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Choudhary R, Khan MA, Dosi R, Choudhari S, Pawar D, Shahavi V, Sharma A. Fixed dose combination of aspirin and pantoprazole: Results of a multicenter, comparative, randomized, double-blind, double dummy, phase III study in Indian patients. Indian Heart J 2024:S0019-4832(24)00160-3. [PMID: 39009075 DOI: 10.1016/j.ihj.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 02/05/2024] [Accepted: 07/12/2024] [Indexed: 07/17/2024] Open
Abstract
OBJECTIVE To compare the efficacy and safety of a fixed-dose combination of aspirin and pantoprazole with that of aspirin alone for the prevention of gastro duodenal mucosal damage in patients taking aspirin for secondary prevention of cardiovascular disease or cerebrovascular disease. METHODS This was a comparative, double-blind, double-dummy, randomized, multicenter, phase III study conducted in patients taking aspirin ≤150 mg daily for ≥3 to ≤6 months and expected to require daily aspirin therapy for at least 6 months for the secondary prevention of cardiovascular disease or cerebrovascular disease. RESULTS A total of 240 patients were randomized to receive either a fixed-dose combination of aspirin 150 mg and pantoprazole 20 mg or aspirin 150 mg alone in a 2:1 ratio. The proportion of non-responders (patients experiencing gastroduodenal events) was 9.7 % in the test group (fixed-dose combination of aspirin 150 mg and pantoprazole 20 mg) compared to 19.7 % in the comparator group (aspirin 150 mg) at week 12, while the proportions were 11.0 % in the test group and 22.4 % in the comparator group at the end of 24 weeks of treatment (p-value was <0.05 at week 12 and 24). GI injuries were significantly less in test group as compared to comparator group. Both drugs were well tolerated by all patients. CONCLUSION The fixed-dose combination of aspirin 150 mg and pantoprazole 20 mg was found to be more efficacious and safer compared to aspirin 150 mg alone for the prevention of gastroduodenal mucosal damage in patients receiving aspirin.
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Affiliation(s)
- Rahul Choudhary
- Cardiology OPD 4 C-Block, AIIMS, Jodhpur, 342005, Rajasthan, India.
| | - Mohd Aziz Khan
- Crescent Hospital and Heart Centre, Near Lokmat Square, Dhantoli, Nagpur, 440012, Maharashtra, India.
| | - Rupal Dosi
- Department of Medicine Sir Sayajirao General Hospital, Medical College-Baroda, Jail Road, Indira Avenue, Vadodara, 390001, Gujarat, India.
| | - Sachin Choudhari
- Medical Affairs, Alkem Laboratories Ltd, ALKEM HOUSE, "Devashish", Adjacent to Matulya Centre, Senapati Bapat Marg, Lower Parel, Mumbai, 400 013, India.
| | - Dattatray Pawar
- Medical Affairs, Alkem Laboratories Ltd, ALKEM HOUSE, "Devashish", Adjacent to Matulya Centre, Senapati Bapat Marg, Lower Parel, Mumbai, 400 013, India.
| | - Vinayak Shahavi
- Medical Affairs, Alkem Laboratories Ltd, ALKEM HOUSE, "Devashish", Adjacent to Matulya Centre, Senapati Bapat Marg, Lower Parel, Mumbai, 400 013, India.
| | - Akhilesh Sharma
- Medical Affairs, Alkem Laboratories Ltd, ALKEM HOUSE, "Devashish", Adjacent to Matulya Centre, Senapati Bapat Marg, Lower Parel, Mumbai, 400 013, India.
