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Almadi MA, Lu Y, Alali AA, Barkun AN. Peptic ulcer disease. Lancet 2024:S0140-6736(24)00155-7. [PMID: 38885678 DOI: 10.1016/s0140-6736(24)00155-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/22/2023] [Accepted: 01/24/2024] [Indexed: 06/20/2024]
Abstract
Annual prevalence estimates of peptic ulcer disease range between 0·12% and 1·5%. Peptic ulcer disease is usually attributable to Helicobacter pylori infection, intake of some medications (such as aspirin and non-steroidal anti-inflammatory medications), or being critically ill (stress-related), or it can be idiopathic. The clinical presentation is usually uncomplicated, with peptic ulcer disease management based on eradicating H pylori if present, the use of acid-suppressing medications-most often proton pump inhibitors (PPIs)-or addressing complications, such as with early endoscopy and high-dose PPIs for peptic ulcer bleeding. Special considerations apply to patients on antiplatelet and antithrombotic agents. H pylori treatment has evolved, with the choice of regimen dictated by local antibiotic resistance patterns. Indications for primary and secondary prophylaxis vary across societies; most suggest PPIs for patients at highest risk of developing a peptic ulcer, its complications, or its recurrence. Additional research areas include the use of potassium-competitive acid blockers and H pylori vaccination; the optimal approach for patients at risk of stress ulcer bleeding requires more robust determinations of optimal patient selection and treatment selection, if any. Appropriate continuation of PPI use outweighs most possible side-effects if given for approved indications, while de-prescribing should be trialled when a definitive indication is no longer present.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada
| | - Yidan Lu
- Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada
| | - Ali A Alali
- Department of Medicine, Faculty of Medicine, Kuwait University, Jabriyah, Kuwait
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada.
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Khawaja M, Thakker J, Kherallah R, Kitakaze M, Jneid H, Angiolillo DJ, Birnbaum Y. Antacid Therapy in Coronary Artery Disease and Heart Failure: Proton Pump Inhibitors vs. H 2 Receptor Blockers. Cardiovasc Drugs Ther 2024; 38:181-189. [PMID: 35715526 DOI: 10.1007/s10557-022-07358-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Acid suppressive therapy using histamine H2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) can be utilized for the prevention of gastrointestinal bleeding (GIB) among patients with cardiovascular disease receiving dual antiplatelet therapy (DAPT). However, emerging data suggests underlying associations between PPI or H2RA use and cardiovascular disease incidence, progression, and mortality. This review explores the history of acid suppressive therapies and their use in cardiovascular disease patients and the growing evidence in support of H2RA use. RECENT FINDINGS PPIs were originally championed as better than H2RAs for preventing GIB events in cardiovascular disease patients on DAPT therapy, but there is evidence to suggest that drug-drug interactions between clopidogrel and PPIs may translate to worse cardiovascular outcomes. Studies demonstrating PPI superiority in the setting of DAPT were also limited due to small sample sizes and high levels of bias. Consequently, there is renewed interest in H2RAs for patients on DAPT with some data demonstrating similar or improved clinical outcomes over PPI therapy. Additionally, studies have discovered a possible role for H2RAs in the management of heart failure (HF) incidence, symptoms, and mortality. Studies comparing H2RAs and PPIs in patients on DAPT have demonstrated mixed results for cardiovascular and GIB outcomes, with several studies being underpowered and limited by biases. Recent clinical and pre-clinical studies now support the noninferiority of H2RAs for major outcomes and even utility in HF. These findings suggest that H2RAs may warrant reconsideration as an acid suppressive therapy over PPIs for patients on DAPT or with HF.
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Affiliation(s)
- Muzamil Khawaja
- The Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Janki Thakker
- The Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Riyad Kherallah
- The Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Masafumi Kitakaze
- Center of Medical Innovation and Translational Research, Department of Medical Data Science, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hani Jneid
- The Section of Cardiology, The Department of Medicine, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX, 77030, USA
| | - Dominick J Angiolillo
- Division of Cardiology, The University of Florida College of Medicine, Jacksonville, FL, USA
| | - Yochai Birnbaum
- The Section of Cardiology, The Department of Medicine, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX, 77030, USA.
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3
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Yang HG, Kim DK. Concomitant Use of Antiplatelet Agents and Proton-Pump Inhibitors Increases the Risk of Adverse Cardiovascular Events: A Nationwide Population-Based Cohort Study Using Balanced Operational Definitions. J Cardiovasc Dev Dis 2023; 10:264. [PMID: 37367429 DOI: 10.3390/jcdd10060264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/02/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
Antiplatelet agents are commonly used in combination with proton-pump inhibitors (PPIs) in patients with acute coronary syndrome who are at risk of gastrointestinal hemorrhage. However, studies have reported that PPIs can alter the pharmacokinetics of antiplatelet agents and result in adverse cardiovascular events. We enrolled 311 patients who received antiplatelet therapy with PPIs for >30 days and 1244 matched controls following a 1:4 propensity score matching during the index period. Patients were followed up until death, myocardial infarction, coronary revascularization, or the end of the follow-up period. Patients who used antiplatelet therapy with PPIs were found to be at higher risk of mortality than the controls (adjusted hazard ratio (HR): 1.77; 95% confidence interval (CI): 1.30-2.40). The adjusted HR for patients who used antiplatelet agents with PPIs developing myocardial infarction and coronary revascularization events was 3.52 (95% CI: 1.34-9.22) and 4.74 (95% CI: 2.03-11.05), respectively. Additionally, middle-aged patients or those within 3 years of concomitant use showed a higher risk of myocardial infarction and coronary revascularization. Our findings suggest that antiplatelet therapy combined with PPIs has a higher mortality risk in patients with gastrointestinal bleeding and is associated with an increased risk of myocardial infarction and coronary revascularization.
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Affiliation(s)
- Hee Gyu Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
| | - Dong-Kyu Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
- Division of Big Data and Artificial Intelligence, Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
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Chen HL, Lei WY, Wang JH, Bair MJ, Chen CL. Proton pump inhibitor use and the risk for Parkinson's disease: A nationwide population-based study in Taiwan. Medicine (Baltimore) 2023; 102:e33711. [PMID: 37171333 PMCID: PMC10174385 DOI: 10.1097/md.0000000000033711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
Previous studies have shown that proton pump inhibitors (PPIs) are associated with an increased risk of dementia. However, little is known about the relationship between PPIs use and Parkinson's disease (PD). This study aimed to examine whether PPI use was associated with an increased risk of developing clinically verified PD. This used data from the Taiwan National Health Insurance Research Database for the period between 1999 and 2011, and patients with PPI use were compared with 1 to 1 propensity score-matched controls by age, sex, cohort entry year, and comorbidity. A multivariate analysis was performed using Cox proportional hazards models to estimate the association between PPI use and PD risk. Subgroup analyses according to sex, age, and comorbidities were also conducted. In total, 56,785 PPI users and 56,785 matched controls were enrolled in this study. In the PPI cohort, 366 patients developed PD during a median follow-up of 5.0 years. The incidence rate of PD was 1.48-fold higher in PPI users than in non-PPI users (90.0 vs 133.2 per 100,000 person-years), with an adjusted hazard ratio of 1.76 (95% confidence interval, 1.48-2.08). In the subgroup analysis, the adjusted risk of PD in the PPI and non-PPI cohorts increased in the subgroups regardless of age, sex, and comorbidities. The results of this retrospective, nationwide, population-based cohort study in Taiwan indicate that PPI use is associated with the risk of PD development. Further mechanistic studies on the effect of PPI on PD are needed.
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Affiliation(s)
- Huan-Lin Chen
- Division of Gastroenterology, Department of Internal Medicine, Taitung MacKay Memorial Hospital, Taitung, Taiwan
- Mackay Medical College, New Taipei, Taiwan
| | - Wei-Yi Lei
- Division of Gastroenterology, Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Ming-Jong Bair
- Division of Gastroenterology, Department of Internal Medicine, Taitung MacKay Memorial Hospital, Taitung, Taiwan
- Mackay Medical College, New Taipei, Taiwan
| | - Chien-Lin Chen
- Division of Gastroenterology, Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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Zhou T, Gong Y, Li J, Wang Y, Wang X. Efficacy and safety of rivaroxaban plus clopidogrel versus aspirin plus clopidogrel in patients with coronary atherosclerotic heart disease and gastrointestinal disease undergoing percutaneous coronary intervention: study protocol for a non-inferiority randomized controlled trial. Trials 2023; 24:209. [PMID: 36945020 PMCID: PMC10031942 DOI: 10.1186/s13063-023-07236-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 03/10/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended for patients with coronary heart disease (CHD) undergoing percutaneous coronary intervention (PCI) to antithrombosis, meanwhile, increasing the risks of gastrointestinal bleeding. Rivaroxaban, a novel oral anticoagulant, combined with a P2Y12 receptor inhibitor reduces adverse events in patients with CHD and atrial fibrillation who underwent PCI. The effect of rivaroxaban plus P2Y12 inhibitor on reducing bleeding events in patients with CHD and gastrointestinal disease (GID) undergoing PCI remains unclear. METHOD The study is a prospective, single-center, randomized controlled trial. A total of 1020 patients with CHD and GID undergoing PCI will be enrolled. Patients are randomized (1:1) to receive either rivaroxaban 10 mg plus clopidogrel 75 mg daily or aspirin 100 mg plus clopidogrel 75 mg daily; both treatments will last 6 months. The primary endpoint is Bleeding Academic Research Consortium (BARC) type 2-5 bleeding requiring medical intervention. The secondary endpoint is a composite of major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause death, cardiac death, nonfatal myocardial infarction, stent thrombosis, ischemia-driven target vessel revascularization, and stroke. DISCUSSION The objective of this study is to evaluate the efficacy and safety of rivaroxaban plus clopidogrel versus aspirin plus clopidogrel in patients with CHD and GID undergoing PCI. We aim to explore an optimized antithrombotic strategy, which achieves the same anti-ischemic effect as standard DAPT without increasing the risk of GIB, for patients with CHD and GID undergoing PCI. TRIAL REGISTRATION This protocol is registered at the Chinese Clinical Trial Registry under the number ChiCTR2100044319. And this publication is based on version 1.4 of the trial protocol dated Sep 6, 2021.
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Affiliation(s)
- Tienan Zhou
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Yinghui Gong
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Jingyuan Li
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Yasong Wang
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Xiaozeng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China.
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C-Phycocyanin and Lycium barbarum Polysaccharides Protect against Aspirin-Induced Inflammation and Apoptosis in Gastric RGM-1 Cells. Nutrients 2022; 14:nu14235113. [PMID: 36501143 PMCID: PMC9736128 DOI: 10.3390/nu14235113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Aspirin causes gastrotoxicity and damaged epithelial defense via cyclooxygenase inhibition. C-phycocyanin (CPC) and Lycium barbarum polysaccharides (LBP), an active ingredient of Spirulina platensis and wolfberry, respectively, exerted antioxidation, anti-inflammation, and/or immunoregulation. The actions of CPC and/or LBP on gastric damage induced by aspirin were explored in rat gastric mucosal RGM-1 cells. Gastric injury was performed by 21 mM aspirin for 3 h after the pretreatment of CPC and/or LBP (100-500 μg/mL) for 24 h in RGM-1 cells. Proinflammatory, anti-inflammatory, and apoptotic markers were examined by ELISA or gel electrophoresis and Western blotting. Cell viability and interleukin 10 (IL-10) were reduced by aspirin. Increased proinflammatory markers, caspase 3 activity, and Bax protein were observed in RGM-1 cells with aspirin treatment. Aspirin elevated nuclear factor-κB (NF-κB), extracellular signal-regulated kinase (ERK), p38, and c-Jun N-terminal kinase (JNK) activation, while CPC and/or LBP increased IL-10, and attenuated proinflammatory markers, Bax protein, NF-κB, and the activation of ERK and JNK. Therefore, CPC and/or LBP possess anti-inflammation by restraining the activation of the ERK signaling pathway, and LBP decreases apoptosis by suppressing the JNK signaling pathway activation in gastric RGM-1 cells with aspirin-induced epithelial damage.
