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Zaher A, ElSaygh J, Midani A, Treihaft A, Banerji B, Bouso MF, Mushannen M, Hussein R, Crawford CV. A Closer Look into Gastrointestinal Bleeding in Heart Failure Patients. Curr Probl Cardiol 2024; 49:102739. [PMID: 38972470 DOI: 10.1016/j.cpcardiol.2024.102739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 07/04/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND The frequency and risk factors for gastrointestinal bleed (GIB) in patients with heart failure with reduced ejection fraction (HFrEF) have not been extensively researched. OBJECTIVE We aim to assess the frequency of GIB in this subset of patients and identify potential risk factors for bleeding. This study will evaluate the frequency of commonly used antiplatelet and anticoagulation agents in the HFrEF population, as well as look at some of the endoscopic features of the GIB. METHODS A retrospective cohort analysis of 670 patients admitted between November 2021 to August 2023 to a single urban, tertiary teaching institution with acute HFrEF ICD-10 codes. Upper or lower GIB (hematemesis, coffee ground emesis, melena or hematochezia during admission) was identified on a manual chart review. Patients with GIB were defined as our cases. No GIB was defined as our controls. Sub analysis included comparing the use of anticoagulant and antiplatelet between the cohort. Independent t test assessed statistical differences in the case and control groups RESULTS: Out of the 670 patients, 134 (20%) were identified with GIB. The cases were older than the controls (median age 77 vs. 70 years) (p = 0.001), had a lower hemoglobin (9 g/dL vs. 12 g/dL) (p =<0.05), and had higher BNP levels (7,938 pg/ml vs. 6472 pg/ml) (IQR: 3,239, 23,701) (p =<0.01). Among the anticoagulant users, 64% of cases were on an anticoagulant compared to 42% of the controls (p<0.05). Among the antiplatelet users, 68% of the controls were on one or more antiplatelet agents, compared to 52% in the controls (p = 0.01). When combining AC and AP treatment, there was no statistical difference between cases and controls. Ninety-three (69%) patients from cases had cross-sectional imaging with only 23 (25%) showing abnormal findings which included diverticulosis, colitis, and GI masses. When comparing upper endoscopy findings, the presence of esophageal diseases (esophagitis and esophageal varices) and gastric/duodenal diseases (gastritis, gastric ulcer, duodenal ulcer and AVM) were significantly higher in cases compared to controls (p < 0.05). In addition to the colonoscopy findings, polyps and diverticulosis were more prevalent in the cases compared to the controls (p = 0.01). CONCLUSION Heart failure patients are at risk of developing GIB. Age and high BNP on admission are risk factors for GIB, the higher the BNP levels the higher risk of GIB. Anticoagulant and antiplatelet use are associated with a higher risk of bleeding. However, the addition of dual antiplatelet therapy or concurrent antiplatelet and anticoagulation does not increase the risk of GIB. Some of the most common upper endoscopy findings include esophagitis/gastritis and esophageal/gastric ulcer. In terms of colonoscopy, findings include colonic mass, diverticulosis and hemorrhoids.
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Affiliation(s)
- Anas Zaher
- New York Presbyterian-Brooklyn Methodist Hospital/ Weill Cornell Medicine, 506 6th street, Brooklyn, NY 11215, United States.
| | - Jude ElSaygh
- New York Presbyterian-Brooklyn Methodist Hospital/ Weill Cornell Medicine, 506 6th street, Brooklyn, NY 11215, United States
| | - Akram Midani
- New York Presbyterian-Brooklyn Methodist Hospital/ Weill Cornell Medicine, 506 6th street, Brooklyn, NY 11215, United States
| | - Andrew Treihaft
- New York Presbyterian-Brooklyn Methodist Hospital/ Weill Cornell Medicine, 506 6th street, Brooklyn, NY 11215, United States
| | - Brinda Banerji
- New York Presbyterian-Brooklyn Methodist Hospital/ Weill Cornell Medicine, 506 6th street, Brooklyn, NY 11215, United States
| | - Muhammed Fouad Bouso
- New York Presbyterian-Brooklyn Methodist Hospital/ Weill Cornell Medicine, 506 6th street, Brooklyn, NY 11215, United States
| | - Malik Mushannen
- New York Presbyterian-Brooklyn Methodist Hospital/ Weill Cornell Medicine, 506 6th street, Brooklyn, NY 11215, United States
| | - Rawan Hussein
- New York Presbyterian-Brooklyn Methodist Hospital/ Weill Cornell Medicine, 506 6th street, Brooklyn, NY 11215, United States
| | - Carl V Crawford
- New York Presbyterian-Weill Cornell Medicine, 1300 York Ave, New York, NY 10065, United States
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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024; 21:574-592. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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Fischbach W, Bornschein J, Hoffmann JC, Koletzko S, Link A, Macke L, Malfertheiner P, Schütte K, Selgrad DM, Suerbaum S, Schulz C. Update S2k-Guideline Helicobacter pylori and gastroduodenal ulcer disease of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:261-321. [PMID: 38364851 DOI: 10.1055/a-2181-2225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
| | - Jan Bornschein
- Translational Gastroenterology Unit John, John Radcliffe Hospital Oxford University Hospitals, Oxford, United Kingdom
| | - Jörg C Hoffmann
- Medizinische Klinik I, St. Marien- und St. Annastiftskrankenhaus, Ludwigshafen, Deutschland
| | - Sibylle Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum Munich, Munich, Deutschland
- Department of Paediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Alexander Link
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Lukas Macke
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Peter Malfertheiner
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
| | - Kerstin Schütte
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Niels-Stensen-Kliniken Marienhospital Osnabrück, Osnabrück, Deutschland
| | - Dieter-Michael Selgrad
- Medizinische Klinik Gastroenterologie und Onkologie, Klinikum Fürstenfeldbruck, Fürstenfeldbruck, Deutschland
- Klinik für Innere Medizin 1, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Sebastian Suerbaum
- Universität Munich, Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Munich, Deutschland
- Nationales Referenzzentrum Helicobacter pylori, Pettenkoferstr. 9a, 80336 Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Christian Schulz
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
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Abstract
Gastrointestinal (GI) complications are seen in over 50% of ischemic stroke survivors; the most common complications are dysphagia, constipation, and GI bleeding. The bidirectional relationship of the gut-brain axis and stroke has recently gained traction, wherein stroke contributes to gut dysbiosis (alterations in the normal host intestinal microbiome) and gut dysbiosis perpetuates poor functional neurologic outcomes in stroke. It is postulated that the propagation of proinflammatory cells and gut metabolites (including trimethylamine N-oxide and short-chain fatty acids) from the GI tract to the central nervous system play a central role in gut-brain axis dysfunction. In this review, we discuss the known GI complications in acute ischemic stroke, our current knowledge from experimental stroke models for gut-brain axis dysfunction in stroke, and emerging therapeutics that target the gut-brain axis.
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Affiliation(s)
- Heather Y F Yong
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Carlos Camara-Lemarroy
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Canada
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5
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Aktualisierte S2k-Leitlinie Helicobacter
pylori und gastroduodenale Ulkuskrankheit der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – Juli 2022 – AWMF-Registernummer: 021–001. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:544-606. [PMID: 37146633 DOI: 10.1055/a-1975-0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
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Murthy D, Attri KS. PTGES Expression Is Associated with Metabolic and Immune Reprogramming in Pancreatic Ductal Adenocarcinoma. Int J Mol Sci 2023; 24:ijms24087304. [PMID: 37108468 PMCID: PMC10138618 DOI: 10.3390/ijms24087304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/18/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Metabolic reprogramming is an established hallmark of multiple cancers, including pancreatic cancer. Dysregulated metabolism is utilized by cancer cells for tumor progression, metastasis, immune microenvironment remodeling, and therapeutic resistance. Prostaglandin metabolites have been shown to be critical for inflammation and tumorigenesis. While the functional role of prostaglandin E2 metabolite has been extensively studied, there is a limited understanding of the PTGES enzyme in pancreatic cancer. Here, we investigated the relationship between expression of prostaglandin E synthase (PTGES) isoforms and the pathogenesis and regulation of pancreatic cancer. Our analysis identified higher expression of PTGES in pancreatic tumors compared to normal pancreatic tissues, suggesting an oncogenic function. Only PTGES1 expression was significantly correlated with worse prognosis of pancreatic cancer patients. Further, utilizing cancer genome atlas data, PTGES was found to be positively correlated with epithelial-mesenchymal transition, metabolic pathways, mucin oncogenic proteins, and immune pathways in cancer cells. PTGES expression was also correlated with higher mutational burden in key driver genes, such as TP53 and KRAS. Furthermore, our analysis indicated that the oncogenic pathway controlled by PTGES1 could be regulated via DNA methylation-dependent epigenetic mechanisms. Notably, the glycolysis pathway was positively correlated with PTGES and may fuel cancer cell growth. PTGES expression was also associated with downregulation of the MHC pathway and negatively correlated with CD8+ T cell activation markers. In summary, our study established an association of PTGES expression with pancreatic cancer metabolism and the immune microenvironment.
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Affiliation(s)
- Divya Murthy
- Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Kuldeep S Attri
- Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA
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Marmo R, Occhipinti V, Zullo A, Soncini M. Improved Survival for Patients With Acute Upper Gastrointestinal Bleeding While on Antithrombotic Therapy: A Multicenter Prospective Cohort Study. J Clin Gastroenterol 2023; 57:278-284. [PMID: 35152241 DOI: 10.1097/mcg.0000000000001674] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/04/2022] [Indexed: 12/10/2022]
Abstract
GOALS Aim of the study was to determine if patients with acute upper gastrointestinal bleeding (AUGIB) while on antithrombotic agents (ATs) are at higher risk for worse outcomes. BACKGROUND ATs are risk factors of AUGIB, but their impact on clinical outcomes is uncertain. STUDY Patients with AUGIB (nonvariceal, NV-AUGIB or variceal, V-AUGIB) in 50 Italian hospitals were prospectively enrolled from January 1, 2014 to December 31, 2015. Clinical data, laboratory tests, comorbidities, prognostic scores, received therapies, and outcomes (death, rebleeding, surgery/radiology, transfusions, length of hospitalization) were analyzed. RESULTS A total of 3324 patients (2764 NV-AUGIB, 83.2% and 560 V-AUGIB, 16.8%) were enrolled, 1399 (42.1%) on ATs. Patients taking ATs were older (75.4 vs. 62.8 y, P <0.001), had higher American Society of Anesthesiologists (ASA), Rockall and Glasgow-Blatchford scores ( P <0.001). At multivariate analysis considering comorbidities, ATs use resulted an independent protective factor against death [odds ratio (OR): 0.63, 95% confidence interval (CI): 0.45-0.87, P =0.006]. Rebleeding (5.5% vs. 5.8%, P =0.71) and need for salvage surgery/radiology (4.2% vs. 4.8%, P =0.41) were similar in the 2 groups. Considering specific ATs, low-dose aspirin was the most powerful factor lowering the death risk (OR: 0.51, 95% CI: 0.33-0.81, P =0.004). While the generic use of AT therapy did not emerge as a statistically significant independent protective factor considering separately NV-AUGIB (OR: 0.80, 95% CI: 0.56-1.13, P =0.21) and V-AUGIB (OR: 0.40, 95% CI: 0.15-1.07, P =0.068), the protective effect of low-dose aspirin was confirmed for NV-AUGIB (OR: 0.62, 95% CI: 0.41-0.94, P =0.025). CONCLUSIONS ATs use is an independent protective factor against death in AUGIB. The protective effect is mainly derived from low-dose aspirin.
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Affiliation(s)
| | | | - Angelo Zullo
- Nuovo Regina Margherita Hospital, Gastroenterology and Digestive Endoscopy, Rome
| | - Marco Soncini
- Department of Internal Medicine, A. Manzoni Hospital, Lecco, Italy
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Grancher A, Michel P, Di Fiore F, Sefrioui D. Colorectal cancer chemoprevention: is aspirin still in the game? Cancer Biol Ther 2022; 23:446-461. [PMID: 35905195 PMCID: PMC9341367 DOI: 10.1080/15384047.2022.2104561] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Screening strategies have demonstrated their potential for decreasing the incidence and mortality of cancers, particularly that of colorectal cancer (CRC). Another strategy that has been developed to reduce CRC occurrence is the use of chemoprevention agents. Among them, aspirin is the most promising. Aspirin acts in colorectal tumourigenesis through several mechanisms, either directly in tumor cells or in their microenvironment, such as through its anti-inflammatory activity or its effect on the modulation of platelet function. Many retrospective studies, as well as follow-up of large cohorts from trials with primary cardiovascular end points, have shown that long-term treatment with daily low-dose aspirin decreases the incidence of adenomas and colorectal cancers. Therefore, aspirin is currently recommended by the United States Preventive Services Task Force (USPSTF) for primary prevention of CRC in all patients aged 50 to 59 with a 10-y risk of cardiovascular events greater than 10%. Furthermore, several studies have also reported that long-term aspirin treatment taking after CRC resection decreases recurrence risk and increases overall survival, especially in patients with PIK3CA-mutated tumors. This review summarizes current knowledge on the pathophysiological mechanisms of aspirin chemoprevention, discusses the primary clinical results on CRC prevention and highlights the potential biomarkers identified to predict aspirin efficacy.