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2
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Viazis N, Christodoulou D, Papastergiou V, Mousourakis K, Kozompoli D, Stasinos G, Dimopoulou K, Apostolopoulos P, Fousekis F, Liatsos C, Kyriakos N, Argyropoulos T, Tribonias G. Diagnostic Yield and Outcomes of Small Bowel Capsule Endoscopy in Patients with Small Bowel Bleeding Receiving Antithrombotics. Diagnostics (Basel) 2024; 14:1361. [PMID: 39001251 PMCID: PMC11240733 DOI: 10.3390/diagnostics14131361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024] Open
Abstract
We aimed to determine the diagnostic yield and outcome of patients receiving antithrombotic drug therapy subjected to small bowel capsule endoscopy (SBCE) for the investigation of small bowel bleeding (SBB). A multicenter retrospective analysis of collected data from all patients undergoing SBCE for the investigation of SBB from March 2003 to June 2023 was performed. The diagnostic yield of SBCE was defined as the detection of positive findings that could explain the cause of the patient's bleeding. Rebleeding was defined as evidence of bleeding within 1 year after the index episode. During the study period, 8401 patients underwent SBCE for SBB investigation. Bleeding lesions were detected in 1103/2535 (43.5%) antithrombotic users, compared to 1113/5866 (18.9%) in nonusers (p < 0.00001). Following capsule endoscopy, a therapeutic intervention was possible in 390/2216 (17.5%) patients with a bleeding lesion. Rebleeding occurred in 927 (36.5%) of antithrombotic users (36.5%), compared to 795 (13.5%) of nonusers (13.5%, p < 0.00001). Both the diagnostic yield of SBCE and the rebleeding rates were higher in patients with SBB receiving antithrombotics. Therapeutic intervention was possible in a real-world setting only for a minority of patients with positive findings.
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Affiliation(s)
- Nikos Viazis
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Dimitris Christodoulou
- Department of Gastroenterology and Hepatology, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (D.C.); (F.F.)
| | - Vasilis Papastergiou
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Konstantinos Mousourakis
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Dimitra Kozompoli
- Gastroenterology Department, “Evangelismos” General Hospital, 16121 Athens, Greece; (V.P.); (K.M.); (D.K.)
| | - Giannis Stasinos
- Gastroenterology Department, NIMTS, 19010 Kalivia, Greece; (G.S.); (P.A.)
| | - Konstantina Dimopoulou
- Gastroenterology Department, Red Cross Hospital, 11526 Athens, Greece; (K.D.); (T.A.); (G.T.)
| | | | - Fotios Fousekis
- Department of Gastroenterology and Hepatology, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece; (D.C.); (F.F.)
| | - Christos Liatsos
- Gastroenterology Department, 401 Military Hospital of Athens, 11525 Athens, Greece; (C.L.); (N.K.)
| | - Nikolaos Kyriakos
- Gastroenterology Department, 401 Military Hospital of Athens, 11525 Athens, Greece; (C.L.); (N.K.)
| | - Theodoros Argyropoulos
- Gastroenterology Department, Red Cross Hospital, 11526 Athens, Greece; (K.D.); (T.A.); (G.T.)
| | - George Tribonias
- Gastroenterology Department, Red Cross Hospital, 11526 Athens, Greece; (K.D.); (T.A.); (G.T.)
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3
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Lee Y, Choi HJ, Park S, Je NK. Temporal trends in use of antisecretory agents among patients administered clopidogrel-based dual antiplatelet therapy after percutaneous coronary intervention. Pharmacoepidemiol Drug Saf 2024; 33:e5816. [PMID: 38773801 DOI: 10.1002/pds.5816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 04/02/2024] [Accepted: 05/01/2024] [Indexed: 05/24/2024]
Abstract
BACKGROUND Antisecretory drugs are commonly prescribed with clopidogrel-based dual antiplatelet therapy (DAPT) to prevent gastrointestinal bleeding in high-risk patients after percutaneous coronary intervention (PCI). However, omeprazole and esomeprazole (inhibiting proton pump inhibitors [PPIs]) may increase cardiovascular event rates on co-administration with clopidogrel. This study aimed to examine trends in the use of antisecretory agents in patients administered clopidogrel-based DAPT and the concomitant use of clopidogrel and inhibiting PPIs. METHODS We used National Inpatient Sample data compiled by the Health Insurance Review & Assessment Service from 2009 to 2020. Further, we identified patients who were prescribed clopidogrel-based DAPT after PCI and investigated the concomitant use of antisecretory agents with clopidogrel. To verify the annual trend of drug utilization, we used the Cochran-Armitage trend test. RESULTS From 2009 to 2020, the percentage of H2 receptor antagonist users decreased steadily (from 82.5% in 2009 to 25.3% in 2020); instead, the percentage of PPI users increased (from 23.7% in 2009 to 82.0% in 2020). The use of inhibiting PPI also increased (from 4.2% in 2009 to 30.7% in 2020). Potassium competitive acid blockers (P-CABs) were rarely used before 2019; however, in 2020, it accounted for 7.8% of the antisecretory users. CONCLUSIONS Our study demonstrates that the use of inhibiting PPIs increased steadily in patients administered clopidogrel-based DAPT therapy. This is a major concern since the concomitant use of inhibiting PPIs with clopidogrel could increase the risk of cardiovascular events.
