. Recent studies suggest that dietary supplement may improve CGS, but inconsistent results exist. The goal of this study is to evaluate the effect of a polyherbal-based supplement ColonVita on the gastrointestinal quality of life index (GIQLI) in 100 old adults with CGS (63.1 ± 9.6 years) who were randomly assigned to daily ColonVita or placebo tablets (n = 50/group) for 12 weeks in a double-blind, randomized controlled trial design. No significant fibrdifferences were found between ColonVita and placebo in the baseline total GIQLI score (101.12 ± 16.87 vs. 101.80 ± 16.48) (P > 0.05) or postintervention total GIQLI score (114.78 ± 9.62 vs. 111.74 ± 13.01) (P > 0.05). However, ColonVita significantly improved 16 scores of the 19 core GI symptoms compared with 10 items improved by placebo. The ColonVita group significantly improved the remission rate of 5 core GI symptoms compared to placebo and significantly improved the total GIQLI scores (118.09 ± 7.88 vs. 109.50 ± 16.71) (P < 0.05) and core GI symptom scores (64.61 ± 3.99 vs. 60.00 ± 8.65) (P < 0.05) in people ≥60 years of age (n = 49) but not in those under 60 y (n = 51). ColonVita significantly improved the total GIQLI scores and core GI symptom scores in people without cardiovascular diseases (CVD) (n = 56) (116.74 ± 9.38 vs. 110.10 ± 14.28) (P < 0.05) and (63.11 ± 4.53 vs. 59.93 ± 8.03) (P=0.07), respectively, but not in those with CVD (n = 44). Thus, ColonVita was beneficial for old adults with CGS, especially those ≥60 years of age and without CVD. Because a heterogenous pathogenesis of CGS-like irritable bowel syndrome (IBS) and inflammatory bowel disease (ISD) is differentially associated with CVD, different comorbidities may have influenced the outcomes of different trials that should be controlled in further studies.

The Aging Bowel Dysfunction and Elderly Vulnerability towards COVID-19 Infection

Severe acute respiratory syndrome coronavirus 2, primarily a respiratory tract virus, also affects the enteric organs. The most affected sector of the community are the retirement and nursing home elderly residents. Along their life the senescent gastrointestinal functions are deteriorating and failing to fully execute their digestive, absorptive, mucosal barriers, and immune protective duties. Adding the decreased motility, increased intestinal permeability, dysbiosis, morbid chronic disease background, the consumed polypharmacy enteric adverse effects to the presence of the SARS-CoV-2 host receptor along the intestinal tracts put the basis for the current hypothesis. It is hypothesized that the disadvantages and failures of the aging enteric tract contribute to the elderly morbidity and mortality during the current new coronavirus pandemic. In a more optimistic look, several nutraceuticals can prevent or restore the dysfunctional intestinal barrier functions, mainly in the elderly and potentially in those who are SARS-CoV-2 infected.

Evaluation of prescription pattern of analgesic use among ambulatory elderly in South-Western Nigeria

Background:

Inappropriate prescribing of analgesics has a global impact on the health of elderly patients and the society. Empirical evidence on the prescription of analgesics among elderly Nigerians is scarce.

Objectives:

The objective of the study was to evaluate the prescription pattern of analgesics and describe the co-prescribing of gastroprotective agents with non-steroidal anti-inflammatory drugs (NSAIDs) among elderly patients at the geriatric center, University College Hospital, Ibadan.

Methods:

A retrospective cross-sectional, hospital-based study was carried out among elderly patients (≥60 years) who were prescribed analgesics. Using a data extraction sheet, information on demographic characteristics, drug utilization pattern, and morbidities was obtained from patients’ case files via electronic health records.

Results:

A total of 337 patients case files were reviewed, the mean age was 72 ± 8.8 years, and 210 (62.3%) were females. There were a total of 2074 medications prescribed, with 733 (35.3%) being analgesics. Majority of the elderly patients (259, 76.9%) were on nonopioids, with 252 (74.8%) on NSAIDs. Paracetamol was the most commonly prescribed analgesics (181, 24.6%), followed by diclofenac/misoprostol (177, 24.1%), opioid analgesic prescribed was 88 (12.0%), with paracetamol/codeine 58 (65.9%), and tramadol 16 (18.2%) being the most prescribed opioid. A significant proportion of the hypertensive elderly patients (160, 78.8%; P < 0.036) were on NSAIDs. The oral route of administration (302, 89.6%) was the most common route of administration. Majority (310, 92%) of elderly patients taking NSAIDs had a co-prescription for gastroprotective agents.

Conclusions:

Majority of hypertensive patients were on NSAIDs. This calls for prompt awareness of rational analgesic use among the elderly to improve management and their survival.