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Popa P, Iordache S, Florescu DN, Iovanescu VF, Vieru A, Barbu V, Bezna MC, Alexandru DO, Ungureanu BS, Cazacu SM. Mortality Rate in Upper Gastrointestinal Bleeding Associated with Anti-Thrombotic Therapy Before and During Covid-19 Pandemic. J Multidiscip Healthc 2022; 15:2679-2692. [PMID: 36425876 PMCID: PMC9680964 DOI: 10.2147/jmdh.s380500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/09/2022] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION During the last few years, a progressive higher proportion of patients have had upper gastrointestinal bleeding (UGIB) related to antithrombotic therapy. The introduction of direct oral anticoagulant (DOAC) and COVID-19 pandemic may change the incidence, mortality, and follow-up, especially in patients at high risk of bleeding. PATIENTS AND METHODS We studied the use of anti-thrombotic therapy (AT) in patients with upper gastrointestinal bleeding for 5 years (January 2017-December 2021) including Covid-19 pandemic period (March 2020-December 2021). We analyzed mortality rate, rebleeding rate and need for transfusion in patients with AT therapy compared with those without AT therapy and risk factors for mortality, and also the incidence of gastrointestinal bleeding in patients admitted for COVID-19 infection. RESULTS A total of 824 patients were admitted during Covid-19 pandemic period and 1631 before pandemic period; a total of 426 cases of bleeding were recorded in patients taking antithrombotic therapy and the frequency of antithrombotic therapy in patients with UGIB was higher in pandemic period (24.39% versus 13.8%). Unadjusted mortality was 12.21%, similar with patients with no antithrombotic treatment but age-adjusted mortality was 9.62% (28% lower). The rate of endoscopy was similar but fewer therapeutic procedures were required. Mean Hb level was 10% lower, and more than 60% of patients required blood transfusion. CONCLUSION Mortality was similar compared with patients with no antithrombotic therapy, fewer therapeutic endoscopies were performed and similar rebleeding rate and emergency surgery were noted. Hb level was 10% lower and a higher proportion of patients required blood transfusions. Mortality was higher in DOAC treatment group compared with VKA patients but with no statistical significance. The rate of upper gastrointestinal bleeding in Covid-19 positive hospitalized cases was 0.58%. The mortality risk in multivariate analysis was associated with GB score, with no endoscopy performed, with obscure and variceal bleeding and with LMWH versus VKA therapy.
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Affiliation(s)
- Petrica Popa
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Sevastita Iordache
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Dan Nicolae Florescu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Vlad Florin Iovanescu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Alexandru Vieru
- Gastroenterology Department, Clinical Emergency County Hospital Craiova, Craiova, Dolj County, Romania
| | - Valentin Barbu
- Gastroenterology Department, Clinical Emergency County Hospital Craiova, Craiova, Dolj County, Romania
| | - Maria-Cristina Bezna
- Cardiology Department, Clinical Emergency County Hospital Craiova, Craiova, Romania
| | - Dragos Ovidiu Alexandru
- Department of Medical Informatics and Statistics, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Bogdan Silviu Ungureanu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Sergiu Marian Cazacu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
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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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Liu Y, Feng DJ, Wang LF, Liu LH, Ren ZH, Hao JY, Li KB, Chen ML. The Impact of Cardiac Dysfunction Based on Killip Classification on Gastrointestinal Bleeding in Acute Myocardial Infarction. Front Med (Lausanne) 2022; 9:865663. [PMID: 35814749 PMCID: PMC9260836 DOI: 10.3389/fmed.2022.865663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background Owing to limited data, the effect of cardiac dysfunction categorized according to the Killip classification on gastrointestinal bleeding (GIB) in patients with acute myocardial infarction (AMI) is unclear. The present study aimed to investigate the impact of cardiac dysfunction on GIB in patients with AMI and to determine if patients in the higher Killip classes are more prone to it. Methods This retrospective study was comprised of patients with AMI who were admitted to the cardiac intensive care unit in the Heart Center of the Beijing Chaoyang Hospital between December 2010 and June 2019. The in-hospital clinical data of the patients were collected. Both GIB and cardiac function, according to the Killip classification system, were confirmed using the discharge diagnosis of the International Classification of Diseases, Tenth Revision coding system. Univariate and multivariate conditional logistic regression models were constructed to test the association between GIB and the four Killip cardiac function classes. Results In total, 6,458 patients with AMI were analyzed, and GIB was diagnosed in 131 patients (2.03%). The multivariate logistic regression analysis showed that the risk of GIB was significantly correlated with the cardiac dysfunction [compared with the Killip class 1, Killip class 2’s odds ratio (OR) = 1.15, 95% confidence interval (CI): 0.73–1.08; Killip class 3’s OR = 2.63, 95% CI: 1.44–4.81; and Killip class 4’s OR = 4.33, 95% CI: 2.34–8.06]. Conclusion This study demonstrates that the degree of cardiac dysfunction in patients with acute myocardial infarction is closely linked with GIB. The higher Killip classes are associated with an increased risk of developing GIB.
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Affiliation(s)
- Yu Liu
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - De-Jing Feng
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Le-Feng Wang
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- *Correspondence: Le-Feng Wang,
| | - Li-Hong Liu
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zheng-Hong Ren
- School of Public Health, Peking University Health Science Center, Beijing, China
| | - Jian-Yu Hao
- Department of Gastroenterology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kui-Bao Li
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Mu-Lei Chen
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Nikaido M, Miyamoto S, Utsumi T, Shimizu T, Nakanishi Y, Kumagai K, Teramura M, Setoyama T, Seno H. Gastric Hyperplastic Polyps Can Shrink After Discontinuation of Proton Pump Inhibitors: A Case Series Compared With Continuation of Proton Pump Inhibitors. J Clin Gastroenterol 2022; 56:e216-e221. [PMID: 34107516 DOI: 10.1097/mcg.0000000000001577] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 05/16/2021] [Indexed: 12/27/2022]
Abstract
GOAL This study investigated whether gastric hyperplastic polyps (GHPs) shrink after discontinuation of proton pump inhibitor (PPI) alone. BACKGROUND Long-term use of PPIs has been reported to increase the incidence of GHPs, which sometimes bleed and cause anemia. We experienced a patient whose recurrent hemorrhagic GHPs associated with long-term use of PPIs had disappeared after discontinuation of PPIs. STUDY This study was conducted retrospectively at Kyoto University Hospital. Patients with histologically confirmed GHPs who had been taking PPIs for >6 months and who had undergone a repeat endoscopy within 2 years were included. Polyp shrinkage was defined as the disappearance of polyps or a reduction of >50% in the long diameter of the largest polyp. RESULTS Six patients who discontinued PPIs were compared with 17 patients who continued PPIs. Polyp shrinkage was significantly more frequent in the PPI-discontinuation group (5/6, 83%) than in the PPI continuation group (0/17, 0%) (P<0.001). In 2 patients in the PPI-discontinuation group, the polyps completely disappeared finally. CONCLUSION These findings suggest that discontinuation of PPIs can shrink GHPs in patients using PPIs.
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Affiliation(s)
- Mitsuhiro Nikaido
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine
| | - Shin'ichi Miyamoto
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto
| | - Takahiro Utsumi
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine
| | - Takahiro Shimizu
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine
| | - Yuki Nakanishi
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine
| | - Ken Kumagai
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine
| | - Mari Teramura
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine
| | - Takeshi Setoyama
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine
- Department of Gastroenterology, Osaka Red Cross Hospital, Osaka, Japan
| | - Hiroshi Seno
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine
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11
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Khumalo GP, Van Wyk BE, Feng Y, Cock IE. A review of the traditional use of southern African medicinal plants for the treatment of inflammation and inflammatory pain. JOURNAL OF ETHNOPHARMACOLOGY 2022; 283:114436. [PMID: 34289396 DOI: 10.1016/j.jep.2021.114436] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 06/13/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Inflammation is a serious global concern due to its debilitating symptoms, resulting in considerable suffering and lost productivity. Chronic and auto-immune inflammatory diseases are of particular concern. Several pharmaceutical therapies are already available. However, the use of non-steroidal anti-inflammatory drugs (NSAID's) is accompanied by harmful and toxic side effects. Hence, the search for safer alternative therapeutics with limited side effects is imperative. The use of medicinal plants is common practice amongst the southern African population and may provide targets for drug development. AIM OF THE STUDY This study aims to review and document the medicinal uses and pharmacological properties of southern African medicinal plants used for inflammation and pain-related ailments. MATERIAL AND METHODS An extensive literature review was undertaken to identify southern African plants used traditionally to treat inflammation. A variety of ethnobotanical books and grey literature, as well as ScienceDirect, Google Scholar and Scopus search engines were used as sources of information. RESULTS This review identified 555 medicinal plants from 118 families which were traditionally used in southern Africa to treat inflammation and pain. Fabaceae was the most prominent family with 63 species, followed by Asteraceae (54 species) and Apocynaceae (33 species). The top category of ailments indicated include non-specific inflammation with 150 species, followed by inflammatory pain (148 species), headache (114 species) and toothache (114 species). CONCLUSION Despite a large number of southern African medicinal plants used to treat inflammation and pain, relatively few have been screened for their anti-inflammatory properties. Furthermore, biologically active plant extracts have been tested against relatively few inflammatory markers and considerable further work is required.
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Affiliation(s)
- Gugulethu P Khumalo
- Environmental Futures Research Institute, Nathan Campus, Griffith University, 170 Kessels Rd, Nathan, Queensland, 4111, Australia; School of Environment and Science, Nathan Campus, Griffith University, 170 Kessels Rd, Nathan, Queensland, 4111, Australia; Griffith Research Institute for Drug Discovery, Griffith University, 46 Don Young Rd, Nathan, Queensland, 4111, Australia
| | - Ben Erik Van Wyk
- Department of Botany and Plant Biotechnology, University of Johannesburg, P.O. Box 524, Auckland Park, 2006, Johannesburg, South Africa
| | - Yunjiang Feng
- School of Environment and Science, Nathan Campus, Griffith University, 170 Kessels Rd, Nathan, Queensland, 4111, Australia; Griffith Research Institute for Drug Discovery, Griffith University, 46 Don Young Rd, Nathan, Queensland, 4111, Australia
| | - Ian E Cock
- Environmental Futures Research Institute, Nathan Campus, Griffith University, 170 Kessels Rd, Nathan, Queensland, 4111, Australia; School of Environment and Science, Nathan Campus, Griffith University, 170 Kessels Rd, Nathan, Queensland, 4111, Australia.