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Affiliation(s)
- Yonghyuk Lee
- College of Pharmacy, Pusan National University, Busan, Republic of Korea
| | - Hye-Jeong Choi
- College of Pharmacy, Pusan National University, Busan, Republic of Korea
| | - Susin Park
- College of Pharmacy, Woosuk University, Wanju, Republic of Korea
| | - Nam Kyung Je
- College of Pharmacy, Pusan National University, Busan, Republic of Korea
- Research Institute for drug development, Pusan National University, Busan, Republic of Korea
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Kurlander JE, Laine L, Kim HM, Roberts CB, Saffar D, Myers A, Holleman R, Gao Y, Shank M, Nelson R, Forman J, Helfrich CD, Krein SL, Saini SD, Yang YX. Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study. BMJ 2024; 385:e076484. [PMID: 38604668 PMCID: PMC11007585 DOI: 10.1136/bmj-2023-076484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes. DESIGN Difference-in-difference study. SETTING US Veterans Affairs Healthcare System, in which one regional network implemented the overuse intervention and all 17 others served as controls. PARTICIPANTS All individuals receiving primary care from 2009 to 2019. INTERVENTION Limits on PPI refills for patients without a documented indication for long term use, voiding of PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and education for patients and clinicians. MAIN OUTCOME MEASURES The primary outcome was the percentage of patients who filled a PPI prescription per 6 months. Secondary outcomes included percentage of days PPI gastroprotection was prescribed in patients at high risk for upper gastrointestinal bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults appropriate for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and PPI associated clinical conditions. RESULTS The number of patients analyzed per interval ranged from 192 607 to 250 349 in intervention sites and from 3 775 953 to 4 360 868 in control sites, with 26% of patients receiving PPIs before the intervention. The intervention was associated with an absolute reduction of 7.3% (95% confidence interval -7.6% to -7.0%) in patients who filled PPI prescriptions, an absolute reduction of 11.3% (-12.0% to -10.5%) in PPI use among patients appropriate for gastroprotection, and an absolute reduction of 5.72% (-6.08% to -5.36%) in patients who filled a PPI or H2 receptor antagonist prescription. No increases were seen in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients appropriate for gastroprotection. No clinically significant changes were seen in any PPI associated clinical conditions. CONCLUSIONS The multicomponent intervention was associated with reduced PPI use overall but also in patients appropriate for gastroprotection, with minimal evidence of either clinical benefits or harms.
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Affiliation(s)
- Jacob E Kurlander
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Loren Laine
- Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Hyungjin Myra Kim
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Christopher B Roberts
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Darcy Saffar
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Aimee Myers
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Robert Holleman
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Yuqing Gao
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Michelle Shank
- Department of Veterans Affairs, Pharmacy Services, Washington, DC, USA (retired)
| | - Richard Nelson
- IDEAS Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jane Forman
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Christian D Helfrich
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Sarah L Krein
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Sameer D Saini
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Yu-Xiao Yang
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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5
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Kurlander JE, Mafi JN, Racz MJ, Barnes GD, Saini SD, Meek PD. Prescribing of Proton Pump Inhibitors for Prevention of Upper Gastrointestinal Bleeding in US Outpatient Visits. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00200-3. [PMID: 38367740 DOI: 10.1016/j.cgh.2024.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 01/24/2024] [Accepted: 01/30/2024] [Indexed: 02/19/2024]
Abstract
Antisecretory medications, primarily proton pump inhibitors (PPIs), have proven effective in reducing upper gastrointestinal toxicities, including upper gastrointestinal bleeding (UGIB), associated with nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, which are among the most commonly used medications in the United States.1 Accordingly, professional guidance recommends PPIs for patients at high risk for UGIB.2-4 However, little is known about trends in use of antisecretory medications for gastrointestinal prophylaxis ("gastroprotection"). Herein, we examined contemporary use and prescribing of antisecretory medications in visits by patients at high risk for UGIB, relative to visits by patients diagnosed with acid-related disorders.