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Affiliation(s)
- Adrien Grancher
- Normandy Centre for Genomic and Personalized Medicine and Department of Hepatogastroenterology, Normandie Univ, Iron Group, Rouen University Hospital, Rouen, France
| | - Pierre Michel
- Normandy Centre for Genomic and Personalized Medicine and Department of Hepatogastroenterology, Normandie Univ, Iron Group, Rouen University Hospital, Rouen, France
| | - Frederic Di Fiore
- Normandy Centre for Genomic and Personalized Medicine, Department of Hepatogastroenterology and Department of Medical Oncology, Henri Becquerel Centre, Normandie Univ, IRON group, Rouen University Hospital, Rouen, France
| | - David Sefrioui
- Normandy Centre for Genomic and Personalized Medicine and Department of Hepatogastroenterology, Normandie Univ, Iron Group, Rouen University Hospital, Rouen, France
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Elwood P, Protty M, Morgan G, Pickering J, Delon C, Watkins J. Aspirin and cancer: biological mechanisms and clinical outcomes. Open Biol 2022; 12:220124. [PMID: 36099932 PMCID: PMC9470249 DOI: 10.1098/rsob.220124] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Evidence on aspirin and cancer comes from two main sources: (1) the effect of aspirin upon biological mechanisms in cancer, and (2) clinical studies of patients with cancer, some of whom take aspirin. A series of systematic literature searches identified published reports relevant to these two sources. The effects of aspirin upon biological mechanisms involved in cancer initiation and growth appear to generate reasonable expectations of effects upon the progress and mortality of cancer. Clinical evidence on aspirin appears overall to be favourable to the use of aspirin, but evidence from randomized trials is limited, and inconsistent. The main body of evidence comes from meta-analyses of observational studies of patients with a wide range of cancers, about 25% of whom were taking aspirin. Heterogeneity is large but, overall, aspirin is associated with increases in survival and reductions in metastatic spread and vascular complications of different cancers. It is important that evaluations of aspirin used as an adjunct cancer treatment are based upon all the available relevant evidence, and there appears to be a marked harmony between the effects of aspirin upon biological mechanisms and upon the clinical progress of cancer.
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Affiliation(s)
- Peter Elwood
- Division of Population Medicine, University of Cardiff, Cardiff, Wales CF10 3AT, UK
| | - Majd Protty
- Department of Cardiology, Cardiff Lipidomic Group, University of Cardiff, Cardiff, Wales, UK
| | | | - Janet Pickering
- Division of Population Medicine, University of Cardiff, Cardiff, Wales CF10 3AT, UK
| | | | - John Watkins
- Division of Population Medicine, University of Cardiff, Cardiff, Wales CF10 3AT, UK
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10
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Kawaguchi K, Isomoto H. How can guidelines contribute to reducing "preventable" mortality in patients with upper gastrointestinal bleeding on antithrombotic drugs? Dig Endosc 2022; 34:738-740. [PMID: 35233834 DOI: 10.1111/den.14268] [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: 02/08/2023]
Affiliation(s)
- Koichiro Kawaguchi
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Hajime Isomoto
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Tottori, Japan
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11
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Dehmer SP, O'Keefe LR, Evans CV, Guirguis-Blake JM, Perdue LA, Maciosek MV. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Modeling Study for the US Preventive Services Task Force. JAMA 2022; 327:1598-1607. [PMID: 35471506 DOI: 10.1001/jama.2022.3385] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE The US Preventive Services Task Force (USPSTF) is updating its 2016 recommendation on the use of aspirin for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC). OBJECTIVE To provide updated model-based estimates of the net balance in benefits and harms from routine use of low-dose aspirin for primary prevention. DESIGN, SETTING, AND PARTICIPANTS Microsimulation modeling was used to estimate long-term benefits and harms for hypothetical US cohorts of men and women aged 40 to 79 years with up to 20% 10-year risk for an atherosclerotic CVD event and without prior history of CVD or elevated bleeding risks. EXPOSURES Low-dose (≤100 mg/d) aspirin for lifetime use, unless contraindicated by a bleeding event, and with stopping ages in 5-year intervals from age 65 to 85 years. MAIN OUTCOMES AND MEASURES Primary outcomes were lifetime net benefits measured in quality-adjusted life-years (QALYs) and life-years. Benefits included reduced nonfatal myocardial infarction and ischemic stroke. Harms included increased nonfatal major gastrointestinal bleeding and intracranial hemorrhage. Reduced CRC incidence was considered in sensitivity analysis. RESULTS Estimated lifetime net QALYs were positive for both men and women at 5% or greater 10-year CVD risk when starting between ages 40 and 59 years and at 10% or greater 10-year CVD risk when starting between ages 60 and 69 years. These estimates ranged from 2.3 (95% CI, -2.7 to 7.4) to 66.2 (95% CI, 58.2 to 74.1) QALYs per 1000 persons. Lifetime net life-years were positive for men at 5% or greater and women at 10% or greater 10-year CVD risk starting aspirin at ages 40 to 49 years and for men at 7.5% or greater and women at 15% or greater 10-year CVD risk at ages 50 to 59 years. These estimates ranged from 0.4 (95% CI, -6.1 to 6.9) to 52.4 (95% CI, 43.9 to 60.9) life-years per 1000 persons. Lifetime net life-years were negative in most cases for persons starting aspirin between ages 60 and 79 years, as were lifetime net QALYs for persons aged 70 to 79 years. Stopping aspirin between ages 65 and 85 years generally showed little advantage compared with lifetime use. Sensitivity analyses showed lifetime net benefits may be higher if aspirin reduced CRC incidence or CVD mortality and lower if aspirin increased fatal major gastrointestinal bleeding or reduced quality of life with routine use. CONCLUSIONS AND RELEVANCE This microsimulation study suggested that several population groups may benefit from taking aspirin for the primary prevention of CVD, primarily in persons starting at younger ages with higher 10-year CVD risk.
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Affiliation(s)
| | | | - Corinne V Evans
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Janelle M Guirguis-Blake
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
- Department of Family Medicine, University of Washington, Tacoma
| | - Leslie A Perdue
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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12
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The Use of Bioactive Compounds in Hyperglycemia- and Amyloid Fibrils-Induced Toxicity in Type 2 Diabetes and Alzheimer’s Disease. Pharmaceutics 2022; 14:pharmaceutics14020235. [PMID: 35213966 PMCID: PMC8879577 DOI: 10.3390/pharmaceutics14020235] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 12/29/2022] Open
Abstract
It has become increasingly apparent that defective insulin signaling may increase the risk for developing Alzheimer’s disease (AD), influence neurodegeneration through promotion of amyloid formation or by increasing inflammatory responses to intraneuronal β-amyloid. Recent work has demonstrated that hyperglycemia is linked to cognitive decline, with elevated levels of glucose causing oxidative stress in vulnerable tissues such as the brain. The ability of β-amyloid peptide to form β-sheet-rich aggregates and induce apoptosis has made amyloid fibrils a leading target for the development of novel pharmacotherapies used in managing and treatment of neuropathological conditions such as AD-related cognitive decline. Additionally, deposits of β-sheets folded amylin, a glucose homeostasis regulator, are also present in diabetic patients. Thus, therapeutic compounds capable of reducing intracellular protein aggregation in models of neurodegenerative disorders may prove useful in ameliorating type 2 diabetes mellitus symptoms. Furthermore, both diabetes and neurodegenerative conditions, such as AD, are characterized by chronic inflammatory responses accompanied by the presence of dysregulated inflammatory biomarkers. This review presents current evidence describing the role of various small bioactive molecules known to ameliorate amyloidosis and subsequent effects in prevention and development of diabetes and AD. It also highlights the potential efficacy of peptide–drug conjugates capable of targeting intracellular targets.
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13
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Mollace R, Gliozzi M, Macrì R, Tavernese A, Musolino V, Carresi C, Maiuolo J, Muscoli C, Tomino C, Rosano GM, Fini M, Volterrani M, Silvestrini B, Mollace V. Efficacy and Safety of Novel Aspirin Formulations: A Randomized, Double-Blind, Placebo-Controlled Study. Pharmaceutics 2022; 14:pharmaceutics14010187. [PMID: 35057084 PMCID: PMC8779026 DOI: 10.3390/pharmaceutics14010187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 01/17/2023] Open
Abstract
Low-dose aspirin represents the best option in the secondary prevention of coronary artery disease, but its extensive use in primary prevention is limited by the occurrence of gastric mucosal lesions and increased risk of bleeding. We investigated the safety profile of a novel sublingual aspirin formulation in 200 healthy volunteers, randomly assigned to ten (n = 20 each) different 7-day once-daily treatment regimens. Gastric mucosal injury based on the modified Lanza score (MLS), the histopathology of gastric mucosa and the serum determination of thromboxane B2 (TXB2) and urinary 11-dehydro-TXB2 levels were evaluated at basal as well as after 7 days of each placebo or aspirin treatment regimen. In Groups A and B (placebo—oral and sublingual, respectively), no changes in MLS and in gastric mucosal micro-vessel diameter were found at day 7. In contrast, in Groups C and D (oral standard aspirin—100 and 50 mg daily, respectively), the median MLS was significantly increased. Very few changes were found in Groups E and F (standard sublingual aspirin—100 and 50 mg, respectively). Groups G and H (oral administration of micronized collagen-cogrinded aspirin) showed gastric protection compared to Groups C and D. Moreover, Groups I and L (sublingual collagen-cogrinded aspirin—100 and 50 mg, respectively) showed a significant reduction (Group I) or total abolition (Group L) of gastric mucosal lesions and no difference compared to the standard one in serum TXB2 and urinary 11-dehydro-TXB2 levels. In conclusion, our data show that the new formulation leads to a better safety profile compared to standard aspirin, representing a better therapeutic option for extended use in primary and secondary prevention of cardiovascular diseases.
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Affiliation(s)
- Rocco Mollace
- Department of Health Science, Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (R.M.); (M.G.); (R.M.); (A.T.); (V.M.); (C.C.); (J.M.); (C.M.); (B.S.)
- IRCCS San Raffaele Pisana, Via di Valcannuta, 00163 Rome, Italy; (C.T.); (G.M.R.); (M.F.); (M.V.)
| | - Micaela Gliozzi
- Department of Health Science, Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (R.M.); (M.G.); (R.M.); (A.T.); (V.M.); (C.C.); (J.M.); (C.M.); (B.S.)
| | - Roberta Macrì
- Department of Health Science, Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (R.M.); (M.G.); (R.M.); (A.T.); (V.M.); (C.C.); (J.M.); (C.M.); (B.S.)
| | - Annamaria Tavernese
- Department of Health Science, Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (R.M.); (M.G.); (R.M.); (A.T.); (V.M.); (C.C.); (J.M.); (C.M.); (B.S.)
| | - Vincenzo Musolino
- Department of Health Science, Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (R.M.); (M.G.); (R.M.); (A.T.); (V.M.); (C.C.); (J.M.); (C.M.); (B.S.)
| | - Cristina Carresi
- Department of Health Science, Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (R.M.); (M.G.); (R.M.); (A.T.); (V.M.); (C.C.); (J.M.); (C.M.); (B.S.)
| | - Jessica Maiuolo
- Department of Health Science, Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (R.M.); (M.G.); (R.M.); (A.T.); (V.M.); (C.C.); (J.M.); (C.M.); (B.S.)
| | - Carolina Muscoli
- Department of Health Science, Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (R.M.); (M.G.); (R.M.); (A.T.); (V.M.); (C.C.); (J.M.); (C.M.); (B.S.)
- IRCCS San Raffaele Pisana, Via di Valcannuta, 00163 Rome, Italy; (C.T.); (G.M.R.); (M.F.); (M.V.)
| | - Carlo Tomino
- IRCCS San Raffaele Pisana, Via di Valcannuta, 00163 Rome, Italy; (C.T.); (G.M.R.); (M.F.); (M.V.)
| | - Giuseppe Maria Rosano
- IRCCS San Raffaele Pisana, Via di Valcannuta, 00163 Rome, Italy; (C.T.); (G.M.R.); (M.F.); (M.V.)
| | - Massimo Fini
- IRCCS San Raffaele Pisana, Via di Valcannuta, 00163 Rome, Italy; (C.T.); (G.M.R.); (M.F.); (M.V.)
| | - Maurizio Volterrani
- IRCCS San Raffaele Pisana, Via di Valcannuta, 00163 Rome, Italy; (C.T.); (G.M.R.); (M.F.); (M.V.)
| | - Bruno Silvestrini
- Department of Health Science, Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (R.M.); (M.G.); (R.M.); (A.T.); (V.M.); (C.C.); (J.M.); (C.M.); (B.S.)
| | - Vincenzo Mollace
- Department of Health Science, Institute of Research for Food Safety & Health IRC-FSH, University Magna Graecia, 88100 Catanzaro, Italy; (R.M.); (M.G.); (R.M.); (A.T.); (V.M.); (C.C.); (J.M.); (C.M.); (B.S.)