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12
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Kurlander JE, Helminski D, Lanham M, Henstock JL, Kidwell KM, Krein SL, Saini SD, Richardson CR, De Vries R, Resnicow K, Ruff AL, Wallace DM, Jones EK, Perry LK, Parsons J, Ha N, Alexandris-Souphis T, Dedrick D, Aldridge E, Barnes GD. Development of a multicomponent implementation strategy to reduce upper gastrointestinal bleeding risk in patients using warfarin and antiplatelet therapy, and protocol for a pragmatic multilevel randomized factorial pilot implementation trial. Implement Sci Commun 2022; 3:8. [PMID: 35090577 PMCID: PMC8796614 DOI: 10.1186/s43058-022-00256-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/09/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The concomitant use of anticoagulant and antiplatelet medications increases the risk of upper gastrointestinal (GI) bleeding. Two underused evidence-based practices (EBPs) can reduce the risk: de-prescribe unnecessary antiplatelet therapy or initiate a proton pump inhibitor. We describe the development of a multicomponent intervention to increase use of these EBPs in patients treated with warfarin and followed by an anticoagulation monitoring service (AMS), and the design of a pilot pragmatic implementation trial. METHODS A participatory planning group iteratively used Implementation Mapping and the Multiphase Optimization Strategy to develop implementation strategies and plan the trial. Informed by qualitative interviews with patients and clinicians, we drew on several implementation science theories, as well as self-determination theory, to design interventions. For patients, we developed an activation guide to help patients discuss the EBPs with their clinicians. For clinicians, we developed two electronic health record (EHR)-based interventions: (1) clinician notification (CN) consists of a templated message that identifies a patient as high risk, summarizes the EBPs, and links to a guidance statement on appropriate use of antiplatelet therapy. (2) Clinician notification with nurse facilitation (CN+NF) consists of a similar notification message but includes additional measures by nursing staff to support appropriate and timely decision-making: the nurse performs a chart review to identify any history of vascular disease, embeds indication-specific guidance on antiplatelet therapy in the message, and offers to assist with medication order entry and patient education. We will conduct a pilot factorial cluster- and individual-level randomized controlled trial with a primary objective of evaluating feasibility. Twelve clinicians will be randomized to receive either CN or CN+NF for all their patients managed by the AMS while 50 patients will be individually randomized to receive either the activation guide or usual care. We will explore implementation outcomes using patient and clinician interviews along with EHR review. DISCUSSION This pilot study will prepare us to conduct a larger optimization study to identify the most potent and resource conscious multicomponent implementation strategy to help AMSs increase the use of best practices for upper GI bleeding risk reduction. TRIAL REGISTRATION ClinicalTrials.gov NCT05085405 . Registered on October 19, 2021-retrospectively registered.
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Affiliation(s)
- 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.
- Veterans Affairs (VA) Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Danielle Helminski
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael Lanham
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Office of Clinical Informatics, Ann Arbor, MI, USA
| | - Jennifer L Henstock
- Health Information Technology and Services, University of Michigan, Ann Arbor, MI, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs (VA) Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Sameer D Saini
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs (VA) Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Caroline R Richardson
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Raymond De Vries
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kenneth Resnicow
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
- University of Michigan Rogel Cancer Center, Ann Arbor, MI, USA
| | | | - David M Wallace
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth K Jones
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Linda K Perry
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jacqueline Parsons
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Nghi Ha
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tina Alexandris-Souphis
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Dale Dedrick
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth Aldridge
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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13
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Koyama K. Comparison of efficacy and safety in the combination therapies of duloxetine and S-flurbiprofen plaster, and of duloxetine and conventional NSAIDs for chronic pain in patients with osteoarthritis (OASIS DUAL study). Drug Discov Ther 2022; 16:217-224. [DOI: 10.5582/ddt.2022.01052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Kenzo Koyama
- Nagasaki Orthopaedic Koyama Clinic, Nagayo, Nishisonogi, Nagasaki, Japan
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14
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Underutilization of Peptic Ulcer Disease Prophylaxis Among Elderly Users of Antiplatelets and Anticoagulants. Dig Dis Sci 2021; 66:3476-3481. [PMID: 33085015 DOI: 10.1007/s10620-020-06665-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 10/07/2020] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Peptic ulcer disease (PUD) develops in approximately 25% of chronic users of non-steroidal anti-inflammatory drugs (NSAIDs). The incidence of uncomplicated PUD has been declining over the past 3 decades unlike that of complicated PUD in the elderly. An expert consensus document published jointly in 2008 by the American College of Gastroenterology (ACG), the American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA) provided recommendations on prevention of PUD among users of antiplatelets and anticoagulants. This work aimed to evaluate physicians' compliance with these guidelines in a tertiary academic setting. METHODS We examined our medical record database for the 9 month period extending from April 2018 until December 2018. Using this database, we identified elderly patients (> 64 years old) who were chronic (> 3 months) users of low dose aspirin (81 mg once daily) and had an indication for PUD prophylaxis as per the ACG-ACCF-AHA guideline document. We performed a retrospective chart review of patients included in this study. Descriptive statistics were compared using χ2 and independent sample t tests. RESULTS A total of 852 patients were included in this study. The mean age was 75 years old, and 43% of patients were females. In addition to aspirin, patients were prescribed P2Y12 inhibitors (45.5%), direct oral anticoagulants (DOACs) (23%), warfarin (12%), steroids (9%) or enoxaparin (1%). Users of DOACs were most commonly prescribed apixaban (16%), followed by rivaroxaban (6%) and dabigatran (1%). Overall, only 40% of patients with an indication for PUD prophylaxis received a proton pump inhibitor. CONCLUSION PUD prophylaxis may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and an aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.
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15
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Hellström PM, Benno P, Malfertheiner P. Gastrointestinal bleeding in patients with Helicobacter pylori and dual platelet inhibition after myocardial infarction. Lancet Gastroenterol Hepatol 2021; 6:684-685. [PMID: 34391514 DOI: 10.1016/s2468-1253(21)00192-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/21/2021] [Accepted: 05/26/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Per M Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
| | - Peter Benno
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, Germany; Department of Medicine II, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
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16
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Sasaki S, Sasaki E, Kimura Y, Naraoka T, Yamamoto Y, Tsuda E, Ishibashi Y. Treatment Efficacy of Single Topical NSAID (S-Flurbiprofen Plaster) for Knee Symptoms and Locomotive Dysfunction in Knee Osteoarthritis Patients. Prog Rehabil Med 2021; 6:20210029. [PMID: 34316523 PMCID: PMC8290354 DOI: 10.2490/prm.20210029] [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: 03/09/2021] [Accepted: 07/07/2021] [Indexed: 11/15/2022] Open
Abstract
Objective: The aim of this study was to demonstrate the non-inferiority of S-flurbiprofen plaster
(SFPP) monotherapy for treating knee osteoarthritis compared with the combination of
conventional oral and topical non-steroidal anti-inflammatory drugs (NSAIDs). Methods: A total of 222 participants (114, SFPP group; 108, control group) were treated for 4
weeks. The primary endpoint was the change in the degree of pain felt while rising from
a chair after 2 and 4 weeks of treatment as determined using the visual analog scale
(VAS) . The secondary endpoint was the change in functional scores and test results.
Safety was evaluated in terms of the adverse effects. Results: The VAS score significantly decreased in both groups after 2 and 4 weeks of treatment.
Non-inferiority in the VAS score was established only at 2 weeks. There were no
significant differences in the secondary endpoints between the groups. Skin disorders
were more frequent in the SFPP group; however, there was no difference in
gastrointestinal (GI) adverse effects. Conclusions: The therapeutic efficacy of SFPP monotherapy for knee OA, with respect to changes in
the VAS, was not shown to be non-inferior to conventional treatment at 4 weeks; however,
non-inferiority was established at 2 weeks. The functional improvement in the SFPP group
was comparable to that of the control group. No severe GI adverse effects associated
with SFPP administration were observed; however, it is necessary to pay more attention
to the occurrence of skin disorders with SFPP than with conventional topical NSAIDs.
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Affiliation(s)
- Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiji Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takuya Naraoka
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuji Yamamoto
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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17
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Sung JJ. Clopidogrel is no better or worse than aspirin when combined with proton pump inhibitors in the prevention of major adverse event. Is the jury out? J Gastroenterol Hepatol 2021; 36:1733-1734. [PMID: 34263485 DOI: 10.1111/jgh.15578] [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: 12/09/2022]
Affiliation(s)
- Joseph Jy Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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18
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McEvoy L, Carr DF, Pirmohamed M. Pharmacogenomics of NSAID-Induced Upper Gastrointestinal Toxicity. Front Pharmacol 2021; 12:684162. [PMID: 34234675 PMCID: PMC8256335 DOI: 10.3389/fphar.2021.684162] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/11/2021] [Indexed: 12/19/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are a group of drugs which are widely used globally for the treatment of pain and inflammation, and in the case of aspirin, for secondary prevention of cardiovascular disease. Chronic non-steroidal anti-inflammatory drug use is associated with potentially serious upper gastrointestinal adverse drug reactions (ADRs) including peptic ulcer disease and gastrointestinal bleeding. A few clinical and genetic predisposing factors have been identified; however, genetic data are contradictory. Further research is needed to identify clinically relevant genetic and non-genetic markers predisposing to NSAID-induced peptic ulceration.
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Affiliation(s)
- L McEvoy
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - D F Carr
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - M Pirmohamed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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19
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Lee HJ, Kim HK, Kim BS, Han KD, Park JB, Lee H, Lee SP, Kim YJ. Risk of upper gastrointestinal bleeding in patients on oral anticoagulant and proton pump inhibitor co-therapy. PLoS One 2021; 16:e0253310. [PMID: 34138972 PMCID: PMC8211274 DOI: 10.1371/journal.pone.0253310] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/02/2021] [Indexed: 11/18/2022] Open
Abstract
Background Proton pump inhibitors (PPIs) are known to reduce the risk of upper gastrointestinal bleeding in patients on oral anticoagulants, and patients are increasingly on oral anticoagulants and PPI co-therapy. However, evidence is lacking on the safety and effectiveness of oral anticoagulants when co-administered with PPIs. Methods Among patients initiating oral anticoagulants (warfarin and non-vitamin K antagonist oral anticoagulants [NOACs], i.e. rivaroxaban, dabigatran, apixaban, and edoxaban) during 2013–2017, those concomitantly prescribed PPIs were identified (n = 19,851). The primary endpoint was hospitalization for major upper gastrointestinal bleeding, and secondary endpoints were death and ischemic stroke. Results During a mean 1.4 years of follow-up, the primary endpoint occurred in 512 (2.58%) patients. Overall, NOACs were associated with lower upper gastrointestinal bleeding risk after adjustment for age, sex, comorbidities and concomitant medications (adjusted hazard ratio 0.78, 95% confidence interval 0.65–0.94), compared to warfarin. There was no significant difference in upper gastrointestinal bleeding risk among the individual NOACs. This trend of reduced risk for upper gastrointestinal bleeding in NOACs compared to warfarin was consistent for both regular and reduced doses, throughout bleeding risk groups, and other subgroup analyses. NOACs were also associated with lower risk of death compared to warfarin. The risk for ischemic stroke was not significantly different among the oral anticoagulants in patients with atrial fibrillation. Conclusion In patients on oral anticoagulant and PPI co-therapy, NOACs were associated with lower risk of upper gastrointestinal bleeding and mortality compared to warfarin, while there was no difference among the oral anticoagulants for stroke prevention. In patients on PPI therapy, NOACs may preferred over warfarin for decreasing risk of upper gastrointestinal bleeding and mortality.
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Affiliation(s)
- Hyun-Jung Lee
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyung-Kwan Kim
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
- * E-mail:
| | - Bong-Sung Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Jun-Bean Park
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Heesun Lee
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Seung-Pyo Lee
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Yong-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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Imagami T, Takayama S, Maeda Y, Sakamoto M, Kani H. Transcatheter arterial embolization for hemorrhagic rupture of a simple hepatic cyst: A case report. Radiol Case Rep 2021; 16:1956-1960. [PMID: 34149982 PMCID: PMC8193074 DOI: 10.1016/j.radcr.2021.04.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022] Open
Abstract
Hemorrhagic rupture is a very rare and life-threatening hepatic cyst complication. Several treatment methods have been used for hepatic cyst hemorrhage and/or rupture; however, transcatheter arterial embolization for hepatic cyst hemorrhage has been poorly documented. An 80-year-old man receiving dual antiplatelet therapy was diagnosed with hemorrhagic rupture of a hepatic cyst. Transcatheter arterial embolization using a coil was performed for A6 branch confirmed active extravasation. His condition improved promptly after treatment, and the hepatic cyst gradually became smaller as compared to the size before hemorrhage. Transcatheter arterial embolization is suitable for hepatic cyst hemorrhage and might be a minimally invasive treatment option for a symptomatic hepatic cyst.