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Affiliation(s)
- Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Racz
- Department of Life Sciences, Albany College of Pharmacy and Health Sciences, Albany, New York
| | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sameer D Saini
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Patrick D Meek
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York
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6
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Kinoshita Y, Kato M, Sugizaki K, Ikeuchi S. Rabeprazole Coadministration Controls Ulcer Recurrence in Patients on Low-dose Aspirin Therapy: A Multicenter Prospective Study. Intern Med 2023; 62:495-502. [PMID: 35908971 PMCID: PMC10017235 DOI: 10.2169/internalmedicine.9646-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objective To evaluate the efficacy and safety of rabeprazole coadministration with low-dose aspirin (LDA). Methods From 2015 to 2018, we conducted a large-scale, multicenter, prospective observational study to assess the safety and efficacy of treatment with rabeprazole (5 or 10 mg/day) in combination with LDA. Results The incidence of adverse reactions was 0.73% (11/1,513 patients), with no serious adverse reactions. We found no trend toward increases in the incidence of adverse reactions with increases in treatment duration. The cumulative recurrence rate of ulcers by Week 52 (Kaplan-Meier estimates) was 3.50% (range, 1.56-7.75%). No gastrointestinal bleeding was reported. Conclusion Rabeprazole in combination with LDA appears as safe and effective in real-world situations as in clinical trials.
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Affiliation(s)
| | - Mototsugu Kato
- National Hospital Organization, Hakodate National Hospital, Japan
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Geisler T, Poli S, Huber K, Rath D, Aidery P, Kristensen SD, Storey RF, Ball A, Collet JP, Berg JT. Resumption of Antiplatelet Therapy after Major Bleeding. Thromb Haemost 2023; 123:135-149. [PMID: 35785817 DOI: 10.1055/s-0042-1750419] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Major bleeding is a common threat in patients requiring antiplatelet therapy. Timing and intensity with regard to resumption of antiplatelet therapy represent a major challenge in clinical practice. Knowledge of the patient's bleeding risk, defining transient/treatable and permanent/untreatable risk factors for bleeding, and weighing these against thrombotic risk are key to successful prevention of major adverse events. Shared decision-making involving various disciplines is essential to determine the optimal strategy. The present article addresses clinically relevant questions focusing on the most life-threatening or frequently occurring bleeding events, such as intracranial hemorrhage and gastrointestinal bleeding, and discusses the evidence for antiplatelet therapy resumption using individual risk assessment in high-risk cardiovascular disease patients.