- IRCCS San Raffaele Pisana, Via di Valcannuta, 00163 Rome, Italy; (C.T.); (G.M.R.); (M.F.); (M.V.)
- Correspondence:
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14
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Wang Q, Morris RJ, Bode AM, Zhang T. Prostaglandin Pathways: Opportunities for Cancer Prevention and Therapy. Cancer Res 2021; 82:949-965. [PMID: 34949672 DOI: 10.1158/0008-5472.can-21-2297] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/27/2021] [Accepted: 12/17/2021] [Indexed: 11/16/2022]
Abstract
Because of profound effects observed in carcinogenesis, prostaglandins (PGs), prostaglandin-endoperoxide synthases, and PG receptors are implicated in cancer development and progression. Understanding the molecular mechanisms of PG actions has potential clinical relevance for cancer prevention and therapy. This review focuses on the current status of PG signaling pathways in modulating cancer progression and aims to provide insights into the mechanistic actions of PGs and their receptors in influencing tumor progression. We also examine several small molecules identified as having anticancer activity that target prostaglandin receptors. The literature suggests that targeting PG pathways could provide opportunities for cancer prevention and therapy.
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Affiliation(s)
- Qiushi Wang
- The Hormel Institute, University of Minnesota
| | | | - Ann M Bode
- The Hormel Institute, University of Minnesota
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15
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Carrier M, Blais N, Crowther M, Kavan P, Le Gal G, Moodley O, Shivakumar S, Suryanarayan D, Tagalakis V, Wu C, Lee AYY. Treatment Algorithm in Cancer-Associated Thrombosis: Updated Canadian Expert Consensus. Curr Oncol 2021; 28:5434-5451. [PMID: 34940092 DOI: 10.3390/curroncol28060453] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/02/2021] [Accepted: 12/13/2021] [Indexed: 12/20/2022] Open
Abstract
Patients with cancer-associated thrombosis (CAT) are at high risk of recurrent venous thromboembolism (VTE) and major bleeding complications. Risks vary significantly between individuals based on cancer status, treatment, and other characteristics. To facilitate the evidence-based management of anticoagulant therapy in this patient population, a committee of 11 Canadian clinical experts updated a consensus-based algorithm for the acute and extended treatment of symptomatic and incidental CAT that was developed in 2018. Following a systematic review of the literature, updates to the algorithm were discussed during an online teleconference, and the algorithm was subsequently refined based on feedback from committee members. Clinicians using this treatment algorithm should consider bleeding risk, type of cancer, and drug-drug interactions, as well as patient and clinician preferences, in tailoring anticoagulation for patients with CAT. Anticoagulant therapy should be adapted as the patient's cancer status and management change over time.
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Affiliation(s)
- Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | - Normand Blais
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC H2L 4M1, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON L8N 4A6, Canada
| | - Petr Kavan
- Department of Oncology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | - Otto Moodley
- Department of Hematology, Royal University Hospital, Saskatoon, SK S7N 0W8, Canada
| | - Sudeep Shivakumar
- Department of Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax, NS B3H 3A7, Canada
| | - Deepa Suryanarayan
- Department of Medicine, University of Calgary, Foothills Hospital, Calgary, AB T2N 2T9, Canada
| | - Vicky Tagalakis
- Department of Medicine, Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, QC H3T 1E2, Canada
| | - Cynthia Wu
- Department of Medicine, University of Alberta, Edmonton, AB T5J 2J7, Canada
| | - Agnes Y Y Lee
- Department of Medicine, University of British Columbia, British Columbia Cancer Agency, Vancouver, BC V5Z 4E6, Canada
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16
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Forgerini M, Urbano G, de Nadai TR, Batah SS, Fabro AT, Mastroianni PDC. Genetic Variants in PTGS1 and NOS3 Genes Increase the Risk of Upper Gastrointestinal Bleeding: A Case-Control Study. Front Pharmacol 2021; 12:671835. [PMID: 34290607 PMCID: PMC8287722 DOI: 10.3389/fphar.2021.671835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/04/2021] [Indexed: 12/23/2022] Open
Abstract
Objective: To assess the association between PTGS1 and NOS3 variant alleles and the risk to develop upper gastrointestinal bleeding (UGIB) secondary to complicated peptic disease. Methods: A case-control study was conducted in a Brazilian complex hospital from July 2016 to March 2020. Case: Patients with UGIB diagnosis. Control: Patients admitted for surgery not related to gastrointestinal disorders. Variables: UGIB (outcome), genetic variants in PTGS1 and NOS3 genes (independent), and sex, age, schooling, ethnicity, previous history of gastrointestinal disorders, Helicobacter pylori serology, comorbidity, drug therapy, and lifestyle (confounding). The single-nucleotide polymorphisms (SNPs) of the PTSG1 gene (rs1330344, rs3842787, rs10306114, and rs5788) and NOS3 gene (rs2070744 and rs1799983) were determined using the real-time polymerase chain reaction. Helicobacter pylori serology was determined through the chemiluminescence technique. Logistic regression models were built and deviations of allelic frequencies from Hardy-Weinberg equilibrium were verified. Results: 200 cases and 706 controls were recruited. Carriers of the AG genotype of rs10306114 (OR: 2.55, CI 95%: 1.13-5.76) and CA + AA genotypes of rs5788 (OR: 2.53, CI 95%: 1.14-5.59) were associated with an increased risk for the UGIB development. In nonsteroidal anti-inflammatory drugs (NSAIDs) users, the six variants evaluated modified the magnitude of the risk of UGIB, whereas in low-dose aspirin (LDA) users, an increased risk of UGIB was observed for four of them (rs1330344, rs10306114, rs2070744, and rs1799983). Personal ulcer history (p-value: < 0.001); Helicobacter pylori infection (p-value: < 0.011); NSAIDs, LDA, and oral anticoagulant use (p-value: < 0.001); and alcohol intake (p-value: < 0.001) were also identified as independent risk factors for UGIB. Conclusion: This study presents two unprecedented analyses within the scope of the UGIB (rs10306114 and rs2070744), and our findings showing an increased risk of UGIB in the presence of the genetic variants rs10306114 and rs5788, regardless of the drug exposure. Besides, the presence of the evaluated variants might modify the magnitude of the risk of UGIB in LDA/NSAIDs users. Therefore, our data suggest the need for a personalized therapy and drug use monitoring in order to promote patient safety.
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Affiliation(s)
- Marcela Forgerini
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, Brazil
| | - Gustavo Urbano
- Department of Surgery, School of Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Tales Rubens de Nadai
- Department of Public Health, Bauru School of Dentistry, University of São Paulo (USP), Bauru, Brazil
| | - Sabrina Setembre Batah
- Department of Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Alexandre Todorovic Fabro
- Department of Pathology and Legal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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17
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Elwood PC, Morgan G, Delon C, Protty M, Galante J, Pickering J, Watkins J, Weightman A, Morris D. Aspirin and cancer survival: a systematic review and meta-analyses of 118 observational studies of aspirin and 18 cancers. Ecancermedicalscience 2021; 15:1258. [PMID: 34567243 PMCID: PMC8426031 DOI: 10.3332/ecancer.2021.1258] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Despite the accumulation of research papers on aspirin and cancer, there is doubt as to whether or not aspirin is an acceptable and effective adjunct treatment of cancer. The results of several randomised trials are awaited, and these should give clear evidence on three common cancers: colon, breast and prostate. The biological effects of aspirin appear likely however to be of relevance to cancer generally, and to metastatic spread, rather than just to one or a few cancers, and there is already a lot of evidence, mainly from observational studies, on the association between aspirin and survival in a wide range of cancers. AIMS In order to test the hypothesis that aspirin taking is associated with an increase in the survival of patients with cancer, we conducted a series of systematic literature searches to identify clinical studies of patients with cancer, some of whom took aspirin after having received a diagnosis of cancer. RESULTS Three literature searches identified 118 published observational studies in patients with 18 different cancers. Eighty-one studies report on aspirin and cancer mortality and 63 studies report on all-cause mortality. Within a total of about a quarter of a million patients with cancer who reported taking aspirin, representing 20%-25% of the total cohort, we found aspirin to be associated with a reduction of about 20% in cancer deaths (pooled hazard ratio (HR): 0.79; 95% confidence intervals: 0.73, 0.84 in 70 reports and a pooled odds ratio (OR): 0.67; 0.45, 1.00 in 11 reports) with similar reductions in all-cause mortality (HR: 0.80; 0.74, 0.86 in 56 studies and OR: 0.57; 0.36, 0.89 in seven studies). The relative safety of aspirin taking was examined in the studies and the corresponding author of every paper was written to asking for additional information on bleeding. As expected, the frequency of bleeding increased in the patients taking aspirin, but fatal bleeding was rare and no author reported a significant excess in fatal bleeds associated with aspirin. No author mentioned cerebral bleeding in the patients they had followed. CONCLUSIONS There is a considerable body of evidence suggestive of about a 20% reduction in mortality in patients with cancer who take aspirin, and the benefit appears not to be restricted to one or a few cancers. Aspirin, therefore, appears to deserve serious consideration as an adjuvant treatment of cancer, and patients with cancer, and their carers, have a right to be informed of the available evidence.
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Affiliation(s)
- Peter C Elwood
- Division of Population Medicine, Cardiff University, Cardiff CF14 4XN, UK
| | - Gareth Morgan
- Division of Population Medicine, Cardiff University, Cardiff CF14 4XN, UK
| | | | - Majd Protty
- Cardiff Lipidomics Group, Cardiff University, UK
| | - Julieta Galante
- University of Cambridge, Cambridge, UK
- National Institute for Health Research (NIHR) Applied Research Collaboration East of England, Cambridge, UK
| | - Janet Pickering
- Division of Population Medicine, Cardiff University, Cardiff CF14 4XN, UK
| | - John Watkins
- Division of Population Medicine, Cardiff University, Cardiff CF14 4XN, UK
- Public Health Wales, Cardiff, UK
| | - Alison Weightman
- Specialist Unit for Review Evidence, Cardiff University, Cardiff, UK
| | - Delyth Morris
- University Library Service, Cardiff University, Cardiff, UK
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18
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Siwik D, Gajewska M, Karoń K, Pluta K, Wondołkowski M, Wilimski R, Szarpak Ł, Filipiak KJ, Gąsecka A. Pleiotropic Effects of Acetylsalicylic Acid after Coronary Artery Bypass Grafting-Beyond Platelet Inhibition. J Clin Med 2021; 10:2317. [PMID: 34073241 PMCID: PMC8198192 DOI: 10.3390/jcm10112317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 01/05/2023] Open
Abstract
Acetylsalicylic acid (ASA) is one of the most frequently used medications worldwide. Yet, the main indications for ASA are the atherosclerosis-based cardiovascular diseases, including coronary artery disease (CAD). Despite the increasing number of percutaneous procedures to treat CAD, coronary artery bypass grafting (CABG) remains the treatment of choice in patients with multivessel CAD and intermediate or high anatomical lesion complexity. Taking into account that CABG is a potent activator of inflammation, ASA is an important part in the postoperative therapy, not only due to ASA antiplatelet action, but also as an anti-inflammatory agent. Additional benefits of ASA after CABG include anticancerogenic, hypotensive, antiproliferative, anti-osteoporotic, and neuroprotective effects, which are especially important in patients after CABG, prone to hypertension, graft occlusion, atherosclerosis progression, and cognitive impairment. Here, we discuss the pleiotropic effects of ASA after CABG and provide insights into the mechanisms underlying the benefits of treatment with ASA, beyond platelet inhibition. Since some of ASA pleiotropic effects seem to increase the risk of bleeding, it could be considered a starting point to investigate whether the increase of the intensity of the treatment with ASA after CABG is beneficial for the CABG group of patients.
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Affiliation(s)
- Dominika Siwik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland; (D.S.); (M.G.); (K.K.); (K.P.); (K.J.F.)
| | - Magdalena Gajewska
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland; (D.S.); (M.G.); (K.K.); (K.P.); (K.J.F.)
| | - Katarzyna Karoń
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland; (D.S.); (M.G.); (K.K.); (K.P.); (K.J.F.)
| | - Kinga Pluta
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland; (D.S.); (M.G.); (K.K.); (K.P.); (K.J.F.)
| | - Mateusz Wondołkowski
- Department of Cardiac Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.W.); (R.W.)
| | - Radosław Wilimski
- Department of Cardiac Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland; (M.W.); (R.W.)
| | - Łukasz Szarpak
- Bialystok Oncology Center, 15-027 Bialystok, Poland;
- Maria Sklodowska-Curie Medical Academy in Warsaw, 00-001 Warsaw, Poland
| | - Krzysztof J. Filipiak
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland; (D.S.); (M.G.); (K.K.); (K.P.); (K.J.F.)