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Affiliation(s)
- Toru Imagami
- Department of surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Satoru Takayama
- Department of surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Yohei Maeda
- Department of surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Masaki Sakamoto
- Department of surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
| | - Hisanori Kani
- Department of surgery, Nagoya Tokushukai General Hospital, Kasugai City, Japan
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21
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Pioppo L, Bhurwal A, Reja D, Tawadros A, Mutneja H, Goel A, Patel A. Incidence of Non-variceal Upper Gastrointestinal Bleeding Worsens Outcomes with Acute Coronary Syndrome: Result of a National Cohort. Dig Dis Sci 2021; 66:999-1008. [PMID: 32328894 DOI: 10.1007/s10620-020-06266-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/10/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndrome (ACS) and has been shown to increase morbidity and mortality. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization. METHODS This was a retrospective cohort study analyzing the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI, and UA) in patients over 18 years old were included. Non-variceal UGIB with interventions including endoscopy, angiography, and embolization were also evaluated. Primary outcome was the national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included in-hospital mortality, length of stay, and cost of stay. RESULTS A total of 661,404 discharges with principal discharge diagnosis of ACS in 2016 were analyzed. Of the included cohort, 0.80% (n = 5324) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.03, 95% CI 1.03-1.04; p = 0.0001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography. After adjustment of confounders, inpatient mortality was significantly higher in patients with UGIB (OR 2.07, 95% CI 1.63-2.63, p = 0.0001). Non-variceal UGIB also led to significantly longer LOS (10.38 days vs 4.37 days, p = 0.0001) and cost of stay ($177,324 vs $88,468, p = 0.0001). DISCUSSION Our study shows that the national incidence of non-variceal UGIB complicating ACS is low at less than 1%, but resulted in significantly higher inpatient mortality, LOS, and hospitalization charges.
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Affiliation(s)
- Lauren Pioppo
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA.
| | - Abhishek Bhurwal
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
| | - Debashis Reja
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
| | - Augustine Tawadros
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
| | - Hemant Mutneja
- Department of Internal Medicine, John H Stroger, Hospital of Cook County, 1969 Ogden Ave, Chicago, IL, 60612, USA
| | - Akshay Goel
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
| | - Anish Patel
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
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Abrignani MG, Gatta L, Gabrielli D, Milazzo G, De Francesco V, De Luca L, Francese M, Imazio M, Riccio E, Rossini R, Scotto di Uccio F, Soncini M, Zullo A, Colivicchi F, Di Lenarda A, Gulizia MM, Monica F. Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO). Eur J Intern Med 2021; 85:1-13. [PMID: 33279389 DOI: 10.1016/j.ejim.2020.11.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/03/2020] [Accepted: 11/16/2020] [Indexed: 02/05/2023]
Abstract
Aspirin and P2Y12 receptor antagonists are widely used across the spectrum of cardiovascular and cerebrovascular diseases. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed. However, potential increased risk of cardiovascular events has been suggested for PPIs, and, in recent years, it has been discussed whether these drugs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Indeed, pharmacodynamic and pharmacokinetic studies suggested an interaction through hepatic CYP2C19 between PPIs and clopidogrel, which could translate into clinical inefficacy, leading to higher rates of cardiovascular events. The FDA and the EMA sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. In addition, whether the use of PPIs may affect the clinical efficacy of the new P2Y12 receptor antagonists, ticagrelor and prasugrel, remains less known. According to current guidelines, PPIs in combination with antiplatelet treatment are recommended in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids or non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection. Like vitamin K antagonists (VKAs), DOACs can determine gastrointestinal bleeding. Results from both randomized clinical trials and observational studies suggest that high-dose dabigatran (150 mg bid), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GI bleeding as compared with apixaban and warfarin. In patients taking oral anticoagulant with GI risk factor, PPI could be recommended, even if usefulness of PPIs in these patients deserves further data. Helicobacter pylori should always be searched, and treated, in patients with history of peptic ulcer disease (with or without complication). Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition or anticoagulant effect potentially carries a considerable clinical impact. The present joint statement by ANMCO and AIGO summarizes the current knowledge regarding the widespread use of platelet inhibitors, anticoagulants, and PPIs in combination. Moreover, it outlines evidence supporting or opposing drug interactions between these drugs and discusses consequent clinical implications.
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Affiliation(s)
| | - Luigi Gatta
- Gastroenterogy Unit, Versilia Hospital, Lido di Camaiore, Italy
| | | | - Giuseppe Milazzo
- Department of Medicine, Ospedale Vittorio Emanuele III, Salemi, Italy
| | | | - Leonardo De Luca
- Dept. Of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
| | - Maura Francese
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy
| | - Massimo Imazio
- Cardiology, AOU Città della Salute e della Scienza, Turin, Italy
| | - Elisabetta Riccio
- Department of Transplantation, UOSC of Gastroenterology and Endoscopy, AORN 'A. Cardarelli', Napoli, Italy
| | | | | | | | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL ROMA 1, Rome, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, University Hospital and Health Services of Trieste, Italy
| | - Michele Massimo Gulizia
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy; President, Heart Care Foundation, Italy
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste, Italy
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Keller MS, Truong L, Mays AM, Needleman J, Heilemann MSV, Nuckols TK. How do contraindications to non-opioid analgesics and opioids affect the likelihood that patients with back pain diagnoses in the primary care setting receive an opioid prescription? An observational cross-sectional study. BMC FAMILY PRACTICE 2021; 22:41. [PMID: 33610181 PMCID: PMC7896404 DOI: 10.1186/s12875-021-01386-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/08/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Given the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care. METHODS We identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2-4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication. RESULTS In our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1-4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1-3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5-9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0-3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: - 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08-0.23%), 0.44% (95%CI: 0.30-0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03-0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13-0.26%). CONCLUSIONS Patients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.
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Affiliation(s)
- Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA.
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
| | - Lyna Truong
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Allison M Mays
- Division of Geriatrics, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jack Needleman
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | | | - Teryl K Nuckols
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA
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Magnani G, Ardissino D, Im K, Budaj A, Storey RF, Steg PG, Bhatt DL, Cohen M, Oude Ophius T, Goudev A, Parkhomenko A, Kamensky G, Angiolillo DJ, López-Sendón J, Johanson P, Braunwald E, Sabatine MS, Bonaca MP. Predictors, Type, and Impact of Bleeding on the Net Clinical Benefit of Long-Term Ticagrelor in Stable Patients With Prior Myocardial Infarction. J Am Heart Assoc 2021; 10:e017008. [PMID: 33559485 PMCID: PMC7955333 DOI: 10.1161/jaha.120.017008] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Ticagrelor reduces ischemic risk but increases bleeding in patients with prior myocardial infarction. Identification of patients at lower bleeding risk is important in selecting patients who are likely to derive more favorable outcomes versus risk from this strategy. Methods and Results PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis in Myocardial Infarction 54) randomized 21 162 patients with prior myocardial infarction in a 1:1:1 fashion to ticagrelor 60 mg or 90 mg twice daily or placebo, with ticagrelor 60 mg approved for long-term use. TIMI major or minor bleeding was the primary end point for this analysis. Causes of bleeding were categorized by site and etiology, and independent predictors were identified. At 3 years, ticagrelor 60 mg increased the rate of TIMI major or minor bleeding by 2.0% versus placebo (1.4% placebo versus 3.4% ticagrelor). The bleeding excess was driven primarily by spontaneous gastrointestinal bleeds. A history of spontaneous bleeding requiring hospitalization and the presence of anemia were independent predictors of bleeding but not of ischemic risk. Patients with at least 1 risk predictor had 3-fold higher rates of bleeding with ticagrelor 60 mg versus those who had neither (absolute risk increase, 4.4% versus 1.5%; P=0.01). Patients with neither predictor had a more favorable benefit profile with ticagrelor 60 mg versus placebo including lower mortality (hazard ratio, 0.79; 95% CI, 0.65-0.96; P interaction = 0.03). Conclusions In patients with prior myocardial infarction, bleeding with ticagrelor 60 mg twice daily is predominantly spontaneous gastrointestinal. A history of spontaneous bleeding requiring hospitalization or the presence of anemia identifies patients at higher risk of bleeding, and the absence of either identifies patients likely to have a more favorable net benefit with ticagrelor. Registration URL https://www.clinicaltrials.gov/. Unique identifier: NCT01225562.
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Affiliation(s)
| | | | - KyungAh Im
- TIMI Study GroupBrigham and Women's Hospital Boston MA
| | | | | | - P Gabriel Steg
- Dept de Cardiologie Hôpital BichatHôpitaux de Paris Paris France
| | | | - Marc Cohen
- Newark Beth Israel Medical CenterRutgers Medical school Newark NJ
| | | | - Assen Goudev
- Queen Giovanna University Hospital St Sofia Bulgaria
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25
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Abstract
Upper gastrointestinal (GI) bleeding is a common reason for hospital admission in older adult patients and carries a high morbidity and mortality if not properly managed. Risk factors include advanced age, Helicobacter pylori infection, medication use, smoking, and history of liver disease. Patients with known or suspected liver disease and suspected variceal bleeding should also receive antibiotics and somatostatin analogues. Risk stratification scores should be used to determine patients at highest risk for further decompensation. Upper endoscopy is both a diagnostic and therapeutic tool used in the management of upper GI bleeding. Endoscopy should be performed within 24 hours of presentation after appropriate resuscitation. Management of anticoagulation in upper GI bleeding largely depends on the indication for anticoagulation, the risk of continued bleeding with continuing the medication, and the risk of thrombosis with discontinuing the medication. A multidisciplinary approach to the decision of anticoagulation continuation is preferred when possible.
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Affiliation(s)
- Nicholas J Costable
- Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustav L Levy Place, New York, NY 10029, USA
| | - David A Greenwald
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, 11th Floor, New York, NY 10029, USA.
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26
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Chu SJ, Yoon KT, Kim JS. Prevention of Non-steroidal Anti-inflammatory Drug-induced Peptic Ulcers. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2020; 76:232-237. [PMID: 33234769 DOI: 10.4166/kjg.2020.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 11/03/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAID) are some of the most commonly prescribed medications in clinical practice. The long-term use of NSAIDs is one of the main causes of peptic ulcers and the increased risk of upper gastrointestinal tract complications, such as perforation and bleeding. Thus, the prevention of NSAID-induced peptic ulcers is an important clinical issue. Previous studies have evaluated various strategies for preventing ulcers in patients requiring prolonged NSAID use. The Korean clinical practice guidelines have been published recently based on the evidence of the currently available data. This review describes the strategies for the prevention of peptic ulcers due to NSAID. An assessment of the risk factors for peptic ulcers from NSAID is recommended to identify patients who should be considered for primary prophylaxis. The risk of NSAID-induced peptic ulcers can be reduced by the concomitant use of proton pump inhibitors (PPI), misoprostol, and histamine-2 receptor antagonists. Selective cyclooxygenase-2 inhibitors can be used with caution due to concerns regarding cardiovascular toxicity. Attempts should be made to use the lowest dose and shortest duration of the NSAID.