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Affiliation(s)
- Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls-University Tuebingen, Tuebingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Dominik Rath
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Parwez Aidery
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Steen D Kristensen
- Department of Cardiology, Aarhus University Hospital, Faculty of Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Alex Ball
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Sorbonne Université, Paris, France
| | - Jurriën Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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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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9
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Tarabay RB, Osman MH, Aridi RS, Hlais SA, Beshara RY, Lakkis NA. The effect of a patient informative leaflet on chronic use of proton pump inhibitors in a primary care center: a randomized control trial. Hosp Pract (1995) 2022; 50:318-325. [PMID: 35993151 DOI: 10.1080/21548331.2022.2114743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND Chronic non-medically indicated PPIs are highly prescribed worldwide. The long-term side effects of PPI must be wisely considered during an extended prescription duration. Our study purpose is to assess the impact of providing patients and physicians with educational guides on the rates of reducing or eliminating PPIs. DESIGN AND METHODS A controlled study targeting adult patients with chronic PPI use was conducted in a family medicine center in Beirut. Block randomization was employed. Patients (n = 140) were equally divided into an intervention group consisting of a patient-oriented informative and motivational leaflet and a control group having the same follow-up without having the leaflet. All participants filled a questionnaire. All participants received a short phone call in 2 and 6 months. An e-mail clarifying the objective of this study was sent to all physicians and supplemented with a PPI deprescribing algorithm. RESULTS At the 6-month follow-up, the rate of participants who talked to treating physicians about their PPI therapy was higher in the intervention group (p-value<0.0001), and the rate of participants who stepped down or off PPI was higher in the intervention group (p-value<0.0001). In participants who stepped down or off PPI, the reported breakthrough symptoms decreased over time (moderate: 24.2%, mild: 35.5%, and nil: 40.3% at 2-month follow-up; and moderate: 0%, mild: 55.4% and nil: 44.6% at 6-month follow-up; p-value<0.0001). CONCLUSION A low-intensity, low-cost, and easily replicable intervention encouraged a significant number of long-term users of PPIs to reduce or stop these medications without causing significant breakthrough symptoms.
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Affiliation(s)
- Rami B Tarabay
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Mona H Osman
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Riwa S Aridi
- Faculty of Pharmacy, Lebanese International University (LIU), Beirut, Lebanon
| | - Sani A Hlais
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon.,Department of Family Medicine, Saint Joseph University Beirut (USJ), Beirut, Lebanon
| | - Ranin Y Beshara
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Najla A Lakkis
- Department of Family Medicine, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
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10
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Zhou G, Peng Y, Guo M, Qu C, Luo S, Jiang Y, Chen D, Wang X, Guo Y. Esomeprazole inhibits endoplasmic reticulum stress and ameliorates myocardial ischemia-reperfusion injury. Biochem Biophys Res Commun 2022; 627:84-90. [PMID: 36030656 DOI: 10.1016/j.bbrc.2022.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 07/24/2022] [Accepted: 08/04/2022] [Indexed: 11/18/2022]
Abstract
Proton pump inhibitors (PPIs) are often prescribed in association with clopidogrel and aspirin to patients with myocardial infraction (MI), but their effects on heart is controversial. The purpose of this study was to investigate the effects and potential mechanism of omeprazole (OME) and esomeprazole (ESO) in myocardial ischemia reperfusion (I/R) injury. In the present study, mice were treated with OME, ESO or vehicle for 3 weeks and then subjected to myocardial I/R or sham surgery. At 1 day after surgery, echocardiography was performed to access cardiac injury. Hematoxylin and eosin (H&E) staining was performed to evaluate cardiomyocyte morphology. The IL1β was evaluated by Immunohistochemistry (IHC). Elisa was used to detect cTnt content in serum. The expression of CD86, CD206, CHOP, ATF6, eIF2α and p eIF2α were determined by Western blot (WB). The result showed that ESO markedly improved the left ventricular ejection fraction (LVEF), shortening fraction (FS), suppressed inflammatory infiltration, endoplasmic reticulum stress (ERS) and decreased proinflammatory macrophages in I/R hearts, while OME had no significant effects on cardiac function, inflammation and ERS in the I/R heart. In conclusion, ESO but not OME pretreatment reduces the proportion of proinflammatory macrophages, inhibits endoplasmic reticulum stress, and alleviates I/R injury in mice, indicating that ESO maybe a more proper PPI than OME for application in I/R injury.