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland; (D.S.); (M.G.); (K.K.); (K.P.); (K.J.F.)
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19
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Galusko V, Protty M, Haboubi HN, Verhemel S, Bundhoo S, Yeoman AD. Endoscopy findings in patients on dual antiplatelet therapy following percutaneous coronary intervention. Postgrad Med J 2021; 98:591-597. [PMID: 33879553 DOI: 10.1136/postgradmedj-2021-139928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE OF STUDY This study examines the associations between dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) and gastrointestinal bleeding (GIB), to explore possible predictors of outcomes. STUDY DESIGN Retrospective analysis of 3342 patients who underwent PCI between 1 August 2011 and 31 December 2018 in a single centre was carried out. Oesophagogastroduodenoscopies (OGDs) for patients 12 months post-PCI were analysed. RESULTS Blood loss occurred in 2% of all (3342) patients post-PCI within 12 months. 128 patients (63% male, mean age (SD) of 69.8 (10) years) who had PCI subsequently underwent an OGD within 12 months of the index PCI procedure. GIB occurred within the first 30 days of DAPT in 36% (n=13/36) of cases. There were no thrombotic events associated with cessation of one antiplatelet agent. Increased age, haemoglobin (Hb) ≤109 g/L and Glasgow-Blatchford score ≥8 were associated with increased 12-month mortality. An Hb drop of ≥30 g/L was a sensitive and specific marker for significant pathology and evidence of bleeding on OGD (sensitivity=0.83, specificity=0.81). CONCLUSIONS GIB bleeding occurred infrequently in the patients post-PCI on DAPT. Risk assessment scores (such as Glasgow-Blatchford and Rockall scores) are useful tools to assess the urgency of OGD and need for endoscopic therapy.
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Affiliation(s)
- Victor Galusko
- Department of Cardiology, Royal Gwent Hospital, Newport, UK
| | - Majd Protty
- Department of Cardiology, Royal Gwent Hospital, Newport, UK.,Systems Immunity University Research Institute, Cardiff University, Cardiff, UK
| | - Hasan N Haboubi
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Sarah Verhemel
- Department of Cardiology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Shantu Bundhoo
- Department of Cardiology, Royal Gwent Hospital, Newport, UK
| | - Andrew D Yeoman
- Department of Gastroenterology, Royal Gwent Hospital, Newport, UK
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20
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Kamada T, Satoh K, Itoh T, Ito M, Iwamoto J, Okimoto T, Kanno T, Sugimoto M, Chiba T, Nomura S, Mieda M, Hiraishi H, Yoshino J, Takagi A, Watanabe S, Koike K. Evidence-based clinical practice guidelines for peptic ulcer disease 2020. J Gastroenterol 2021; 56:303-322. [PMID: 33620586 PMCID: PMC8005399 DOI: 10.1007/s00535-021-01769-0] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/03/2021] [Indexed: 02/05/2023]
Abstract
The Japanese Society of Gastroenterology (JSGE) revised the third edition of evidence-based clinical practice guidelines for peptic ulcer disease in 2020 and created an English version. The revised guidelines consist of nine items: epidemiology, hemorrhagic gastric and duodenal ulcers, Helicobacter pylori (H. pylori) eradication therapy, non-eradication therapy, drug-induced ulcers, non-H. pylori, and nonsteroidal anti-inflammatory drug (NSAID) ulcers, remnant gastric ulcers, surgical treatment, and conservative therapy for perforation and stenosis. Therapeutic algorithms for the treatment of peptic ulcers differ based on ulcer complications. In patients with NSAID-induced ulcers, NSAIDs are discontinued and anti-ulcer therapy is administered. If NSAIDs cannot be discontinued, the ulcer is treated with proton pump inhibitors (PPIs). Vonoprazan (VPZ) with antibiotics is recommended as the first-line treatment for H. pylori eradication, and PPIs or VPZ with antibiotics is recommended as a second-line therapy. Patients who do not use NSAIDs and are H. pylori negative are considered to have idiopathic peptic ulcers. Algorithms for the prevention of NSAID- and low-dose aspirin (LDA)-related ulcers are presented in this guideline. These algorithms differ based on the concomitant use of LDA or NSAIDs and ulcer history or hemorrhagic ulcer history. In patients with a history of ulcers receiving NSAID therapy, PPIs with or without celecoxib are recommended and the administration of VPZ is suggested for the prevention of ulcer recurrence. In patients with a history of ulcers receiving LDA therapy, PPIs or VPZ are recommended and the administration of a histamine 2-receptor antagonist is suggested for the prevention of ulcer recurrence.
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Affiliation(s)
- Tomoari Kamada
- Department of Health Care Medicine, Kawasaki Medical School General Medical Center, 2-6-1, Nakasange, Kita-ku, Okayama, 700-8505, Japan.
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan.
| | - Kiichi Satoh
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshiyuki Itoh
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Masanori Ito
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Junichi Iwamoto
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Tadayoshi Okimoto
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Takeshi Kanno
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Mitsushige Sugimoto
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Toshimi Chiba
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Sachiyo Nomura
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Mitsuyo Mieda
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Hideyuki Hiraishi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Junji Yoshino
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Atsushi Takagi
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Sumio Watanabe
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
| | - Kazuhiko Koike
- Guidelines Committee for Creating and Evaluating the ''Evidence-Based Clinical Practice Guidelines for Peptic Ulcer," the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6-2 Shimbashi, Minato-ku, Tokyo, 105-0004, Japan
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21
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 390] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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22
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Xie S, Wang Y, Huang Y, Yang B. Mechanisms of the antiangiogenic effects of aspirin in cancer. Eur J Pharmacol 2021; 898:173989. [PMID: 33657423 DOI: 10.1016/j.ejphar.2021.173989] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 02/14/2021] [Accepted: 02/22/2021] [Indexed: 01/04/2023]
Abstract
Aspirin is an old drug extracted from willow bark and is widely used for the prevention and treatment of cardiovascular diseases. Accumulating evidence has shown that aspirin use may significantly reduce the angiogenesis of cancer; however, the mechanism of the association between angiogenesis and aspirin is complex. Although COX-1 is widely known as a target of aspirin, several studies reveal other antiangiogenic targets of aspirin, such as angiotensin II, glucose transporter 1, heparanase, and matrix metalloproteinase. In addition, some data indicates that aspirin may produce antiangiogenic effects after acting in different cell types, such as endothelial cells, platelets, pericytes, and macrophages. In this review, we concentrate on research regarding the antiangiogenic effects of aspirin in cancer, and we discuss the molecular mechanisms of aspirin and its metabolites. Moreover, we discuss some mechanisms through which aspirin treatment may normalize existing blood vessels, including preventing the disintegration of endothelial adheres junctions and the recruitment of pericytes. We also address the antiangiogenic effects and the underlying mechanisms of aspirin derivatives, which are aimed at improving safety and efficacy.
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Affiliation(s)
- Shiyuan Xie
- College of Pharmacy, Guangxi Medical University, Nanning, 530021, Guangxi, PR China
| | - Youqiong Wang
- College of Pharmacy, Guangxi Medical University, Nanning, 530021, Guangxi, PR China
| | - Yixuan Huang
- College of Pharmacy, Guangxi Medical University, Nanning, 530021, Guangxi, PR China
| | - Bin Yang
- College of Pharmacy, Guangxi Medical University, Nanning, 530021, Guangxi, PR China.
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23
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Forgerini M, Lucchetta RC, Urbano G, de Nadai TR, de Carvalho Mastroianni P. Genetic polymorphisms associated with upper gastrointestinal bleeding: a systematic review. THE PHARMACOGENOMICS JOURNAL 2021; 21:20-36. [PMID: 32948830 DOI: 10.1038/s41397-020-00185-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/17/2020] [Accepted: 09/08/2020] [Indexed: 02/07/2023]
Abstract
Non-variceal upper gastrointestinal bleeding (non-variceal UGIB) is a frequent and severe adverse drug reaction. Idiosyncratic responses due to genetic susceptibility to non-variceal UGIB has been suggested. A systematic review was conducted to assess the association between genetic polymorphisms and non-variceal UGIB. Twenty-one publications and 7134 participants were included. Thirteen studies evaluated genetic polymorphism in patients exposed to non-steroidal anti-inflammatory drugs, low-dose aspirin, and warfarin. Eight studies present at least one methodological problem. Only six studies clearly defined that the outcome evaluated was non-variceal UGIB. Genetic polymorphisms involved in platelet activation and aggregation, angiogenesis, inflammatory process, and drug metabolism were associated with risk of non-variceal UGIB (NOS3, COX-1; COX-2; PLA2G7; GP1BA; GRS; IL1RN; F13A1; CDKN2B-AS1; DPP6; TBXA2R; TNF-alpha; VKORC1; CYP2C9; and AGT). Further well-designed studies are needed (e.g., clear restriction to non-variceal UGIB; proper selection of participants; and adjustment of confounding factors) to provide strong evidence for pharmacogenetic and personalized medicine.
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Affiliation(s)
- Marcela Forgerini
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, Brazil
| | - Rosa Camila Lucchetta
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, Brazil
| | - Gustavo Urbano
- Department of Surgery, School of Medicine, University of São Paulo (USP), Ribeirão Preto, Brazil
| | - Tales Rubens de Nadai
- Department of Public Health, Bauru School of Dentistry, University of São Paulo (USP), Bauru, Brazil
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24
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Saiz Ladera GM, Pejenaute Labari ME, García Pascual JN. [Updating in prescription of proton pump inhibitors. What to do and what not to do]. Semergen 2020; 47:267-279. [PMID: 33223372 DOI: 10.1016/j.semerg.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/22/2020] [Accepted: 09/29/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) are the most prescribed pharmacological subgroup of the National Health System and their use has been related to possible potentially serious adverse effects. OBJECTIVE To review the current indications for treatment with PPIs as well as the data related to their safety, in order to promote their adecuate use. MATERIAL AND METHODS A review of the literature focused on the following topics has been carried out: a) molecules and mechanism of action; b) current indications for treatment and adherence to them; c) adverse effects related to its use; d) drug interactions; e) alternatives in deprescription. RESULTS The current indications have not changed substantially in recent years and are well established, however, there is a high percentage of inappropriate prescription, mainly in individuals with low or no risk. CONCLUSIONS PPIs are safe drugs and generally well tolerated and their benefits are higher than possible adverse effects. Adhering to evidence-based recommendations represents the only rational approach to safe and effective therapy.
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Affiliation(s)
- G M Saiz Ladera
- Medicina de Familia, Centro de Salud Panaderas, Fuenlabrada (Madrid), España.
| | | | - J N García Pascual
- Medicina de Familia, Centro de Salud Arganda del Rey, Arganda del Rey (Madrid), España
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25
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Kanno T, Moayyedi P. Who Needs Gastroprotection in 2020? CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2020; 18:557-573. [PMID: 33199955 PMCID: PMC7656506 DOI: 10.1007/s11938-020-00316-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 02/07/2023]
Abstract
Purpose of review Peptic ulcer disease (PUD) is a recognized complication of non-steroidal anti-inflammatory drugs (NSAIDs). Stress ulcers are a concern for intensive care unit (ICU) patients; PUD is also an issue for patients taking anticoagulation. Helicobacter pylori test and treat is an option for patients starting NSAID therapy, and proton pump inhibitors (PPIs) may reduce PUD in NSAID patients and other high-risk groups. Recent findings There are a large number of trials that demonstrate that Helicobacter pylori eradication reduces PUD in NSAID patients. PPI is also effective at reducing PUD in this group and is also effective in ICU patients and those on anticoagulants. The effect is too modest for PPI to be recommended in everyone, and more research is needed as to which groups would benefit the most. Increasing age, past history of PUD, and comorbidity are the most important risk factors. Summary H. pylori test and treat should be offered to older patients starting NSAIDS, while PPIs should be prescribed to patients that are at high risk of developing PUD and at risk of dying from PUD complications.
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Affiliation(s)
- Takeshi Kanno
- Division of Gastroenterology, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575 Japan
- Farncombe Family Digestive Health Institute, McMaster University, Hamilton, Ontario Canada
| | - Paul Moayyedi
- Farncombe Family Digestive Health Institute, McMaster University, Hamilton, Ontario Canada
- Audrey Campbell Chair of Ulcerative Colitis Research, Division of Gastroenterology, Department of Medicine, McMaster University, 1280 Main St. W. HSC 3V3, Hamilton, ON L8S 4K1 Canada
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Abstract
High-quality evidence indicates that regular use of aspirin is effective in reducing the risk for precancerous colorectal neoplasia and colorectal cancer (CRC). This has led to US and international guidelines recommending aspirin for the primary prevention of CRC in specific populations. In this review, we summarize key questions that require addressing prior to broader adoption of aspirin-based chemoprevention, review recent evidence related to the benefits and harms of aspirin use among specific populations, and offer a rationale for precision prevention approaches. We specifically consider the mechanistic implications of evidence showing differences in aspirin's effects according to age, the potential role of modifiable mechanistic biomarkers for personalizing prevention, and emerging evidence that the gut microbiota may offer novel aspirin-associated preventive targets to reduce high-risk neoplasia.