Risk of rebleeding, vascular events and death after gastrointestinal bleeding in anticoagulant and/or antiplatelet users

BACKGROUND

Patients with gastrointestinal bleeding during anticoagulant and/or antiplatelet therapy represent a clinical challenge.

AIM

To determine the risk/rates of rebleeding, vascular events and death in patients treated with antiplatelet or anticoagulant agents who developed major gastrointestinal bleeding METHODS: This was an observational cohort study of patients who developed gastrointestinal bleeding while on antiplatelet and/or anticoagulant therapy. Drug use information was collected prospectively during bleeding events. Cox proportional hazards models were used to evaluate rebleeding, vascular events and death.

RESULTS

Among 871 patients (mean age 78.9 ± 8.6 years), 38.9% used an anticoagulant, 52.5% used an antiplatelet and 8.6% used both; 93.1% interrupted treatment after gastrointestinal bleeding and 80.5% restarted therapy within 7.6 ± 36.4 days; 38.7% had upper gastrointestinal bleeds, 46.7% lower gastrointestinal bleeds and 14.6% gastrointestinal bleeds of unknown origin. Median follow-up was 24.9 months (IQR: 7.0-38.0). Resumption of both therapies was associated with a higher risk of rebleeding, lower risk of ischaemic events or death and a similar risk for upper and lower gastrointestinal events. Resumption of therapy ≤ 7 days after bleeding showed a similar pattern with no differences in death. Rebleeding rates were higher in anticoagulant vs antiplatelet patients (138.0 vs 99.0 events per 1000 patient-years), and the bleeding location was identical in 61.8% of cases.

CONCLUSIONS

Resumption of anticoagulant or antiplatelet therapy after a gastrointestinal bleeding event was associated with a lower risk of vascular events and death and a higher rebleeding risk. The benefits of early reinstitution of anticoagulant/antiplatelet therapy outweigh the gastrointestinal-related risks.

Potentially inappropriate medication use in institutionalized older adults according to the Beers Criteria

The need for specific care, coupled with new family arrangements, has contributed to the increasing institutionalization of elderly members. The purpose of this study was to evaluate drug use by institutionalized older adults according to Beers Criteria. This prospective, longitudinal study was conducted in the three non-profit long-stay geriatric care institutions of Campo Grande, in the Central-West region of Brazil. All subjects aged 60 years and above on November 2011 were included and followed until November 2012. Eighteen subjects were excluded and the final sample consisted of 133 individuals aged 60 to 113 years. Overall, 212 medications were used at geriatric care institution A, 532 at B, and 1329 at C. Thirty-four drugs were inappropriately prescribed 89 times at geriatric care institution A (41.98%), 49 prescribed 177 times at B (33.27%), and 91 prescribed 461 times at C (34.68%). Statistical differences in the inappropriate drug use were found between genders (p=0.007). The most commonly used potentially inappropriate medication were first-generation antihistamines (15.34%). There was a high frequency in the use of potentially inappropriate medications which can initiate marked side effects and may compromise the fragile health of institutionalized elderly. Thus, adopting the Beers Criteria in prescribing medication contributes to minimize adverse reactions and drug interactions.

Common GI Drug Interactions in the Elderly

OPINION STATEMENT

The careful review of drug-drug interactions is vital to the safe prescribing of medications for chronic medical conditions. The elderly population suffers from multiple medical problems, and polypharmacy leads to further morbidity in this vulnerable group of patients. We discuss gastrointestinal conditions such as GERD, peptic ulcer disease, gastroparesis, diarrhea, constipation, irritable bowel syndrome, inflammatory bowel disease, chronic liver disease and the commonly used medications in these conditions. Treatment options must be individualized and tailored to accommodate the underlying pharmacokinetics and known drug-drug interactions. The indication for the use of a therapeutic agent in the elderly and the duration of use must be frequently readdressed to help prevent polypharmacy and adverse drug reactions. Medications should be started at a low dose with careful titration to achieve a clinical response to prevent toxicity. The aim of this article is to increase awareness of important drug-drug interactions of commonly prescribed gastrointestinal medications in the elderly.

Co-prescription of gastroprotective agents and their efficacy in elderly patients taking nonsteroidal anti-inflammatory drugs: a systematic review of observational studies

BACKGROUND & AIMS

Guidelines recommend prescribing gastroprotective agents (proton pump inhibitors, misoprostol) to older patients (primarily ≥65 years old) taking nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent gastrointestinal ulcers. Older individuals are underrepresented in clinical trials of these agents. We systematically reviewed evidence from observational studies on the use of gastroprotective agents in elderly patients and their ability to prevent NSAID-related ulcers in this population.