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Affiliation(s)
- Seong Jun Chu
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyu-Tae Yoon
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Patil T, Murphy K, Woodard L, Lebrecht M. Proton Pump Inhibitor Utilization in Veteran Patients on Combined Antithrombotic Therapy and Validation of Simplified Bleeding Risk Score. Pharmacotherapy 2020; 40:1219-1227. [PMID: 33073362 DOI: 10.1002/phar.2477] [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] [Indexed: 12/29/2022]
Abstract
BACKGROUND Concomitant use of anticoagulant and antiplatelet agents can increase the risk of gastrointestinal bleed (GIB). Use of proton pump inhibitors (PPIs) has been proposed to decrease the risk of GIB in patients on combined antithrombotic therapy (CAT). OBJECTIVE To describe the current utilization of PPIs in veteran patients on CAT and associated clinical predictors of GIB. METHODS This retrospective study included patients on CAT receiving PPIs, with at least one of the CAT agents initiated between January 1, 2018 and October 30, 2018. Data were extracted from the computerized patient record system. Primary end point included estimating proportion of patients on CAT receiving PPI co-therapy, describing patient characteristics, and identifying clinical predictors of GIB. Secondary outcomes included reporting GIB events and all-cause mortality. Additional outcome was to validate the five-factor risk score (FFRS) for GIB in patients on CAT and compare its overall predictive performance to HAS-BLED score. RESULTS This study reports an overall rate of PPI co-therapy in patients on CAT of 40.9% (484/1181), with only 22.3% of patients on CAT receiving PPI for GIB prophylaxis. There was no difference in the mean follow up duration of PPI users and PPI co-therapy (264.01 vs 271.92 days; p=0.3761). Current alcohol use (p=0.005), current smokers (p=0.022), chronic kidney disease (p=0.004), peptic ulcer disease (p<0.001), and non-steroidal anti-inflammatory drug use (p=0.048) were significant predictors of GIB in multivariate analyses of our study cohort. We further provide exploratory validation that use of a simplified FFRS to predict GIB showed a trend towards better overall predictive performance as compared to HAS-BLED score (C-statistic: 0.738; 95% CI 0.684-0.787 for FFRS vs C-statistic: 0.596; 95% CI 0.538-0.653 for HAS-BLED; p=0.0094). CONCLUSION This study reports lower rate of PPI co-therapy in veteran patients on CAT per currently available guidance. Further we explore utilization of simplified FFRS model to predict GIB in patients on CAT with long-term PPI co-therapy.
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Affiliation(s)
- Tanvi Patil
- Veterans Health Administration - Pharmacy, Salem, Virginia, USA
| | - Kimberly Murphy
- Veterans Health Administration - Pharmacy, Salem, Virginia, USA
| | - Laura Woodard
- Veterans Health Administration - Pharmacy, Salem, Virginia, USA
| | - Morgan Lebrecht
- Veterans Health Administration - Pharmacy, Salem, Virginia, USA
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28
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Tyler KR, Hullick C, Newton BA, Adams CB, Arendts G. Emergency department pain management in older patients. Emerg Med Australas 2020; 32:840-846. [PMID: 32594659 DOI: 10.1111/1742-6723.13562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Katren R Tyler
- Department of Emergency Medicine, University of California, Davis, Davis, California, USA
| | - Carolyn Hullick
- Emergency Department, Hunter New England Health, Newcastle, New South Wales, Australia
| | - Brittany A Newton
- Department of Pharmacy Services, UC Davis Health System, University of California, Davis, Davis, California, USA
| | - Christopher B Adams
- Department of Pharmacy Services, UC Davis Health System, University of California, Davis, Davis, California, USA
| | - Glenn Arendts
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Emergency Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
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29
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Tang C, Zhu Y, Yang X, Xu B, Ye C, Yang Y, Zhong J, Zhao Q, Yu L. Upper gastrointestinal mucosal injury associated with ticagrelor plus aspirin, ticagrelor alone, or aspirin alone at 1-year after coronary artery bypass grafting. J Gastroenterol Hepatol 2020; 35:1720-1730. [PMID: 32154936 DOI: 10.1111/jgh.15030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 02/11/2020] [Accepted: 03/07/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM The presence and severity of upper gastrointestinal mucosal lesions have not been evaluated using esophagogastroduodenoscopy (EGD) in patients receiving ticagrelor plus aspirin or alone after myocardial revascularization. We assessed upper gastrointestinal mucosal injury and the use of proton pump inhibitors (PPIs) in patients receiving 1 year of antiplatelet therapy after coronary artery bypass grafting (CABG). METHODS In this single-center prospective substudy of a randomized trial, 231 patients completing 1-year antiplatelet therapy (ticagrelor 90 mg twice daily plus aspirin 100 mg once daily, ticagrelor 90 mg twice daily, or aspirin 100 mg once daily, in 81, 80, and 70 patients, respectively) after CABG underwent 13 C urea breath testing and EGD. Gastroduodenal lesions were assessed by modified Lanza score, and reflux esophagitis was evaluated according to Los Angeles classification. Additionally, at least one ulcer ≥ 5 mm was separately analyzed. RESULTS Among 231 patients, EGD showed 28 (12.1%) with ulcers ≥ 5 mm, which were detected in 13.6% (11/81) of ticagrelor plus aspirin recipients, 8.8% (7/80) of ticagrelor recipients, and 14.3% (10/70) of aspirin recipients, and 24 (10.4%) had reflux esophagitis. Eighty-eight (38.1%) patients had a positive 13 C urea breath testing after 1 year of treatment, and one patient received eradication therapy during follow up. Nineteen (8.2%) patients received a PPI for ≥ 6 months. CONCLUSIONS Severe upper gastrointestinal mucosal lesions were more frequently observed in patients treated with ticagrelor plus aspirin and aspirin monotherapy than in patients treated with ticagrelor monotherapy for 1 year post-CABG. Prophylactic use of PPIs might be inadequate.
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Affiliation(s)
- Chenyue Tang
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaobo Yang
- Department of Geriatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bin Xu
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cong Ye
- Department of Cardiovascular Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Yang
- Department of Cardiovascular Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Zhong
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lifen Yu
- Department of Gastroenterology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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30
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Extended antiplatelet therapy with clopidogrel alone versus clopidogrel plus aspirin after completion of 9- to 12-month dual antiplatelet therapy for acute coronary syndrome patients with both high bleeding and ischemic risk. Rationale and design of the OPT-BIRISK double-blinded, placebo-controlled randomized trial. Am Heart J 2020; 228:1-7. [PMID: 32739652 PMCID: PMC7346838 DOI: 10.1016/j.ahj.2020.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 07/05/2020] [Indexed: 12/15/2022]
Abstract
Background Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is the cornerstone for prevention ischemic events in patients with acute coronary syndromes (ACS) and undergoing percutaneous coronary intervention. However, the optimal antiplatelet strategy for ACS patients with both high bleeding and high ischemic risks is unclear. Study design The OPT-BIRISK trial is a multicenter, double-blinded, placebo-controlled randomized study designed to test the superiority of extended antiplatelet therapy with clopidogrel monotherapy compared with aspirin and clopidogrel for reduction of bleeding events in ACS patients with both high bleeding and high ischemic risks (“bi-risk”). A total of 7,700 patients who completed 9- to 12-month dual antiplatelet therapy after new-generation drug-eluting stent implantation for the treatment of ACS will be randomized to receive clopidogrel monotherapy or aspirin plus clopidogrel for 9 months followed by aspirin monotherapy for 3 months. The primary end point is Bleeding Academic Research Consortium type 2, 3, or 5 bleedings at 9 months after randomization. The key secondary end point is major adverse cardiac and cerebral events at 9 months after randomization, defined as a composite of all-cause death, myocardial infarction, stroke, or coronary artery revascularization. Conclusions OPT-BIRISK is the first large-scale randomized trial aimed to explore the optimal antiplatelet strategy for bi-risk ACS patients after percutaneous coronary intervention in current clinical practice. The results will add evidence regarding de-escalation antiplatelet therapy for patients at special risk.
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31
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Ho KY, Cardosa MS, Chaiamnuay S, Hidayat R, Ho HQT, Kamil O, Mokhtar SA, Nakata K, Navarra SV, Nguyen VH, Pinzon R, Tsuruoka S, Yim HB, Choy E. Practice Advisory on the Appropriate Use of NSAIDs in Primary Care. J Pain Res 2020; 13:1925-1939. [PMID: 32821151 PMCID: PMC7422842 DOI: 10.2147/jpr.s247781] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/24/2020] [Indexed: 12/14/2022] Open
Abstract
Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks.
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Affiliation(s)
- Kok Yuen Ho
- The Pain Clinic, Mt Alvernia Hospital, Singapore
| | | | - Sumapa Chaiamnuay
- Rheumatic Disease Unit, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Rudy Hidayat
- Rheumatology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusomo Hospital, Jakarta, Indonesia
| | | | - Ozlan Kamil
- Gleneagles Hospital, Kuala Lumpur, Malaysia.,Prince Court Medical Center, Kuala Lumpur, Malaysia
| | - Sabarul A Mokhtar
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Ken Nakata
- Department of Health and Sport Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Sandra V Navarra
- Section of Rheumatology, Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Van Hung Nguyen
- Department of Rheumatology, Bach Mai Hospital, Hanoi, Vietnam
| | - Rizaldy Pinzon
- Department of Neurology, Faculty of Medicine, Kristen Duta Wacana University, Bethesda Hospital, Yogyakarta, Indonesia
| | | | - Heng Boon Yim
- Mount Elizabeth Novena Hospital, Singapore.,Faculty of Medicine, National University of Singapore, Singapore
| | - Ernest Choy
- Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
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Farhat N, Birkett N, Haddad N, Fortin Y, Momoli F, Wen SW, Wielgosz A, McNair DS, Mattison DR, Krewski D. Risk of Adverse Cardiovascular Events Following a Myocardial Infarction in Patients Receiving Combined Clopidogrel and Proton Pump Inhibitor Treatment: A Nested Case-Control Study. Drugs Real World Outcomes 2020; 7:191-203. [PMID: 32617885 PMCID: PMC7392938 DOI: 10.1007/s40801-020-00204-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background The clinical implications of potential interactions between proton pump inhibitors (PPIs) and clopidogrel have been debated for over a decade. Objective We assessed the association between combined clopidogrel–PPI treatment and the risk of recurrent myocardial infarction (MI) and three secondary outcomes. Patients and Methods A nested case–control study was conducted within Cerner Corporation’s Health Facts® database. A retrospective cohort of patients who experienced a first MI and started clopidogrel treatment was created. Within this cohort, patients experiencing a second MI (cases) were matched with up to five controls. Logistic regression was used to estimate adjusted odds ratios (aORs). Findings were compared with those obtained from models with three negative control exposure drugs: H2 receptor antagonists, prasugrel, and ticagrelor. Results In total, 2890 recurrent MI cases were identified within 12 months following entry into the cohort of clopidogrel users (N = 52,006). aOR for PPI use versus non-use among clopidogrel users was 1.08 [95% confidence interval (CI) 0.95–1.23]. Similar ORs were obtained for secondary endpoints. A positive association between combined use of clopidogrel/PPIs and increased risk of MI was seen in the group aged 80–89 years (aOR 1.26; 95% CI 1.05–1.51). No associations with MI were observed for (1) H2 receptor antagonist use versus non-use among clopidogrel users or (2) PPI use versus non-use among prasugrel users or among ticagrelor users. Conclusions Overall, our findings do not support a significant adverse clinical impact of concomitant clopidogrel/PPI use by patients with MI. Nonetheless, investigation of the possible association seen in those aged 80–89 years may be warranted. Electronic supplementary material The online version of this article (10.1007/s40801-020-00204-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nawal Farhat
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada. .,McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada.
| | - Nicholas Birkett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada
| | - Nisrine Haddad
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada
| | - Yannick Fortin
- McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Risk Sciences International, Ottawa, ON, Canada
| | - Shi Wu Wen
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,OMNI Research Group, Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, ON, Canada
| | | | | | - Donald R Mattison
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada.,Risk Sciences International, Ottawa, ON, Canada
| | - Daniel Krewski
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,McLaughlin Centre for Population Health Risk Assessment, Ottawa, ON, Canada.,Risk Sciences International, Ottawa, ON, Canada
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Gramont B, Bertoletti L, Roy M, Roblin X, Tardy B, Cathébras P. [Use and management of proton pump inhibitors: An observational study]. Therapie 2020; 75:649-662. [PMID: 32591130 DOI: 10.1016/j.therap.2020.03.002] [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: 12/10/2019] [Revised: 03/09/2020] [Accepted: 03/17/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) have improved the management and prevention of digestive diseases, leading to a heavy prescription of this therapy. In 2015, nearly one quarter of the French population had consumed a PPI and half of them were long-term users. The main objective of this study was to analyze, in patients hospitalized in several medical departments, the adequacy of long-term PPI prescriptions to recommendations. METHOD The Use and management of proton pump inhibitors: an observational study project (UTOPPIA) is a longitudinal observational study conducted at the University Hospital of Saint-Étienne in the departments of hepato-gastroenterology, infectious and tropical diseases, internal medicine, vascular medicine and nephrology. All patients with PPI treatment on their usual outpatient prescription were interviewed. RESULTS Over a 3-month period, 334 of hospitalized patients (30.7%) had received a long-term PPI prescription and 181 patients (54.2%) could be included in the study for a total of 274 indications. Ninety-nine patients (54.7%) had a long-term PPI prescription in accordance with the recommendations. The most frequent indication (70 prescriptions) was the prescription of an antiplatelet drug or anticoagulant for subjects at high risk of bleeding in 70 prescriptions. Fifty-three PPI treatments were amended during the hospital stay, including 9 discontinuations. The justification for the change was documented in the patients' chart in only 17% of cases. Individual interviews of patients revealed that 75.1% of them were in favour of discontinuing their PPI treatment. CONCLUSIONS About one-third of hospitalized patients in medical wards in France have long-term PPI treatment and half of these prescriptions do not comply with good practice recommendations. A majority of patients report being willing to try to stop PPI therapy.