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Affiliation(s)
- David A Drew
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA; ,
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA; , .,Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, Massachusetts 02114, USA.,Broad Institute of MIT and Harvard, Cambridge, Massachusetts 02142, USA
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27
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Bouget J, Viglino D, Yvetot Q, Oger E. Major gastrointestinal bleeding and antithrombotics: Characteristics and management. World J Gastroenterol 2020; 26:5463-5473. [PMID: 33024397 PMCID: PMC7520611 DOI: 10.3748/wjg.v26.i36.5463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/30/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There are few reports on major gastrointestinal (GI) bleeding among patients receiving an antithrombotic.
AIM To describe clinical characteristics, bleeding locations, management and in-hospital mortality related to these events.
METHODS Over a three-year period, we prospectively identified 1080 consecutive adult patients admitted in two tertiary care hospitals between January 1, 2013 and December 31, 2015 for major GI bleeding while receiving an antithrombotic. The bleeding events were medically validated. Clinical characteristics, causative lesions, management and fatalities were described. The distribution of antithrombotics prescribed was compared across the bleeding lesions identified.
RESULTS Of 576 patients had symptoms of upper GI bleeding and 504 symptoms of lower GI bleeding. No cause was identified for 383 (35.5%) patients. Gastro-duodenal ulcer was the first causative lesion in the upper tract (209 out of 408) and colonic diverticulum the first causative lesion in the lower tract (120 out of 289). There was a larger proportion of direct oral anticoagulant use among patients with lower GI than among those with upper GI lesion locations (P = 0.03). There was an independent association between gastro-duodenal ulcer and antithrombotic use (P = 0.03), taking account of confounders and proton pump inhibitor co-prescription. Pair wise comparisons pointed to a difference between vitamin K antagonist, direct oral anticoagulants, and antiplatelet agents in monotherapy vs dual antiplatelet agents.
CONCLUSION We showed a higher rate of bleeding lesion identification and suggested a different pattern of antithrombotic exposure between upper and lower GI lesion locations and between gastro-duodenal ulcer and other identified upper GI causes of bleeding. Management was similar across antithrombotics and in-hospital mortality was low (5.95%).
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Affiliation(s)
- Jacques Bouget
- EA 7449 REPERES, Pharmacoepidemiology and Health Services Research, Univ Rennes, Rennes 35000, France
| | - Damien Viglino
- Emergency Department and Mobile Intensive Care Unit-HP2 Laboratory INSERM U1042, University Grenoble Alps, La Tronche 38700, France
| | | | - Emmanuel Oger
- EA 7449 REPERES, Université de Rennes 1, Rennes 35000, France
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28
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Gelbenegger G, Postula M, Pecen L, Halvorsen S, Lesiak M, Schoergenhofer C, Jilma B, Hengstenberg C, Siller-Matula JM. Aspirin for primary prevention of cardiovascular disease: a meta-analysis with a particular focus on subgroups. BMC Med 2019; 17:198. [PMID: 31679516 PMCID: PMC6827248 DOI: 10.1186/s12916-019-1428-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The role of aspirin in primary prevention of cardiovascular disease (CVD) remains unclear. We aimed to investigate the benefit-risk ratio of aspirin for primary prevention of CVD with a particular focus on subgroups. METHODS Randomized controlled trials comparing the effects of aspirin for primary prevention of CVD versus control and including at least 1000 patients were eligible for this meta-analysis. The primary efficacy outcome was all-cause mortality. Secondary outcomes included cardiovascular mortality, major adverse cardiovascular events (MACE), myocardial infarction, ischemic stroke, and net clinical benefit. The primary safety outcome was major bleeding. Subgroup analyses involving sex, concomitant statin treatment, diabetes, and smoking were performed. RESULTS Thirteen randomized controlled trials comprising 164,225 patients were included. The risk of all-cause and cardiovascular mortality was similar for aspirin and control groups (RR 0.98; 95% CI, 0.93-1.02; RR 0.99; 95% CI, 0.90-1.08; respectively). Aspirin reduced the relative risk (RRR) of major adverse cardiovascular events (MACE) by 9% (RR 0.91; 95% CI, 0.86-0.95), myocardial infarction by 14% (RR 0.86; 95% CI, 0.77-0.95), and ischemic stroke by 10% (RR 0.90; 95% CI, 0.82-0.99), but was associated with a 46% relative risk increase of major bleeding events (RR 1.46; 95% CI, 1.30-1.64) compared with controls. Aspirin use did not translate into a net clinical benefit adjusted for event-associated mortality risk (mean 0.034%; 95% CI, - 0.18 to 0.25%). There was an interaction for aspirin effect in three patient subgroups: (i) in patients under statin treatment, aspirin was associated with a 12% RRR of MACE (RR 0.88; 95% CI, 0.80-0.96), and this effect was lacking in the no-statin group; (ii) in non-smokers, aspirin was associated with a 10% RRR of MACE (RR 0.90; 95% CI, 0.82-0.99), and this effect was not present in smokers; and (iii) in males, aspirin use resulted in a 11% RRR of MACE (RR 0.89; 95% CI, 0.83-0.95), with a non-significant effect in females. CONCLUSIONS Aspirin use does not reduce all-cause or cardiovascular mortality and results in an insufficient benefit-risk ratio for CVD primary prevention. Non-smokers, patients treated with statins, and males had the greatest risk reduction of MACE across subgroups. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019118474.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Marek Postula
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Ladislav Pecen
- Institute of Computer Science of Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Jolanta M Siller-Matula
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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29
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Kitay AM, Ferstl FS, Link A, Geibel JP. Induction of Secretagogue Independent Gastric Acid Secretion via a Novel Aspirin-Activated Pathway. Front Physiol 2019; 10:1264. [PMID: 31649553 PMCID: PMC6795678 DOI: 10.3389/fphys.2019.01264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 09/17/2019] [Indexed: 12/21/2022] Open
Abstract
Aspirin has been widely recommended for acute and chronic conditions for over 2,000 years. Either single or repetitive doses are commonly used for analgesic and antipyretic reasons and to prevent heart attacks, stroke, and blood clot formation. Recent studies show that it can also be used chronically to dramatically reduce the risk of a variety of cancers. However, prolonged usage of aspirin can cause severe damage to the mucosal barrier, increasing the risk of ulcer formation and GI-bleeding events. In the present study, we show the effects of acute low-dose aspirin exposure as an active secretagogue-inducing gastric acid secretion. Studies were carried out with isolated gastric glands using the pH-sensitive dye BCECF-AM to assess acid secretion. The non-selective NOS inhibitor L-NAME (30 μM), or the specific inhibitor ODQ (1H-[1,2,4]Oxadiazolo[4,3-a]quinoxalin-1-one) was applied while monitoring intracellular pH. The effects of basolateral exposure to aspirin (acetylsalicylic acid, ASA) caused activation of gastric acid secretion via the H+, K+-ATPase. Our data suggest that aspirin increases nitric oxide (NO) production, which in turn activates acid secretion. Exposure of gastric glands to either the non-selective NOS inhibitor L-NAME, and the highly selective, soluble guanylyl cyclase inhibitor 1H-[1,2,4]Oxadiazolo[4,3-a]quinoxalin-1-one (ODQ) effectively inhibited aspirin-dependent gastric acid secretion. Aspirin can be considered as a novel secretagogue, in the way that it activates the H+, K+-ATPase. With increased daily aspirin consumption, our findings have important implications for all individuals consuming aspirin even in low doses and the potential risks for increased acid secretion.
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Affiliation(s)
- Alice Miriam Kitay
- Department of Surgery, School of Medicine, Yale University, New Haven, CT, United States.,Department of Internal Medicine, Medical Faculty University Hospital, Otto-von-Guericke University, Magdeburg, Germany
| | | | - Alexander Link
- Department of Internal Medicine, Medical Faculty University Hospital, Otto-von-Guericke University, Magdeburg, Germany
| | - John Peter Geibel
- Department of Surgery, School of Medicine, Yale University, New Haven, CT, United States.,Department of Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, CT, United States
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Cervino G, Fiorillo L, Monte IP, De Stefano R, Laino L, Crimi S, Bianchi A, Herford AS, Biondi A, Cicciù M. Advances in Antiplatelet Therapy for Dentofacial Surgery Patients: Focus on Past and Present Strategies. MATERIALS (BASEL, SWITZERLAND) 2019; 12:E1524. [PMID: 31075947 PMCID: PMC6540095 DOI: 10.3390/ma12091524] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Nowadays, patients involved in antiplatelet therapy required special attention during oral surgery procedures, due to the antiplatelet drugs assumption. The motivations of the assumption may be different and related to the patient's different systemic condition. For this reason, accordingly to the current international guidelines, different protocols can be followed. The aim of this work is to analyze how the dentist's approach to these patients has changed from the past to the present, evaluating the risk exposure for the patients. METHODS This review paper considered different published papers in literature through quoted scientific channels, going in search of "ancient" works in such a way as to highlight the differences in the protocols undertaken. The analyzed manuscripts are in the English language, taking into consideration reviews, case reports, and case series in such a way as to extrapolate a sufficient amount of data and for evaluating the past therapeutic approaches compared to those of today. RESULTS Colleagues in the past preferred to subject patients to substitution therapy with low molecular weight anticoagulants, by suspending antiplatelet agents to treatment patients, often for an arbitrary number of days. The new guidelines clarify everything, without highlighting an increased risk of bleeding during simple oral surgery in patients undergoing antiplatelet therapy. CONCLUSION Either patients take these medications for different reasons, because of cardiovascular pathologies, recent cardiovascular events, or even for simple prevention, although the latest research shows that there is no decrease of cardiovascular accidents in patients who carry out preventive therapy. Surely, it will be at the expense of the doctor to assess the patient's situation and risk according to the guidelines. For simple oral surgery, it is not necessary to stop therapy with antiplatelet agents because the risk of bleeding has not increased, and is localized to a post-extraction alveolus or to an implant preparation, compared to patients who do not carry out this therapy. From an analysis of the results it emerges that the substitutive therapy should no longer be performed and that it is possible to perform oral surgery safely in patients who take antiplatelet drugs, after a thorough medical history. Furthermore, by suspending therapy, we expose our patients to more serious risks, concerning their main pathology, where present.
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Affiliation(s)
- Gabriele Cervino
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, Messina University, 98100 Messina ME, Italy.
| | - Luca Fiorillo
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, Messina University, 98100 Messina ME, Italy.
- Multidisciplinary Department of Medical-Surgical and Odontostomatological Specialties, University of Campania "Luigi Vanvitelli", 80121 Naples, Italy.
| | - Ines Paola Monte
- Department of General Surgery and Medical-Surgery Specialities, University of Catania, 95100 Catania CT, Italy.
| | - Rosa De Stefano
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, Messina University, 98100 Messina ME, Italy.
| | - Luigi Laino
- Multidisciplinary Department of Medical-Surgical and Odontostomatological Specialties, University of Campania "Luigi Vanvitelli", 80121 Naples, Italy.
| | - Salvatore Crimi
- Department of General Surgery and Medical-Surgery Specialities, University of Catania, 95100 Catania CT, Italy.
| | - Alberto Bianchi
- Department of General Surgery and Medical-Surgery Specialities, University of Catania, 95100 Catania CT, Italy.
| | - Alan Scott Herford
- Department of Maxillofacial Surgery, Loma Linda University, Loma Linda, CA 92354, USA.
| | - Antonio Biondi
- Department of General Surgery and Medical-Surgery Specialities, University of Catania, 95100 Catania CT, Italy.
| | - Marco Cicciù
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, Messina University, 98100 Messina ME, Italy.