METHODS

We performed a systematic search of Embase and MEDLINE and identified 23 observational studies that focused on elderly patients and reported data on co-prescription of gastroprotective agents and NSAIDs and/or the effectiveness of the agents in preventing gastrointestinal events in NSAID users. We collected data on rates of co-prescription and NSAID-related gastrointestinal events in patients with and without gastroprotection.

RESULTS

A median of 24% (range, 10%-69%) of elderly patients taking NSAIDs received a co-prescription for gastroprotective agents; this percentage was only slightly higher in the oldest age groups. All studies of efficacy showed a positive effect of gastroprotection. However, the adjusted results were not suitable for synthesis, and the 5 studies reporting unadjusted results were too heterogeneous for meta-analysis (I(2) = 97%). The studies differed in outcomes, definitions of co-prescription, and differences in baseline risk factors between patients with and without gastroprotection. None of the studies assessed adverse effects of gastroprotective agents. The 2 cost-effectiveness studies reached opposing conclusions.

CONCLUSIONS

In a systematic review, the observational evidence for the efficacy of gastroprotective agents in preventing NSAID-associated gastrointestinal events was in agreement with results of randomized controlled trials. However, because of heterogeneity of included studies, it is not clear what the effect would be if more patients were treated, or at what age gastroprotection should be recommended. We offer suggestions to facilitate comparison with other work and address the questions of risk and benefit in relation to age.

Molecular mechanisms elucidating why old stomach is more vulnerable to indomethacin-induced damage than young stomach

BACKGROUND/AIMS

Detailed underlying changes have never been explored to explain how old stomach is more susceptible to non-steroidal anti-inflammatory drugs (NSAIDs)-induced gastric damage than young stomach, although presumptively speculated as weakened mucosal defense system as well as attenuated regenerating capacity in old stomach.

METHODS

In order to investigate molecular mechanisms relevant to NSAID-induced gastric damage, we administered indomethacin to 6-week-old and 60-week-old rats.

RESULTS

In spite of the same oral administration of indomethacin (0.1 mg indomethacin dissolved in 1 ml carboxyl methylcellulose) irrespective of body weights of rat, gastric mucosal damages were significantly increased in the older rats compared to the younger rats (p < 0.05). Before indomethacin administration, inflammatory mediators including cytokines, chemokines, proteases, and adhesion molecules were significantly increased in old stomach and these differences were further increased after indomethacin administration (p < 0.05). Furthermore, the levels of total oxidants and apoptotic executors were significantly increased in old stomach, whereas lipoxin A4 and anti-apoptotic proteins such as survivin and Bcl-2 were significantly decreased. Increased NF-κB-DNA binding activity as well as the activation of JNK and p38 was responsible for the increased expressions of inflammatory mediators as well as oxidants.

CONCLUSIONS

A preventive strategy to reduce either redox activation or pro-inflammatory mediators should be considered in older patients taking long-standing NSAID administration.

Gastrointestinal lesions and complications of low-dose aspirin in the gastrointestinal tract

Low dose aspirin (ASA) use has been associated with a wide range of adverse side effects in the upper gastrointestinal (GI) tract, which range from troublesome symptoms without mucosal lesions to more serious toxicity, including ulcers, GI bleeding, perforation and even death. Upper GI symptoms in low dose ASA users are common but often careless or misinterpreted and they are not always related to the presence of mucosal injury. Usually, low dose ASA related ulcers are reasonably small and asymptomatic, and probably heal over a period of weeks to a few months. But, the real clinical problem occurs when the ulcer results in a GI complication (mostly bleeding). The estimated average excess risk of symptomatic or complicated ulcer related to low dose ASA is five cases per 1000 ASA users per year. Death is the worst outcome of GI complications in low dose ASA users, but data about this aspect are scarce. Current evidence indicates that low dose ASA can damage the lower GI tract also, but the real size of the problem is still unknown.

Intravenous iron in digestive diseases: a clinical (re)view

Intravenous iron has been considered dangerous by many clinicians. In the last two decades, considerable experience has been gained with new formulations in different clinical settings. Data from clinical trials, observational studies, and postmarketing surveillance studies demonstrate that intravenous iron is safe and effective to treat iron deficiency and iron deficiency anaemia. Iron deficiency is particularly common in many digestive diseases: oral iron often fails while transfusions are not without considerable risks. In particular, in inflammatory bowel diseases, there is enough evidence to recommend intravenous iron in moderate-to-severe iron deficiency anaemia, in intolerance to oral iron, and in patients needing quick recovery (pre-operative setting). New formulations make treatment even easier and more convenient. Recent guidelines are available for inflammatory bowel diseases, and new guidelines in acute and chronic gastrointestinal bleeding are needed.