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Affiliation(s)
- Baptiste Gramont
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France.
| | - Laurent Bertoletti
- Service de médecine vasculaire et thérapeutique, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Michel Roy
- Centre régional de pharmacovigilance, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Xavier Roblin
- Service d'hépato-gastro-entérologie, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Bernard Tardy
- Centre d'investigation clinique, Inserm CIC 1408, 42055 Saint-Étienne, France
| | - Pascal Cathébras
- Service de médecine interne, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France
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Khammissa RAG, Ballyram R, Fourie J, Bouckaert M, Lemmer J, Feller L. Selected pathobiological features and principles of pharmacological pain management. J Int Med Res 2020; 48:300060520903653. [PMID: 32408839 PMCID: PMC7232056 DOI: 10.1177/0300060520903653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 01/07/2020] [Indexed: 12/12/2022] Open
Abstract
Pain induced by inflammation and nerve injury arises from abnormal neural activity of primary afferent nociceptors in response to tissue damage, which causes long-term elevation of the sensitivity and responsiveness of spinal cord neurons. Inflammatory pain typically resolves following resolution of inflammation; however, nerve injury-either peripheral or central-may cause persistent neuropathic pain, which frequently manifests as hyperalgesia or allodynia. Neuralgias, malignant metastatic bone disease, and diabetic neuropathy are some of the conditions associated with severe, often unremitting chronic pain that is both physically and psychologically debilitating or disabling. Therefore, optimal pain management for patients with chronic neuropathic pain requires a multimodal approach that comprises pharmacological and psychological interventions. Non-opioid analgesics (e.g., paracetamol, aspirin, or other non-steroidal anti-inflammatory drugs) are first-line agents used in the treatment of mild-to-moderate acute pain, while opioids of increasing potency are indicated for the treatment of persistent, moderate-to-severe inflammatory pain. N-methyl D-aspartate receptor antagonists, antidepressants, anticonvulsants, or a combination of these should be considered for the treatment of chronic neuropathic pain. This review discusses the various neural signals that mediate acute and chronic pain, as well as the general principles of pain management.
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Affiliation(s)
- Razia Abdool Gafaar Khammissa
- Department of Periodontology and Oral Medicine, Sefako Makgatho
University, Pretoria, South Africa
- Department of Periodontics and Oral Medicine, University of
Pretoria, Pretoria, South Africa
| | - Raoul Ballyram
- Department of Periodontology and Oral Medicine, Sefako Makgatho
University, Pretoria, South Africa
| | - Jeanine Fourie
- Department of Periodontology and Oral Medicine, Sefako Makgatho
University, Pretoria, South Africa
| | - Michael Bouckaert
- Department of Maxillofacial and Oral Surgery, Sefako Makgatho
University, Pretoria, South Africa
| | - Johan Lemmer
- Department of Periodontology and Oral Medicine, Sefako Makgatho
University, Pretoria, South Africa
| | - Liviu Feller
- Department of Periodontology and Oral Medicine, Sefako Makgatho
University, Pretoria, South Africa
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Bielsa-Fernández M, Tamayo-de la Cuesta J, Lizárraga-López J, Remes-Troche J, Carmona-Sánchez R, Aldana-Ledesma J, Avendaño-Reyes J, Ballesteros-Amozorrutia M, De Ariño M, de Giau-Triulzi L, Flores-Rendón R, Huerta-Guerrero H, González-González J, Hernández-Guerrero A, Murcio-Pérez E, Jáquez-Quintana J, Meixueiro-Daza A, Nogueira-de Rojas J, Rodríguez-Hernández H, Santoyo-Valenzuela R, Solorzano-Olmos S, Uscanga-Domínguez L, Zamarripa-Dorsey F. Consenso mexicano sobre diagnóstico, prevención y tratamiento de la gastropatía y enteropatía por antiinflamatorios no esteroideos. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 85:190-206. [DOI: 10.1016/j.rgmx.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/27/2019] [Accepted: 11/27/2019] [Indexed: 02/07/2023]
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36
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Bielsa-Fernández M, Tamayo-de la Cuesta J, Lizárraga-López J, Remes-Troche J, Carmona-Sánchez R, Aldana-Ledesma J, Avendaño-Reyes J, Ballesteros-Amozorrutia M, De Ariño M, de Giau-Triulzi L, Flores-Rendón R, Huerta-Guerrero H, González-González J, Hernández-Guerrero A, Murcio-Pérez E, Jáquez-Quintana J, Meixueiro-Daza A, Nogueira-de Rojas J, Rodríguez-Hernández H, Santoyo-Valenzuela R, Solorzano-Olmos S, Uscanga-Domínguez L, Zamarripa-Dorsey F. The Mexican consensus on the diagnosis, treatment, and prevention of NSAID-induced gastropathy and enteropathy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020. [DOI: 10.1016/j.rgmxen.2019.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Szeto CC, Sugano K, Wang JG, Fujimoto K, Whittle S, Modi GK, Chen CH, Park JB, Tam LS, Vareesangthip K, Tsoi KKF, Chan FKL. Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations. Gut 2020; 69:617-629. [PMID: 31937550 DOI: 10.1136/gutjnl-2019-319300] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/06/2019] [Accepted: 12/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications. OBJECTIVE To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs. METHODS Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations. RESULTS Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases. CONCLUSION NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong
| | - Kentaro Sugano
- Jichi Medical University, Shimotsuke, Tochigi, Japan.,Asian Pacific Association of Gastroenterology (APAGE), Tochigi, Japan
| | - Ji-Guang Wang
- Shanghai Institute of Hypertension, Shanghai, Shanghai, China.,Asia Pacific Society of Hypertension (APSH), Shanghai, China
| | - Kazuma Fujimoto
- Saga University, Saga, Japan.,Asia-Pacific Society for Digestive Endoscopy (APSDE), Saga, Japan
| | - Samuel Whittle
- The University of Adelaide, Adelaide, South Australia, Australia.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Gopesh K Modi
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Samarpan Kidney Institute and Research Center, Bhopal, India
| | - Chen-Huen Chen
- National Yang-Ming University, Taipei, Taiwan.,Pulse of Asia (PoA), Taipei, Taiwan
| | - Jeong-Bae Park
- Pulse of Asia (PoA), Taipei, Taiwan.,JB Lab and Clinic and Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Lai-Shan Tam
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Kriengsak Vareesangthip
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Mahidol University, Nakorn Pathom, Thailand
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McEvoy JW, Keane M, Ng J. Primary prevention aspirin among the elderly: challenges in translating trial evidence to the clinic. THE BRITISH JOURNAL OF CARDIOLOGY 2020; 27:07. [PMID: 35747418 PMCID: PMC8793932 DOI: 10.5837/bjc.2020.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The ASPirin in Reducing Events in the Elderly trial (ASPREE) contributed important knowledge about primary cardiovascular disease (CVD) prevention among healthy older adults. The finding that daily low-dose aspirin (LDA) does not statistically prevent disability or CVD among adults aged over 70 years when compared with placebo, but does significantly increase risk of haemorrhage, immediately influenced clinical practice guidelines. In this article, we discuss nuances of the trial that may impact the extrapolation of the ASPREE trial results to the everyday individual clinical care of older adults.
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Affiliation(s)
- J William McEvoy
- Professor of Preventive Cardiology National University of Ireland and National Institute for Prevention and Cardiovascular Health, Moyola Lane, Newcastle, Galway, H91 FF68, Ireland
| | - Michael Keane
- Consultant Anaesthetist, Casey Hospital, Adjunct Associate Professor, Swinburne University, and Adjunct Senior Lecturer, Monash University Casey Hospital, Monash Health, 62 Kangan Drive, Berwick, Victoria 3806, Australia
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Manolis AA, Manolis TA, Melita H, Katsiki N, Manolis AS. Proton pump inhibitors and cardiovascular adverse effects: Real or surreal worries? Eur J Intern Med 2020; 72:15-26. [PMID: 31796246 DOI: 10.1016/j.ejim.2019.11.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/21/2019] [Accepted: 11/24/2019] [Indexed: 02/06/2023]
Abstract
Proton pump inhibitors (PPIs) are among the most widely prescribed agents, either for treatment or prophylaxis of gastrointestinal (GI) disease, that are often administered for prolonged or chronic use. Patients with cardiovascular (CV) disease frequently receive PPIs for prophylaxis against GI bleeding due to common use of antithrombotic drugs. Over the last several years there is a growing number of reports associating chronic PPI use with a variety of serious CV and non-CV adverse effects. In this context, PPI use has been independently associated with an increased risk of CV morbidity (myocardial infarction, stroke, other CV events) and mortality. However, the critique remains that these data do not largely derive from randomized controlled trials. On the other hand, in certain conditions, the benefits of PPIs may outweigh the risks of adverse CV effects. As the indications for prolonged, particularly lifelong, prophylactic use of PPIs are not compelling and in the light of evidence of serious CV and other adverse effects, clinicians have to reconsider such long-term use of these drugs. Importantly, histamine 2 blockers have not been found to be associated with increased CV risk and thus may be an alternative therapeutic option in certain patients. These issues are amply discussed together with the potential mechanisms of these pleiotropic and off-target effects of PPIs, which are also depicted in an illustrative schema; data are also presented on differential effects of specific agents involved, alternative modes of therapy available, and relevant current guidelines on this issue.
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Affiliation(s)
| | | | | | - Niki Katsiki
- First Department of Internal Medicine, Division of Endocrinology and Metabolism, Diabetes Center, Medical School, AHEPA University Hospital, Thessaloniki, Greece
| | - Antonis S Manolis
- Third and First Department of Cardiology, Athens University School of Medicine, Ippokrateio Hospital, Vas. Sofias 114, Athens 115 27, Greece.