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Does low-dose aspirin use for cardiovascular disease prevention reduce colorectal cancer deaths? A comparison of two cohorts in the Florence district, Italy. Eur J Cancer Prev 2019; 27:134-139. [PMID: 27845951 DOI: 10.1097/cej.0000000000000319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Aspirin has been associated with reduced incidence and mortality of colorectal and a few other cancers. The aim of our paper was to study the effect of low-dose aspirin intake on cancer mortality in a population-based cohort study. The study included inhabitants of the Florence district (Italy) at the beginning of 2007. We considered two cohorts: patients who received prescriptions of low-dose aspirin for the whole year and patients who did not have any prescriptions over the same period. We followed the two cohorts until 31 December 2013. By linking with the Tuscany Mortality Registry, we analysed cause-specific mortality. We used a Cox semiparametric model to compare the mortality of the two cohorts. There was an 18% higher probability [hazard ratio (HR)=1.18, 95% confidence interval (CI): 1.12-1.23] for all causes of death among the cohort of aspirin users, almost completely caused by cardiovascular diseases (CVDs) (HR=1.39, 95% CI: 1.29-1.49). Colorectal cancer mortality was reduced by almost 30% (HR=0.71, 95% CI: 0.52-0.97). Death caused by major bleeding was 11% higher (HR=1.11, 95% CI: 0.86-1.44), but not statistically significant. Our results support the hypothesis that the use of low-dose aspirin for CVD prevention reduces colorectal cancer mortality. Given the growing ability to identify subgroups of individuals with an increased risk of developing cancer, further studies are needed to study the effectiveness of different cancer screening strategies tailored to these specific subgroups. Our study suggests the importance of focusing on this issue from the opposite perspective, that is, considering subgroups of individuals at decreased risk, such as the subgroup of individuals who take low-dose aspirin for CVD prevention. Thus, further assessments are needed to possibly identify subgroup-specific screening strategies that would be more effective than those developed for average-risk individuals.
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Resolution of Gastric Cancer-Promoting Inflammation: A Novel Strategy for Anti-cancer Therapy. Curr Top Microbiol Immunol 2019; 421:319-359. [PMID: 31123895 DOI: 10.1007/978-3-030-15138-6_13] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The connection between inflammation and cancer was initially recognized by Rudolf Virchow in the nineteenth century. During the last decades, a large body of evidence has provided support to his hypothesis, and now inflammation is recognized as one of the hallmarks of cancer, both in etiopathogenesis and ongoing tumor growth. Infection with the pathogen Helicobacter pylori is the primary causal factor in 90% of gastric cancer (GC) cases. As we increase our understanding of how chronic inflammation develops in the stomach and contributes to carcinogenesis, there is increasing interest in targeting cancer-promoting inflammation as a strategy to treat GC. Moreover, once cancer develops and anti-cancer immune responses are suppressed, there is evidence of a substantial shift in the microenvironment and new targets for immune therapy emerge. In this chapter, we provide insight into inflammation-related factors, including T lymphocytes, macrophages, pro-inflammatory chemokines, and cytokines, which promote H. pylori-associated GC initiation and growth. While intervening with chronic inflammation is not a new practice in rheumatology or gastroenterology, this approach has not been fully explored for its potential to prevent carcinogenesis or to contribute to the treatment of GC. This review highlights current and possible strategies for therapeutic intervention including (i) targeting pro-inflammatory mediators, (ii) targeting growth factors and pathways involved in angiogenesis in the gastric tumor microenvironment, and (iii) enhancing anti-tumor immunity. In addition, we highlight a significant number of clinical trials and discuss the importance of individual tumor characterization toward offering personalized immune-related therapy.
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Use of anti-platelet agents in the prevention of hepatic fibrosis in patients at risk for chronic liver disease: a systematic review and meta-analysis. Hepatol Int 2018; 13:84-90. [PMID: 30539518 DOI: 10.1007/s12072-018-9918-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS While the association between platelet activation and hepatic fibrosis has been previously demonstrated in animal studies; the utility of anti-platelet agents in reversing the progression of hepatic fibrosis requires further review. Utilizing systematic review methods, we provide to our knowledge the first meta-analysis combining evidence from all studies aimed to establish the effect of anti-platelet agents in the prevention of hepatic fibrosis. METHODS We searched Medline, EMBASE and PubMed databases from inception to October 2018 to identify all studies aimed at evaluating the role of anti-platelet agents in the prevention of hepatic fibrosis. The primary outcome was hepatic fibrosis. The initial title, abstract, and full-text screening were performed in duplicate. Risk of bias was evaluated using the Newcastle-Ottawa Scale. A fixed-effect generic inverse variance method was used to create a pooled estimate of the odds of hepatic fibrosis in patients with anti-platelet agents versus without anti-platelet agents. RESULTS Among the 2310 unique articles identified during the title screening, 4 studies with a combined population of 3141 patients were deemed eligible for inclusion into the meta-analysis establishing the effect of anti-platelet agents on hepatic fibrosis. One study failed to report their findings in the entire cohort, electing to instead summarize the effects of anti-platelets within subgroups categorized by fibrotic risk factors. Use of anti-platelets was associated with 32% decreased odds of hepatic fibrosis, (adjusted pooled OR 0.68; CI 0.56-0.82, p ≤ 0.0001). The statistical heterogeneity among the studies was insignificant. CONCLUSION Use of anti-platelet agents is associated with the decreased odds of hepatic fibrosis. Due to limited evidence, future high-quality randomized controlled trials with larger comparative samples are required to further delineate the potential beneficial effects of these drugs in preventing hepatic fibrosis.
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Kondo Y, Hatta W, Koike T, Takahashi Y, Saito M, Kanno T, Asanuma K, Asano N, Imatani A, Masamune A. The Use of Higher Dose Steroids Increases the Risk of Rebleeding After Endoscopic Hemostasis for Peptic Ulcer Bleeding. Dig Dis Sci 2018; 63:3033-3040. [PMID: 30022453 DOI: 10.1007/s10620-018-5209-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/10/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Previous studies have shown that several factors such as hemodynamic instability at admission are risk factors for rebleeding of peptic ulcer bleeding. However, whether steroid use increases the risk of rebleeding remains elusive. AIMS This study aimed to clarify the risk factors for rebleeding after endoscopic hemostasis for peptic ulcer bleeding. METHODS A total of 185 patients who underwent endoscopic hemostasis for peptic ulcer bleeding at our institution between 2005 and 2017 were retrospectively analyzed. We evaluated factors, including comorbid conditions, in-hospital onset, and steroid use, associated with rebleeding by logistic regression analysis. In addition, we investigated the association between the dose of steroids and rebleeding. RESULTS The rebleeding rate after endoscopic hemostasis for peptic ulcer bleeding was 14.6%. In the multivariate analysis, the independent risk factors for rebleeding were steroid use (odds ratio 4.56, p = 0.015), multiple ulcers (4.43, p = 0.005), number of comorbidities ≥ 3 3.18, p = 0.026), hemodynamic instability (3.06, p = 0.039), and number of comorbidities ≥ 3 (2.93, p = 0.047). Furthermore, the use of higher dose steroids (≥ 20 mg per day in prednisolone; 10.55, p = 0.002), but not lower dose (< 20 mg per day in prednisolone), was an independent risk factor for rebleeding in the multivariate analysis. The relationship between steroid use and rebleeding was observed in a dose-dependent manner (p for trend = 0.002). CONCLUSIONS This study first revealed that using higher dose steroids was an independent risk factor for rebleeding after endoscopic hemostasis for peptic ulcer bleeding, with a dose-response relation.
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Affiliation(s)
- Yutaka Kondo
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Yasushi Takahashi
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Takeshi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Kiyotaka Asanuma
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Naoki Asano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Akira Imatani
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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Tsoi KK, Chan FC, Hirai HW, Sung JJ. Risk of gastrointestinal bleeding and benefit from colorectal cancer reduction from long-term use of low-dose aspirin: A retrospective study of 612 509 patients. J Gastroenterol Hepatol 2018; 33:1728-1736. [PMID: 29665624 DOI: 10.1111/jgh.14261] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/15/2018] [Accepted: 03/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Aspirin, commonly used for prevention of cardiovascular and cerebrovascular diseases, is well known to protect against development of colorectal cancer (CRC) but increases risk of gastrointestinal bleeding (GIB). This cohort study aims to evaluate the benefit of low-dose aspirin to prevent CRC and its associated risk of GIB. METHOD A population-based dataset was used to compare incidence and mortality of CRC and GIB among patients receiving low-dose aspirin with sex-matched and age-matched controls (1:2). A total of 204 170 aspirin users taking aspirin for at least 6 months and 408 339 nonusers were analyzed. Patients' clinical outcomes were documented for up to 14 years or until death. RESULTS A total of 612 509 patients were included; 5118 (2.51%) out of 204 170 aspirin users were diagnosed with CRC; and 2073 (1.02%) died of the malignancy. On the other hand, 13 336 (3.27%) out of 408 339 non-aspirin users were diagnosed with CRC, and 6953 (1.70%) died. Using the competing risk regression, aspirin usage significantly reduced CRC mortality (subdistribution hazard ratio = 0.59; 95% confidence interval = 0.56 to 0.62). A total of 9483 (4.64%) aspirin users developed GIB, and 820 (0.40%) died, while 11 198 (2.74%) nonusers developed GIB, and 1488 (0.36%) died. Aspirin usage marginally increased risk of bleeding-related mortality (subdistribution hazard ratio = 1.09; 95% confidence interval = 1.00 to 1.19). Subgroup analyses showed the use of acid-secreting agents significantly reduced aspirin-induced mortality. CONCLUSION The long-term use of aspirin reduces both incidence and mortality of CRC and at the same time increases incidence and mortality risk of GIB. With combination use of acid-secreting agents, the bleeding risk can be reduced.
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Affiliation(s)
- Kelvin Kf Tsoi
- Stanley Ho Big Data Decision Analytics Research Centre, The Chinese University of Hong Kong, Sha Tin, Hong Kong.,Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Felix Ch Chan
- Stanley Ho Big Data Decision Analytics Research Centre, The Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Hoyee W Hirai
- Stanley Ho Big Data Decision Analytics Research Centre, The Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Joseph Jy Sung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Sha Tin, Hong Kong
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Patel SS, Guzman LA, Lin FP, Pence T, Reichman T, John B, Celi FS, Liptrap E, Bhati C, Siddiqui MS. Utilization of aspirin and statin in management of coronary artery disease in patients with cirrhosis undergoing liver transplant evaluation. Liver Transpl 2018; 24:872-880. [PMID: 29624871 DOI: 10.1002/lt.25067] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/12/2018] [Accepted: 03/22/2018] [Indexed: 12/12/2022]
Abstract
Coronary artery disease (CAD) assessment is a vital part of liver transplantation (LT) evaluation, as it allows for identification and medical optimization prior to transplantation. Although aspirin and statins are standard of care for CAD, they are not universally used in cirrhosis due to concerns about adverse events. Per protocol, coronary angiography was performed as part of the LT evaluation in all patients over the age of 50 years or with CAD risk factors, even if they were younger than 50. Optimal CAD medical management was defined as the use of both statin and aspirin, unless a contraindication was documented. Impact of these medications on hepatic decompensation, renal function, gastrointestinal bleeding, and need for transfusion was evaluated. CAD was detected in 84/228 (36.8%) patients. Lipid profile was similar in patients with and without CAD. In patients with CAD, statins were started in 19 (23%), while aspirin was used in 30 (36%) patients. In patients with obstructive or multivessel CAD, statin therapy was used only in 41% and 65%, respectively. Statins were more likely to be prescribed in patients with diabetes (32% versus 15%, P = 0.05) and history of dyslipidemia (38% versus 15%, P = 0.02). Use of statin therapy was not linked to hepatic decompensation, hospitalization, or rise in Model for End-Stage Liver Disease (MELD). Similarly, use of aspirin therapy was not associated with increased risk acute variceal hemorrhage, gastrointestinal bleeding, or worsening anemia. In conclusion, in decompensated cirrhosis, lipid profile alone is unable to risk stratify patients with CAD. Statin and aspirin appear to be safe. However, they are significantly underutilized for the management of CAD in this patient population. Liver Transplantation 24 872-880 2018 AASLD.
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Affiliation(s)
- Samarth S Patel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Luis A Guzman
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Fei-Pi Lin
- School of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Taylor Pence
- School of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Trevor Reichman
- Division of Transplant Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Binu John
- Division of Gastroenterology and Hepatology, Hunter-Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University, Richmond, VA
| | - Francesco S Celi
- Division of Endocrinology, Diabetes and Metabolism, Virginia Commonwealth University, Richmond, VA
| | - Erika Liptrap
- Division of Transplant Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Chandra Bhati
- Division of Transplant Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Mohammad S Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
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Schrör K. Why we should not skip aspirin in cardiovascular prevention. Hamostaseologie 2018; 36:33-43. [DOI: 10.5482/hamo-14-10-0048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/06/2015] [Indexed: 01/05/2023] Open
Abstract
SummarySince more than 20 years, aspirin is an approved and established first-line antiplatelet medication in cardiovascular prevention. This is partially due to ist unique mode of action which is not shared with any other antiplatelet agent as well by the reliability of its pharmacological efficacy: inhibition of platelet COX-1 and subsequent thromboxane formation in almost every patient. Aspirin acts synergistic with ADP-antagonists in dual antiplatelet therapy of acute coronary syndroms (ACS) and percutaneous coronary interventions (PCI) and is also approved for long-term secondary prevention. Patients with atrial fibrillation are an exception and benefit more from anticoagulants. After the introduction of the new oral anticoagulants (NOACs), i.e. direct inhibitors of factor Xa or thrombin formation, there is a renewed discussion about the role of antiplatelet agents, specifically if additional dual antiplatelet treatment is still necessary for an optimum clinical effect or whether one component, such as aspirin might be skipped in favor of other classes of oral antiplatelet agents, such as ADP-antagonists. The available data are insufficient to recommend this because of a low number of studies and a still uncertain benefit/ risk (bleeding) ratio. More research on aspirin as a chemopreventive appears also to be necessary and is going on, in particular in individuals at high-risk for vascular thrombotic diseases (diabetics, preeclampsia, venous thrombembolism).
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Johansson S, Nagy P, Soriano LC, Rodríguez LAG. Use of proton pump inhibitors and the risk of coronary events in new users of low-dose acetylsalicylic acid in UK primary care. Thromb Haemost 2017; 111:131-9. [DOI: 10.1160/th13-07-0542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 09/23/2013] [Indexed: 11/05/2022]
Abstract
SummaryThis study evaluated the risk of cardiovascular events associated with the use of proton pump inhibitors (PPIs) in new users of acetylsalicylic acid (ASA) for the secondary prevention of cardiovascular events. Two cohorts of patients aged 50–84 years were identified from UK primary care databases: individuals with a first prescription for ASA (75−300 mg/day) for secondary prevention of cardiovascular events (n = 39,513; CVD cohort) or with a record of hospitalisation for an acute coronary event (n = 42,542; ACS cohort) in 2000–2007. Cases of nonfatal myocardial infarction (MI) and coronary death were identified: 1,222 in the CVD cohort and 604 among new users of ASA in the ACS cohort. A nested case–control analysis estimated the relative risk (RR) of non-fatal MI or coronary death associated with use vs non-use of PPI therapy. Current continuous use of PPI therapy was not associated with a significant increase in RR overall: in the CVD cohort (RR = 1.14 [95% confidence interval = 0.91−1.43]); in the ACS cohort (0.88 [0.66−1.18]); or among current continuous users of ASA as antiplatelet monotherapy (CVD cohort: 1.15 [0.80−1.66]; ACS cohort: 0.73 [0.43−1.23]; pooled analysis of both cohorts: 0.96 [0.62−1.48]). In conclusion, among first-time users of ASA for the secondary prevention of cardiovascular events, PPI use was not shown to be associated with an increased risk of non-fatal MI or coronary death.
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Grancher A, Michel P, Di Fiore F, Sefrioui D. [Aspirin and colorectal cancer]. Bull Cancer 2017; 105:171-180. [PMID: 29153543 DOI: 10.1016/j.bulcan.2017.09.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/18/2017] [Accepted: 09/08/2017] [Indexed: 12/17/2022]
Abstract
Colorectal cancer is a worldwide public health problem. Aspirin has been identified as a protective factor against the apparition of colorectal cancer. There are several mechanisms about the actions by aspirin on colorectal tumorogenesis. These are not perfectly known nowadays. On one hand, there are direct mechanisms on colorectal mucosa, on the other hand there are indirect mechanisms through platelet functions. Aspirin also plays a role by its anti-inflammatory action and the stimulation of antitumor immunity. Several studies show that long-term treatment with low-doses of aspirin decreases the incidence of adenomas and colorectal cancers. In the United States, aspirin is currently recommended for primary prevention of the risk of colorectal cancer in all patients aged 50 to 59, with a 10-year risk of cardiovascular event greater than 10 %. However, primary prevention with aspirin should not be a substitute for screening in colorectal cancer. Furthermore, aspirin seems to be beneficial when used in post-diagnosis of colorectal cancer. It could actually decrease the risk of metastasis in case of a localized colorectal cancer, and increase the survival in particular, concerning PIK3CA mutated tumors. The association of aspirin with neoadjuvant treatment of colorectal cancer by radiochimiotherapy seems to have beneficial effects. French prospective randomized study is currently being conducted to investigate postoperative aspirin in colorectal cancers with a PIK3CA mutation.
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Affiliation(s)
- Adrien Grancher
- Normandie université, UNIROUEN, hôpital universitaire de Rouen, service d'hépato-gastroenterologie, 76000 Rouen, France
| | - Pierre Michel
- Normandie université, UNIROUEN, Inserm 1245, IRON group, hôpital universitaire de Rouen, service d'hépato-gastroentérologie, 76000 Rouen, France.
| | - Frédéric Di Fiore
- Normandie université, UNIROUEN, Inserm 1245, IRON group, hôpital universitaire de Rouen, centre Henri-Becquerel, département d'oncolgie médicale, service d'hépato-gastroentérologie, 76000 Rouen, France
| | - David Sefrioui
- Normandie université, UNIROUEN, Inserm 1245, IRON group, hôpital universitaire de Rouen, service d'hépato-gastroentérologie, 76000 Rouen, France
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Wedi E, von Renteln D, Gonzalez S, Tkachenko O, Jung C, Orkut S, Roth V, Tumay S, Hochberger J. Use of the over-the-scope-clip (OTSC) in non-variceal upper gastrointestinal bleeding in patients with severe cardiovascular comorbidities: a retrospective study. Endosc Int Open 2017; 5:E875-E882. [PMID: 28924593 PMCID: PMC5595576 DOI: 10.1055/s-0043-105496] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/13/2017] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The over-the-scope-clip (OTSC) can potentially overcome limitations of standard clips and achieve more efficient and reliable hemostasis. Data on OTSC use for non-variceal upper gastrointestinal bleeding (NVUGIB) in patients with cardiovascular comorbidities are currently limited. PATIENTS AND METHODS We prospectively collected and retrospectively analyzed our database from February 2009 to September 2015 from all patients who underwent emergency endoscopy for high-risk NVUGIB in 2 academic centers and were treated with OTSC as first-line (n = 81) or second-line therapy (n = 19). RESULTS One hundred patients mean age 72 (range 27 - 97 years) were included in this study. Fifty-one percent (n = 51) had severe cardiovascular co-morbidity (ischemic heart disease, congestive heart failure, hypertension, valvular heart disease, peripheral arterial occlusive disease and atrial fibrillation) and 73 % (n = 73) were on antiplatelet or/and anticoagulation therapy. The median size of the treated ulcers was 3 cm (range 1 - 5 cm). In 94 % (n = 94) primary hemostasis with OTSC was achieved. Clinical long-term success during a mean 6-month follow-up without rebleeding was 86 % (n = 86). CONCLUSIONS In this cohort OTSC was demonstrated to be a safe and effective first- or second-line treatment for NVUGIB in high-risk patients with cardiovascular disease and complex, large ulcers.
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Affiliation(s)
- Edris Wedi
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany,Department of Gastroenterology, Nouvel
Hôpital Civil, University Hospitals, Strasbourg, France,Corresponding author Edris Wedi,
MD Department of Gastroenterology and GI
OncologyUniversity Medical Centre
GoettingenCenter of Interdisciplinary
EndoscopyGeorg-August-UniversityEndoscopyD-37075
GoettingenGermany+495121901241
| | - Daniel von Renteln
- Division of Gastroenterology, Centre
Hospitalier de l’Université de Montréal (CHUM), Research Centre CHUM (CRCHUM)
Montreal, Quebec, Canada
| | - Susana Gonzalez
- Division of Gastroenterology, NYU Langone
Medical Center, New York, New York, United States
| | - Olena Tkachenko
- Division of Reproductive and Developmental
Sciences, Oregon National Primate Research Center, Oregon Health & Science
University, Beaverton, Oregon, United States
| | - Carlo Jung
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany,Department of Gastroenterology, Nouvel
Hôpital Civil, University Hospitals, Strasbourg, France
| | - Sinan Orkut
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany
| | - Victor Roth
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany
| | - Selin Tumay
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany
| | - Juergen Hochberger
- Department of Gastroenterology and
Gastrointestinal Oncology, University Medical Centre Goettingen, Center of
Interdisciplinary Endoscopy, Goettingen, Germany,Division of Gastroenterology, Vivantes
Klinikum in Friedrichshain, Teaching Hospital of Charité Humboldt University,
Berlin, Germany
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Bosch J, Eikelboom JW, Connolly SJ, Bruns NC, Lanius V, Yuan F, Misselwitz F, Chen E, Diaz R, Alings M, Lonn EM, Widimsky P, Hori M, Avezum A, Piegas LS, Bhatt DL, Branch KR, Probstfield JL, Liang Y, Liu L, Zhu J, Maggioni AP, Lopez-Jaramillo P, O'Donnell M, Fox KA, Kakkar A, Parkhomenko AN, Ertl G, Störk S, Keltai K, Keltai M, Ryden L, Dagenais GR, Pogosova N, Dans AL, Lanas F, Commerford PJ, Torp-Pedersen C, Guzik TJ, Verhamme PB, Vinereanu D, Kim JH, Ha JW, Tonkin AM, Varigos JD, Lewis BS, Felix C, Yusoff K, Steg PG, Aboyans V, Metsarinne KP, Anand SS, Hart RG, Lamy A, Moayyedi P, Leong DP, Sharma M, Yusuf S. Rationale, Design and Baseline Characteristics of Participants in the C ardiovascular O utco m es for P eople Using A nticoagulation S trategie s (COMPASS) Trial. Can J Cardiol 2017; 33:1027-1035. [DOI: 10.1016/j.cjca.2017.06.001] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 06/04/2017] [Accepted: 06/04/2017] [Indexed: 12/22/2022] Open
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García-Rayado G, Sostres C, Lanas A. Aspirin and omeprazole for secondary prevention of cardiovascular disease in patients at risk for aspirin-associated gastric ulcers. Expert Rev Clin Pharmacol 2017; 10:875-888. [PMID: 28463532 DOI: 10.1080/17512433.2017.1324782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Cardiovascular disease is the most important cause of morbidity and mortality in the world and low-dose aspirin is considered the cornerstone of the cardiovascular disease prevention. However, low-dose aspirin use is associated with gastrointestinal adverse effects in the whole gastrointestinal tract. In this setting, co-therapy with a proton pump inhibitor is the most accepted strategy to reduce aspirin related upper gastrointestinal damage. In addition, some adverse effects have been described with proton pump inhibitors long term use. Areas covered: Low-dose aspirin related beneficial and adverse effects in cardiovascular system and gastrointestinal tract are reviewed. In addition, this manuscript summarizes current data on upper gastrointestinal damage prevention and adverse events with proton pump inhibition. Finally, we discuss the benefit/risk ratio of proton pump inhibitor use in patients at risk of gastrointestinal damage taking low-dose aspirin. Expert commentary: Nowadays, with the current available evidence, the combination of low-dose aspirin with proton pump inhibitor is the most effective therapy for cardiovascular prevention in patients at high gastrointestinal risk. However, further studies are needed to discover new effective strategies with less related adverse events.
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Affiliation(s)
- Guillermo García-Rayado
- a Service of Digestive Diseases , University Clinic Hospital Lozano Blesa , Zaragoza , Spain.,b Aragón Health Research Institute (IIS Aragón) , Zaragoza , Spain
| | - Carlos Sostres
- a Service of Digestive Diseases , University Clinic Hospital Lozano Blesa , Zaragoza , Spain.,b Aragón Health Research Institute (IIS Aragón) , Zaragoza , Spain.,c CIBERehd , Madrid , Spain.,d University of Zaragoza , Zaragoza , Spain
| | - Angel Lanas
- a Service of Digestive Diseases , University Clinic Hospital Lozano Blesa , Zaragoza , Spain.,b Aragón Health Research Institute (IIS Aragón) , Zaragoza , Spain.,c CIBERehd , Madrid , Spain.,d University of Zaragoza , Zaragoza , Spain
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Upper Gastrointestinal Toxicity Associated With Long-Term Aspirin Therapy: Consequences and Prevention. Curr Probl Cardiol 2017; 42:146-164. [PMID: 28363584 DOI: 10.1016/j.cpcardiol.2017.01.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Antiplatelet therapy represents a fundamental part of preventive management for patients who are at risk of a secondary cardiovascular disease (CVD) event. In most cases, the antiplatelet regimen is based on low-dose aspirin, a drug that is highly effective in reducing the incidence of CVD events, but is associated with a substantial risk of gastrointestinal (GI) toxicity. The dyspeptic symptoms, which can result from aspirin administration, and which may occur with or without associated ulceration and bleeding, may lead patients to discontinue therapy, thus increasing their CVD risk. For patients in whom aspirin is indicated and who are deemed to be at increased risk of upper GI events, concomitant therapy with a proton pump inhibitor (PPI) is currently recommended. These agents are highly effective in reducing the upper GI lesions associated with aspirin therapy and have been associated with increased aspirin adherence. However, widespread under-prescribing of PPIs and potential noncompliance with their use means that substantial numbers of patients are at unnecessary risk of upper GI toxicity and-if aspirin therapy is discontinued-CVD events. Provision of aspirin and an immediate-release PPI as a coordinated-delivery combination tablet has been shown to both reduce the risk of gastric ulcer formation and improve patient compliance. This strategy, which may ultimately reduce the incidence of CVD outcomes because of the associated reduction in GI symptoms and the potential for greater patient adherence to aspirin, warrants further investigation under both randomized controlled conditions (explanatory trials), and in real-life settings (pragmatic trials).