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Sattayalertyanyong O, Thitilertdecha P, Auesomwang C. The inappropriate use of proton pump inhibitors during admission and after discharge: a prospective cross-sectional study. Int J Clin Pharm 2019; 42:174-183. [PMID: 31865594 DOI: 10.1007/s11096-019-00955-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/13/2019] [Indexed: 12/11/2022]
Abstract
Background Proton pump inhibitors are often inappropriately prescribed during hospital admission and after discharge. The inappropriate prescription may be associated with increased and unnecessary healthcare costs. Objective To determine the prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge at Thailand's largest national tertiary referral center. Setting Medicine wards at Siriraj Hospital (Bangkok, Thailand) during September 2016 to September 2017. Method This prospective observational cross-sectional study in hospitalized patients who were prescribed, or who were already taking proton pump inhibitors. Medical records were reviewed to determine whether proton pump inhibitors were prescribed at discharge and at the 1-month follow-up. Main outcome measure Prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge, indication of inappropriate prescription. Results Two hundred and sixty-five patients (mean age: 65.8 ± 18.3 years, 50.9% men) were included. Approximately half of patients had proton pump inhibitor treatment initiated in the hospital, and the other 50.6% started treatment earlier. Among all patients, 50.6% were inappropriately prescribed proton pump inhibitors, in which 79.1% resulted from invalid indications. Fifty-two percent and 47.3% of patients who were prescribed proton pump inhibitors at discharge and at the 1-month follow-up had no indications for them. Gastrointestinal ulcer prophylaxis in low-risk patients was the most commonly observed incorrect indication. Aspirin (p = 0.030) and corticosteroids (p = 0.038) were both found to be significantly associated with the inappropriate prescription of proton pump inhibitors. The estimated cost of inappropriate use among inpatients and outpatients was $118,659 and $214,663 per year, respectively. Conclusion Proton pump inhibitors are excessively and inappropriately prescribed during hospital admission and after discharge in Thailand. The cost of this overprescribing is excessive and needs to be controlled.
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Affiliation(s)
- Onuma Sattayalertyanyong
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Premrutai Thitilertdecha
- Research Group in Immunobiology and Therapeutic Sciences, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chonticha Auesomwang
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
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41
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Kanno T, Moayyedi P. Proton Pump Inhibitors in the Elderly, Balancing Risk and Benefit: an Age-Old Problem. Curr Gastroenterol Rep 2019; 21:65. [PMID: 31807948 DOI: 10.1007/s11894-019-0732-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Proton pump inhibitors (PPIs) are one of the most prescribed drugs in the developed world and elderly patients are particularly likely to be prescribed acid suppression. There have been reports of many diseases being associated with PPI therapy and the elderly would be particular at risk of any harms these drugs may cause. This review therefore reviews the evidence of the risks and benefits of these drugs. RECENT FINDINGS PPIs are very effective at treating acid-related disorders. Recent randomized trials have suggested that the associations between PPI and various diseases are likely to be related to bias and residual confounding and these drugs appear to be safe apart from a possible increase risk of enteric infections. PPIs should be used at the lowest dose and for the shortest duration possible. They are still relatively safe drugs but should only be prescribed for proven indications.
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Affiliation(s)
- Takeshi Kanno
- Farncombe Family Digestive Health Research Institute, McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada
| | - Paul Moayyedi
- Farncombe Family Digestive Health Research Institute, McMaster University, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada.
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42
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Nascimento LO, Scremin J, Mattos GJ, Gomes A, Clausen DN, Sartori ER. A Novel Strategy for Quantifying Clopidogrel Using Square‐wave Voltammetry and a Boron‐doped Diamond Film. ELECTROANAL 2019. [DOI: 10.1002/elan.201900219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Louise Oliveira Nascimento
- Universidade Estadual de Londrina (UEL)Centro de Ciências Exatas, Departamento de Química Rodovia Celso Garcia Cid, PR-445 Km 380 Londrina-PR, C.P. 10.011 86057-970 Brazil
| | - Jessica Scremin
- Universidade Estadual de Londrina (UEL)Centro de Ciências Exatas, Departamento de Química Rodovia Celso Garcia Cid, PR-445 Km 380 Londrina-PR, C.P. 10.011 86057-970 Brazil
| | - Gabriel Junquetti Mattos
- Universidade Estadual de Londrina (UEL)Centro de Ciências Exatas, Departamento de Química Rodovia Celso Garcia Cid, PR-445 Km 380 Londrina-PR, C.P. 10.011 86057-970 Brazil
| | - Adriana Gomes
- Universidade Estadual de Londrina (UEL)Centro de Ciências Exatas, Departamento de Química Rodovia Celso Garcia Cid, PR-445 Km 380 Londrina-PR, C.P. 10.011 86057-970 Brazil
| | - Débora Nobile Clausen
- Universidade Estadual de Londrina (UEL)Centro de Ciências Exatas, Departamento de Química Rodovia Celso Garcia Cid, PR-445 Km 380 Londrina-PR, C.P. 10.011 86057-970 Brazil
| | - Elen Romão Sartori
- Universidade Estadual de Londrina (UEL)Centro de Ciências Exatas, Departamento de Química Rodovia Celso Garcia Cid, PR-445 Km 380 Londrina-PR, C.P. 10.011 86057-970 Brazil
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Abstract
There is increasing concern among patients and health care providers about the associations between PPI use and a multitude of potential adverse outcomes. Therefore, clinicians need to have a rational approach both to identifying PPI users who may not have an ongoing indication for their use and on how to encourage discontinuation of unnecessary PPI use. In this paper, we will provide a detailed review of the specific indications where the benefits of ongoing PPI use is of questionable value and will review the evidence on how to maximize the likelihood of being able to successfully discontinue PPI use while minimizing symptom recurrence.
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44
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Pittayanon R, Piyachaturawat P, Rerknimitr R, Prueksapanich P, Chaitongrat S, Lertsuwunseri V, Srimahachota S, Mahachai V. Cytoprotective agent for peptic ulcer prevention in patients taking dual antiplatelet agents: A randomized, double-blind placebo-controlled trial. J Gastroenterol Hepatol 2019; 34:1517-1522. [PMID: 30919492 DOI: 10.1111/jgh.14671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/13/2019] [Accepted: 03/24/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIM Long-term use of dual antiplatelets is increasing, and most patients need primary peptic ulcer prophylaxis. The long-term use of proton pump inhibitors (PPIs) is associated with adverse events. We evaluated the efficacy of rebamipide for peptic ulcer prevention. METHODS This randomized controlled trial was conducted between July 2014 and November 2017. Patients receiving dual antiplatelets for ≥ 1 year with no history of peptic ulcer bleeding or perforation were recruited and randomly assigned to the rebamipide (300 mg/day) group or the placebo group. Patients who used proton pump inhibitors were excluded. The primary endpoint was a new mucosal break on esophagogastroduodenoscopy at 3 or 12 months after treatment initiation. The secondary endpoints were hematocrit changes from the baseline, gastrointestinal bleeding, and chest pain. Antiplatelet function was assessed. RESULTS In total, 95 eligible patients were identified; 12 were excluded, and 83 patients were randomized, with 66 (79.5%) and 59 (71.1%) patients eligible at the 3- and 12-month follow ups, respectively. The baseline characteristics were equivalent between the groups. During the 12 months of follow up, 13 patients (43.3%) taking rebamipide and 19 (65.5%) taking the placebo experienced mucosal injury (P = 0.07). Two patients (6.7%) taking rebamipide and eight (27.6%) taking the placebo had peptic ulcers ≥ 5 mm or < 5 mm with pigmented spots (P = 0.03). The changes in hematocrit were not different between the two groups. Neither bleeding ulcers nor chest pain was observed. CONCLUSION Rebamipide is safe and may prevent peptic ulcers ≥ 5 mm in diameter or those with pigmented spots in patients receiving dual antiplatelets for 1 year (NCT02166008).
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Affiliation(s)
- Rapat Pittayanon
- Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Panida Piyachaturawat
- Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Piyapan Prueksapanich
- Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Supakarn Chaitongrat
- Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Vorarit Lertsuwunseri
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Suphot Srimahachota
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
| | - Varocha Mahachai
- Division of Gastroenterology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross, Bangkok, Thailand
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Qamar A, Vaduganathan M, Greenberger NJ, Giugliano RP. Oral Anticoagulation in Patients With Liver Disease. J Am Coll Cardiol 2019; 71:2162-2175. [PMID: 29747837 DOI: 10.1016/j.jacc.2018.03.023] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/03/2018] [Accepted: 03/06/2018] [Indexed: 12/13/2022]
Abstract
Patients with liver disease are at increased risks of both thrombotic and bleeding complications. Many have atrial fibrillation (AF) or venous thromboembolism (VTE) necessitating oral anticoagulant agents (OACs). Recent evidence has contradicted the assumption that patients with liver disease are "auto-anticoagulated" and thus protected from thrombotic events. Warfarin and non-vitamin K-antagonist OACs have been shown to reduce thrombotic events safely in patients with either AF or VTE. However, patients with liver disease have largely been excluded from trials of OACs. Because all currently approved OACs undergo metabolism in the liver, hepatic dysfunction may cause increased bleeding. Thus, the optimal anticoagulation strategy for patients with AF or VTE who have liver disease remains unclear. This review discusses pharmacokinetic and clinical studies evaluating the efficacy and safety of OACs in patients with liver disease and provides a practical, clinically oriented approach to the management of OAC therapy in this population.
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Affiliation(s)
- Arman Qamar
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Muthiah Vaduganathan
- Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Norton J Greenberger
- Gastroenterology, Hepatology, and Endoscopy Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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46
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Moayyedi P, Eikelboom JW, Bosch J, Connolly SJ, Dyal L, Shestakovska O, Leong D, Anand SS, Störk S, Branch KRH, Bhatt DL, Verhamme PB, O'Donnell M, Maggioni AP, Lonn EM, Piegas LS, Ertl G, Keltai M, Cook Bruns N, Muehlhofer E, Dagenais GR, Kim JH, Hori M, Steg PG, Hart RG, Diaz R, Alings M, Widimsky P, Avezum A, Probstfield J, Zhu J, Liang Y, Lopez-Jaramillo P, Kakkar A, Parkhomenko AN, Ryden L, Pogosova N, Dans A, Lanas F, Commerford PJ, Torp-Pedersen C, Guzik T, Vinereanu D, Tonkin AM, Lewis BS, Felix C, Yusoff K, Metsarinne K, Fox KAA, Yusuf S. Pantoprazole to Prevent Gastroduodenal Events in Patients Receiving Rivaroxaban and/or Aspirin in a Randomized, Double-Blind, Placebo-Controlled Trial. Gastroenterology 2019; 157:403-412.e5. [PMID: 31054846 DOI: 10.1053/j.gastro.2019.04.041] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Antiplatelets and anticoagulants are associated with increased upper gastrointestinal bleeding. We evaluated whether proton pump inhibitor therapy could reduce this risk. METHODS We performed a 3 × 2 partial factorial double-blind trial of 17,598 participants with stable cardiovascular disease and peripheral artery disease. Participants were randomly assigned to groups given pantoprazole 40 mg daily or placebo, as well as rivaroxaban 2.5 mg twice daily with aspirin 100 mg once daily, rivaroxaban 5 mg twice daily, or aspirin 100 mg alone. The primary outcome was time to first upper gastrointestinal event, defined as a composite of overt bleeding, upper gastrointestinal bleeding from a gastroduodenal lesion or of unknown origin, occult bleeding, symptomatic gastroduodenal ulcer or ≥5 erosions, upper gastrointestinal obstruction, or perforation. RESULTS There was no significant difference in upper gastrointestinal events between the pantoprazole group (102 of 8791 events) and the placebo group (116 of 8807 events) (hazard ratio, 0.88; 95% confidence interval [CI], 0.67-1.15). Pantoprazole significantly reduced bleeding of gastroduodenal lesions (hazard ratio, 0.52; 95% confidence interval, 0.28-0.94; P = .03); this reduction was greater when we used a post-hoc definition of bleeding gastroduodenal lesion (hazard ratio, 0.45; 95% confidence interval, 0.27-0.74), although the number needed to treat still was high (n = 982; 95% confidence interval, 609-2528). CONCLUSIONS In a randomized placebo-controlled trial, we found that routine use of proton pump inhibitors in patients receiving low-dose anticoagulation and/or aspirin for stable cardiovascular disease does not reduce upper gastrointestinal events, but may reduce bleeding from gastroduodenal lesions. ClinicalTrials.gov ID: NCT01776424.