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Elwood PC, Morgan G, Galante J, Chia JWK, Dolwani S, Graziano JM, Kelson M, Lanas A, Longley M, Phillips CJ, Pickering J, Roberts SE, Soon SS, Steward W, Morris D, Weightman AL. Systematic Review and Meta-Analysis of Randomised Trials to Ascertain Fatal Gastrointestinal Bleeding Events Attributable to Preventive Low-Dose Aspirin: No Evidence of Increased Risk. PLoS One 2016; 11:e0166166. [PMID: 27846246 PMCID: PMC5113022 DOI: 10.1371/journal.pone.0166166] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/19/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Aspirin has been shown to lower the incidence and the mortality of vascular disease and cancer but its wider adoption appears to be seriously impeded by concerns about gastrointestinal (GI) bleeding. Unlike heart attacks, stroke and cancer, GI bleeding is an acute event, usually followed by complete recovery. We propose therefore that a more appropriate evaluation of the risk-benefit balance would be based on fatal adverse events, rather than on the incidence of bleeding. We therefore present a literature search and meta-analysis to ascertain fatal events attributable to low-dose aspirin. METHODS In a systematic literature review we identified reports of randomised controlled trials of aspirin in which both total GI bleeding events and bleeds that led to death had been reported. Principal investigators of studies in which fatal events had not been adequately described were contacted via email and asked for further details. A meta-analyses was then performed to estimate the risk of fatal gastrointestinal bleeding attributable to low-dose aspirin. RESULTS Eleven randomised trials were identified in the literature search. In these the relative risk (RR) of 'major' incident GI bleeding in subjects who had been randomised to low-dose aspirin was 1.55 (95% CI 1.33, 1.83), and the risk of a bleed attributable to aspirin being fatal was 0.45 (95% CI 0.25, 0.80). In all the subjects randomised to aspirin, compared with those randomised not to receive aspirin, there was no significant increase in the risk of a fatal bleed (RR 0.77; 95% CI 0.41, 1.43). CONCLUSIONS The majority of the adverse events caused by aspirin are GI bleeds, and there appears to be no valid evidence that the overall frequency of fatal GI bleeds is increased by aspirin. The substantive risk for prophylactic aspirin is therefore cerebral haemorrhage which can be fatal or severely disabling, with an estimated risk of one death and one disabling stroke for every 1,000 people taking aspirin for ten years. These adverse effects of aspirin should be weighed against the reductions in vascular disease and cancer.
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Affiliation(s)
- Peter C. Elwood
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | - Gareth Morgan
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Hywel Dda University Health Board, Llanelli, United Kingdom
| | - Julieta Galante
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - John W. K. Chia
- Division of Medical Oncology, National Cancer Centre, Singapore, Singapore
| | - Sunil Dolwani
- Institute of Cancer & Genetics Cardiff University, Cardiff, United Kingdom
| | | | - Mark Kelson
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | - Angel Lanas
- University Clinic Hospital, University of Zaragoza, IIS Aragón, CIBEReshd, Zaragoza, Spain
| | - Marcus Longley
- Welsh Institute for Health and Social Care, University of South Wales, Cardiff, United Kingdom
| | - Ceri J. Phillips
- Swansea Centre for Health Economics, Swansea University, Swansea, United Kingdom
| | - Janet Pickering
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | | | - Swee S. Soon
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Will Steward
- Department of Cancer Studies, University of Leicester, Leicester, United Kingdom
| | - Delyth Morris
- University Library Services, Cardiff University, Cardiff, United Kingdom
| | - Alison L. Weightman
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Specialist Unit for Review Evidence (SURE), Cardiff University, Cardiff, United Kingdom
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García Rodríguez LA, Martín-Pérez M, Hennekens CH, Rothwell PM, Lanas A. Bleeding Risk with Long-Term Low-Dose Aspirin: A Systematic Review of Observational Studies. PLoS One 2016; 11:e0160046. [PMID: 27490468 PMCID: PMC4973997 DOI: 10.1371/journal.pone.0160046] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 05/30/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Low-dose aspirin has proven effectiveness in secondary and primary prevention of cardiovascular events, but is also associated with an increased risk of major bleeding events. For primary prevention, this absolute risk must be carefully weighed against the benefits of aspirin; such assessments are currently limited by a lack of data from general populations. METHODS Systematic searches of Medline and Embase were conducted to identify observational studies published between 1946 and 4 March 2015 that reported the risks of gastrointestinal (GI) bleeding or intracranial hemorrhage (ICH) with long-term, low-dose aspirin (75-325 mg/day). Pooled estimates of the relative risk (RR) for bleeding events with aspirin versus non-use were calculated using random-effects models, based on reported estimates of RR (including odds ratios, hazard ratios, incidence rate ratios and standardized incidence ratios) in 39 articles. FINDINGS The incidence of GI bleeding with low-dose aspirin was 0.48-3.64 cases per 1000 person-years, and the overall pooled estimate of the RR with low-dose aspirin was 1.4 (95% confidence interval [CI]: 1.2-1.7). For upper and lower GI bleeding, the RRs with low-dose aspirin were 2.3 (2.0-2.6) and 1.8 (1.1-3.0), respectively. Neither aspirin dose nor duration of use had consistent effects on RRs for upper GI bleeding. The estimated RR for ICH with low-dose aspirin was 1.4 (1.2-1.7) overall. Aspirin was associated with increased bleeding risks when combined with non-steroidal anti-inflammatory drugs, clopidogrel and selective serotonin reuptake inhibitors compared with monotherapy. By contrast, concomitant use of proton pump inhibitors decreased upper GI bleeding risks relative to aspirin monotherapy. CONCLUSIONS The risks of major bleeding with low-dose aspirin in real-world settings are of a similar magnitude to those reported in randomized trials. These data will help inform clinical judgements regarding the use of low-dose aspirin in prevention of cardiovascular events.
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Affiliation(s)
| | - Mar Martín-Pérez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain
| | - Charles H. Hennekens
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States of America
| | - Peter M. Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Angel Lanas
- University of Zaragoza, University Clinic Hospital, IIS Aragón, CIBERehd, Zaragoza, Spain
- * E-mail:
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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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48
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Hreinsson JP, Palsdóttir S, Bjornsson ES. The Association of Drugs With Severity and Specific Causes of Acute Lower Gastrointestinal Bleeding: A Prospective Study. J Clin Gastroenterol 2016; 50:408-13. [PMID: 26280706 DOI: 10.1097/mcg.0000000000000393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Studies on the association of acute lower gastrointestinal bleeding (ALGIB) and drugs are scarce. We aimed to investigate the association of drugs and ALGIB, especially regarding specific causes of ALGIB, and their role in the severity of ALGIB. MATERIALS AND METHODS The study was prospective and included all patients undergoing colonoscopy in 2010 and 2013 at the National University Hospital of Iceland. Use of nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose aspirin (LDA), and warfarin before ALGIB was registered. Clinically significant bleeding was defined as: hemoglobin <100 g/L, hemodynamic instability, blood transfusion, surgery, or death. RESULTS Overall, 2392 patients underwent 2751 colonoscopies, of those, 325 (14%) had ALGIB, mean age 64 years (±20). The commonest diagnoses were diverticulosis (22%) and ischemic colitis (14%). In multivariate analysis, NSAIDs, LDA, and warfarin use was associated with ALGIB, odds ratio (OR) 3.3 [95% confidence interval (95% CI), 1.99-5.82], OR 1.5 (95% CI, 1.01-2.13), and OR 2.7 (95% CI, 1.61-4.57), respectively. Clinically significant bleeders were more likely than nonclinically significant bleeders to use NSAIDs or LDA+warfarin, OR 2.3 (95% CI, 1.26-3.76) and OR 33.0 (95% CI, 6.74-595), respectively. Patients with diverticular bleeding had greater odds than controls of NSAID, LDA, and warfarin use, OR 8.3 (95% CI, 3.8-18.3), OR 2.1 (95% CI, 1.15-3.67), and OR 2.6 (95% CI, 1.24-5.56), respectively. Patients with ischemic colitis were more likely than controls to use LDA, OR 2.3 (95% CI, 1.14-4.45). CONCLUSIONS NSAIDs, LDA, and warfarin were associated with ALGIB and diverticular bleeding. These drugs may have a role in other etiologies of ALGIB and seem to increase the risk of clinically significant bleeding.
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Affiliation(s)
- Johann P Hreinsson
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, The National University Hospital of Iceland, Reykjavik, Iceland
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49
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Abstract
Aspirin (acetylsalicylic acid) has become one of the most commonly used drugs, given its role as an analgesic, antipyretic and agent for cardiovascular prophylaxis. Several decades of research have provided considerable evidence demonstrating its potential for the prevention of cancer, particularly colorectal cancer. Broader clinical recommendations for aspirin-based chemoprevention strategies have recently been established; however, given the known hazards of long-term aspirin use, larger-scale adoption of an aspirin chemoprevention strategy is likely to require improved identification of individuals for whom the protective benefits outweigh the harms. Such a precision medicine approach may emerge through further clarification of aspirin's mechanism of action.
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Affiliation(s)
- David A Drew
- Massachusetts General Hospital and Harvard Medical School, Clinical and Translational Epidemiology Unit, 55 Fruit Street, Bartlett Ext. 9, Boston, Massachusetts 02114, USA
| | - Yin Cao
- Massachusetts General Hospital and Harvard Medical School, Clinical and Translational Epidemiology Unit, and Harvard T.H. Chan School of Public Health, Department of Nutrition, 55 Fruit Street, Bartlett Ext. 9, Boston, Massachusetts 02114, USA
| | - Andrew T Chan
- Massachusetts General Hospital and Harvard Medical School, Clinical and Translational Epidemiology Unit, Division of Gastroenterology, GRJ-825C, Boston, Massachusetts 02114, USA
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50
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Satoh K, Yoshino J, Akamatsu T, Itoh T, Kato M, Kamada T, Takagi A, Chiba T, Nomura S, Mizokami Y, Murakami K, Sakamoto C, Hiraishi H, Ichinose M, Uemura N, Goto H, Joh T, Miwa H, Sugano K, Shimosegawa T. Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol 2016; 51:177-94. [PMID: 26879862 DOI: 10.1007/s00535-016-1166-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 01/06/2016] [Indexed: 02/05/2023]
Abstract
The Japanese Society of Gastroenterology (JSGE) revised the evidence-based clinical practice guidelines for peptic ulcer disease in 2014 and has created an English version. The revised guidelines consist of seven items: bleeding gastric and duodenal ulcers, Helicobacter pylori (H. pylori) eradication therapy, non-eradication therapy, drug-induced ulcer, non-H. pylori, non-nonsteroidal anti-inflammatory drug (NSAID) ulcer, surgical treatment, and conservative therapy for perforation and stenosis. Ninety clinical questions (CQs) were developed, and a literature search was performed for the CQs using the Medline, Cochrane, and Igaku Chuo Zasshi databases between 1983 and June 2012. The guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Therapy is initially provided for ulcer complications. Perforation or stenosis is treated with surgery or conservatively. Ulcer bleeding is first treated by endoscopic hemostasis. If it fails, surgery or interventional radiology is chosen. Second, medical therapy is provided. In cases of NSAID-related ulcers, use of NSAIDs is stopped, and anti-ulcer therapy is provided. If NSAID use must continue, the ulcer is treated with a proton pump inhibitor (PPI) or prostaglandin analog. In cases with no NSAID use, H. pylori-positive patients receive eradication and anti-ulcer therapy. If first-line eradication therapy fails, second-line therapy is given. In cases of non-H. pylori, non-NSAID ulcers or H. pylori-positive patients with no indication for eradication therapy, non-eradication therapy is provided. The first choice is PPI therapy, and the second choice is histamine 2-receptor antagonist therapy. After initial therapy, maintenance therapy is provided to prevent ulcer relapse.
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Affiliation(s)
- Kiichi Satoh
- Department of Gastroenterology, International University of Health and Welfare Hospital, 537-3 Iguchi, Nasushiobara-shi, Tochigi, 329-2763, Japan.
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan.
| | - Junji Yoshino
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Taiji Akamatsu
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Toshiyuki Itoh
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Mototsugu Kato
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Tomoari Kamada
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Atsushi Takagi
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Toshimi Chiba
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Sachiyo Nomura
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Yuji Mizokami
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Kazunari Murakami
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Choitsu Sakamoto
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Hideyuki Hiraishi
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Masao Ichinose
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Naomi Uemura
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Hidemi Goto
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Takashi Joh
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Hiroto Miwa
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Kentaro Sugano
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
| | - Tooru Shimosegawa
- Guidelines Committee for creating and evaluating the "Evidence-based clinical practice guidelines for peptic ulcer", the Japanese Society of Gastroenterology (JSGE), K-18 Building 8F, 8-9-13, Ginza, Chuo, Tokyo, 104-0061, Japan
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