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Affiliation(s)
- Paul Moayyedi
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - John W Eikelboom
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jackie Bosch
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Leanne Dyal
- University of Philippines, Manila, Philippines
| | - Olga Shestakovska
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Darryl Leong
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sonia S Anand
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Stefan Störk
- University of Würzburg and University Hospital, Würzburg, Germany
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | | | | | - Aldo P Maggioni
- National Association of Hospital Cardiologists Research Center (ANMCO), Florence, Italy
| | - Eva M Lonn
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada; Bayer, Leverkusen, Germany
| | | | - Georg Ertl
- University of Würzburg and University Hospital, Würzburg, Germany
| | | | | | | | - Gilles R Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec, Canada
| | | | | | | | - Robert G Hart
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Rafael Diaz
- Estudios Clinicos Latino America and Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Marco Alings
- Amphia Ziekenhuis and Werkgroep Cardiologische Centra Nederland (WCN), Utrecht, the Netherlands
| | - Petr Widimsky
- Cardiocenter, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Alvaro Avezum
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | | | - Jun Zhu
- FuWai Hospital, Beijing, China
| | | | - Patricio Lopez-Jaramillo
- Research Institute, Fundaciun Oftalmoligica de Santander (FOSCAL)-Bucaramanga, Bucaramanga, Colombia
| | - Ajay Kakkar
- Thrombosis Research Institute and University College London, London, UK
| | | | - Lars Ryden
- Karolinska Institutet, Stockholm, Sweden
| | - Nana Pogosova
- National Research Center for Preventative Medicine, Moscow, Russia
| | - Antonio Dans
- College of Medicine, University of the Philippines-Manila, Ermita, Manila, Philippines
| | | | | | | | - Tomek Guzik
- University of Glasgow, Glasgow, UK; Collegium Medicum Jagiellonian University, Krakow, Poland
| | - Dragos Vinereanu
- University of Medicine and Pharmacology, Carol Davila University and Emergency Hospital, Bucharest, Romania
| | | | | | - Camilo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo-Universidad Tecnoligica Equinoccial, Quito, Ecuador
| | | | - Kaj Metsarinne
- Universit Paris Diderot, Hopital Bichat, Assistance Publique, Paris, France; Turku University Central Hospital and Turku University, Turku, Finland
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Salim Yusuf
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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Ng JC, Yeomans ND. <em>Helicobacter pylori</em> infection and the risk of upper gastrointestinal bleeding in low dose aspirin users: systematic review and meta-analysis. Med J Aust 2019; 209:306-311. [PMID: 30257623 DOI: 10.5694/mja17.01274] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/25/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether the risk of upper gastrointestinal bleeding in patients taking low dose aspirin (≤ 325 mg/day) is increased in people with Helicobacter pylori infections. STUDY DESIGN A systematic search for all publications since 1989 (when H. pylori was named) using search term equivalents for "upper gastrointestinal haemorrhage" and "aspirin". Articles were assessed individually for inclusion of data on H. pylori infection, as not all relevant papers were indexed with this term. Data that could be pooled were then subjected to meta-analysis, using a random effects model. DATA SOURCES MEDLINE, Embase, Scopus, the Cochrane Library. DATA SYNTHESIS Of 7599 retrieved publications, reports for seven case-control studies contained data suitable for meta-analysis; four were deemed high quality on the Newcastle-Ottawa scale. Upper gastrointestinal haemorrhage was more frequent in aspirin users infected with H. pylori than in those who were not (odds ratio [OR], 2.32; 95% CI, 1.25-4.33; P = 0.008). The heterogeneity of the studies was significant (Q = 19.3, P = 0.004; I<sup>2</sup> = 68.9%, 95% CI, 31.5-85.9%), but the pooled odds ratio was similar after removing the two studies that contributed most to heterogeneity (OR, 2.34; 95% CI, 1.56-3.53; P < 0.001). The number needed to treat to prevent one bleeding event annually was estimated to be between 100 and more than 1000. CONCLUSIONS The odds of upper gastrointestinal bleeding in patients taking low dose aspirin is about twice as great in those infected with H. pylori. Testing for and treating the infection should be considered in such patients, especially if their underlying risk of peptic ulcer bleeding is already high.
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Soubra L, Issa M. Prescribing of proton pump inhibitors for gastrointestinal bleeding prophylaxis in the Lebanese outpatient setting: patterns, compliance with guidelines and risks. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 27:386-392. [DOI: 10.1111/ijpp.12537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Indexed: 12/13/2022]
Abstract
Abstract
Objectives
To determine patterns of proton pump inhibitor (PPIs) prescribing for gastrointestinal bleeding prophylaxis (GIBP) in the Lebanese outpatient setting, to assess their compliance with guidelines for approved GIBP indications and to delineate independent factors that are associated with non-compliance.
Methods
A community-based multicentre cross-sectional study was conducted. Eligible patients were those who presented to the community pharmacy setting with a PPI prescription for GIBP. Prescriptions were reviewed by a clinical pharmacist to ascertain their compliance with guidelines approved for GIBP indications. Several variables were tested to determine independent factors that were associated with guidelines non-compliance.
Key findings
Of the 720 reviewed PPI prescriptions, 297 (41.25%) were found to be compliant with guidelines approved for GIBP indications. The presence of two or more comorbid conditions, prescribing initiated by a primary care physician, patients taking three or more medications, and prescribing of NSAIDs including low-dose aspirin were found to be independent factors that were significantly associated with PPI prescribing non-compliance (P ≤ 0.05). PPIs were also inappropriately coprescribed with corticosteroids (102 (24.1%)), selective serotonin reuptake inhibitors (SSRIs) (48 (11.4%)), amoxicillin-clavulanic acid (20 (4.7%)) and bisphosphonates (13 (3.1%)) for GIBP.
Conclusion
This study demonstrated that PPIs were appropriately prescribed for GIBP in less than the half of the study patients. The need for improvement of clinical practice in this regard is therefore indispensable since inappropriate prescribing is costly and put the patient at risk for adverse health outcomes. Strategies to alter inappropriate prescribing may include education, guidelines awareness and decision support systems.
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Affiliation(s)
- Lama Soubra
- Pharmacy Practice Department, Faculty of Pharmacy, Beirut Arab University, Beirut, Lebanon
| | - Mohamed Issa
- Pharmacy Practice Department, Faculty of Pharmacy, Beirut Arab University, Beirut, Lebanon
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Charlesworth J, Fitzpatrick J, Perera NKP, Orchard J. Osteoarthritis- a systematic review of long-term safety implications for osteoarthritis of the knee. BMC Musculoskelet Disord 2019; 20:151. [PMID: 30961569 PMCID: PMC6454763 DOI: 10.1186/s12891-019-2525-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/24/2019] [Indexed: 12/16/2022] Open
Abstract
Background There is no cure for knee osteoarthritis (KOA) and typically patients live approximately 30-years with the disease. Most common medical treatments result in short-term palliation of symptoms with little consideration of long-term risk. This systematic review aims to appraise the current evidence for the long-term (≥12 months) safety of common treatments for knee osteoarthritis (KOA). Methods Cochrane Database of Systematic Reviews, Medline and PubMed were systematically searched from 1990 to July 2017, inclusive. Inclusion criteria were 1) peer-reviewed publications investigating treatments for KOA referred to in the Australian Clinical Care Standard and/or Therapeutic Guidelines: Rheumatology 2) specifically addressing safety of the treatments 3) with ≥12 months of follow-up and 4) Downs and Black quality score ≥ 13. Results Thirty-four studies fulfilled the inclusion criteria. Lifestyle modifications (moderate exercise and weight loss), paracetamol, glucosamine, Intraarticular Hyaluronic Acid (IAHA) and platelet-rich-plasma (PRP) injections have a low risk of harm and beneficial ≥12 month outcomes. Although Nonsteroidal Anti-inflammatory Drugs (NSAIDs) provide pain relief, they are associated with increased risk of medical complications. Cortisone injections are associated with radiological cartilage degeneration at > 12 months. Arthroscopy for degenerative meniscal tears in KOA leads to a 3-fold increase in total knee arthroplasty (TKA). TKA improves primary outcomes of KOA but has a low rate of significant medical complications. Conclusions Given the safety and effectiveness of lifestyle interventions such as weight loss and exercise, these should be advocated in all patients due to the low risk of harm. The use of NSAIDs should be minimized to avoid gastrointestinal complications. Treatment with opioids has a lack of evidence for use and a high risk of long-term harm. The use of IAHA and PRP may provide additional symptomatic benefit without the risk of harm. TKA is associated with significant medical complications but is justified by the efficacy of joint replacement in late-stage disease. Trial registration PROSPERO International prospective register for systematic reviews; registration number CRD42017072809. Electronic supplementary material The online version of this article (10.1186/s12891-019-2525-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonathon Charlesworth
- Australasian College of Sport and Exercise Physicians, 257 Collins Street, Melbourne, VIC, 3000, Australia.
| | - Jane Fitzpatrick
- Australasian College of Sport and Exercise Physicians, 257 Collins Street, Melbourne, VIC, 3000, Australia.,University of Melbourne, Melbourne, Australia.,Sports Medicine Professionals, University of Melbourne, Level 7, Alan Gilbert Bdg, 161 Barry Street, Melbourne, VIC, 3010, Australia
| | - Nirmala Kanthi Panagodage Perera
- Australasian College of Sport and Exercise Physicians, 257 Collins Street, Melbourne, VIC, 3000, Australia.,Division of Physiotherapy, Department of Medical and Health Science, Linköping University, Linköping, Sweden
| | - John Orchard
- Australasian College of Sport and Exercise Physicians, 257 Collins Street, Melbourne, VIC, 3000, Australia.,School of Public Health, University of Sydney, Sydney, NSW, Australia
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Sarri GL, Grigg SE, Yeomans ND. Helicobacter pylori and low-dose aspirin ulcer risk: A meta-analysis. J Gastroenterol Hepatol 2019; 34:517-525. [PMID: 30408229 DOI: 10.1111/jgh.14539] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 10/25/2018] [Accepted: 10/30/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Owing to wide-spread use, low-dose aspirin (LDA) produces a substantial amount of peptic ulcer disease. Current guidelines are ambivalent about the need for Helicobacter pylori eradication to protect against LDA ulcers. This study aimed to determine, through meta-analysis, if (and by how much) infection alters the baseline risk of peptic ulcers during LDA therapy. METHODS Literature screening was performed in MEDLINE and EMBASE from inception to May 2018. Original studies reporting prevalence or incidence of uncomplicated ulcers in LDA users were included. Ulcer endpoints needed to be specified separately, according to H. pylori infection status. Meta-analysis was performed in MIX 2.0 Pro. RESULTS Ten cross-sectional studies and seven randomized controlled trials were included (n = 5964). The pooled odds ratios with 95% confidence intervals (CI) for the risk of LDA ulcers in H. pylori-positive versus H. pylori-negative individuals were 1.68 (95%CI 1.40-2.02) and 1.65 (95%CI 1.29-2.08) under fixed-effects and random-effects models, respectively. Heterogeneity among studies was minimal (I2 = 26.9%). After adjusting for the protective effects of antisecretory drugs, the odds ratios increased to 1.94 (95%CI 1.54-2.46). CONCLUSION This analysis suggests that H. pylori increases the risk of LDA ulcers by almost 70% in a population where some were taking proton pump inhibitors and/or other acid suppressants. Without antisecretory drugs, the risk almost doubles. Clinically, these findings may support the use of a test-and-treat approach to H. pylori in LDA users, particularly those already at higher risk of developing peptic ulcers.
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Affiliation(s)
- Gino L Sarri
- Melbourne School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Sam E Grigg
- Melbourne School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Neville D Yeomans
- Melbourne School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Office for Research, Austin Health, Melbourne, Victoria, Australia
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