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Affiliation(s)
- Guoxiang Zhou
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yuce Peng
- Division of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Mingyu Guo
- Division of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Can Qu
- Department of Pharmacy, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Suxin Luo
- Division of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yingjiu Jiang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Dan Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiaowen Wang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
| | - Yongzheng Guo
- Division of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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11
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Lee MY, Lee S, Heo KN, Kim WY, Jung SH, Ah YM, Lee JY. Rebamipide as a Potential Alternative Gastroprotective Agent to Proton Pump Inhibitor in Elderly Chronic Nonsteroidal Anti-Inflammatory Drug Users without Risk Factors. Int J Gen Med 2022; 15:2835-2845. [PMID: 35300126 PMCID: PMC8922238 DOI: 10.2147/ijgm.s353098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/23/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mee Yeon Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Suhyun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Kyu-Nam Heo
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Woo-Youn Kim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Sun Hoi Jung
- Department of Pharmacy, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsan-si, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
- Correspondence: Ju-Yeun Lee, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea, Tel +82-2-3668-7472, Email
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12
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Dong Y, He S, Li X, Zhou Z. Prevention of nNon-Vitamin K Oral Anticoagulants-Related Gastrointestinal Bleeding With Acid Suppressants: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2022; 28:10760296211064897. [PMID: 35037779 PMCID: PMC8777378 DOI: 10.1177/10760296211064897] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Whether the use of acid suppressants can reduce non-vitamin K oral anticoagulants
(NOACs)-related gastrointestinal bleeding (GIB) remains unclear. To systemically
evaluate the effect of acid suppressants on the risk of GIB in patients treated
with NOACs. All related studies were searched in four databases (Cochrane,
Embase, PubMed, and Web of Science) from their establishment to August 10, 2021.
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
statement was used to identify studies and Stata 16.0 software was used for
meta-analysis, including sensitivity and subgroup analysis. Six retrospective
cohort studies were included in this study. The use of acid suppressants
significantly reduced the GIB risk in patients taking NOACs, with an overall
relative risk (RR) of 0.70 (95% confidence interval [CI]: 0.61-0.82;
P < 0.001; I2 = 56.3%). This trend of reduced risk for GIB in
NOACs was more significant in upper GIB (UGIB; RR: 0.45; 95%CI: 0.22-0.90;
P = 0.025; I2 = 71.1%). The reduction was stronger for dabigatran
than for rivaroxaban and apixaban. The least reduction in the risk of GIB with
acid suppressant co-therapy was rivaroxaban (dabigatran: RR: 0.53; 95% CI:
0.45-0.62; P = <0.001; I2 = 39.8%; apixaban: RR: 0.67; 95% CI:
0.54-0.84; P = <0.001; I2 = 0; rivaroxaban: RR: 0.73; 95% CI:
0.66-0.81; P = <0.001; I2 = 37.6%). The included studies revealed
the protective effect of acid suppressants against NOACs-related GIB, especially
in the upper gastrointestinal tract. The protective effect was even stronger in
patients using dabigatran than in those using Xa inhibitors (rivaroxaban and
apixaban).
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Affiliation(s)
- Yongqi Dong
- 585250The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Song He
- 585250The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xue Li
- 585250The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhihang Zhou
- 585250The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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13
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Kurlander JE, Helminski D, Kokaly AN, Richardson CR, De Vries R, Saini SD, Krein SL. Barriers to Guideline-Based Use of Proton Pump Inhibitors to Prevent Upper Gastrointestinal Bleeding. Ann Fam Med 2022; 20:5-11. [PMID: 35074761 PMCID: PMC8786436 DOI: 10.1370/afm.2734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/18/2021] [Accepted: 03/30/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Gastrointestinal (GI) bleeding is one of the most common serious adverse drug events. Guidelines recommend proton pump inhibitor (PPI) gastroprotection to prevent upper GI bleeding in high-risk patients, but this practice is underused. METHODS To explore prescribing practices and barriers to the use of PPI gastroprotection, including dynamics within and across specialties, we conducted semistructured interviews with physicians in 4 specialties at a single institution. We performed thematic analysis of barriers, organized around the theoretical domains framework. RESULTS The sample included 5 primary care physicians (PCPs), 4 cardiologists, 3 gastroenterologists, and 3 vascular surgeons. Most PCPs, gastroenterologists, and vascular surgeons seldom prescribed PPI gastroprotection. Cardiologists varied most in their use of PPI gastroprotection, with some prescribing it consistently and others never. Major barriers related to the following 3 themes: (1) knowledge, (2) decision processes, and (3) professional role. Knowledge of guidelines was greatest among cardiologists and gastroenterologists and low among PCPs and vascular surgeons, and PCPs tended to focus on adverse effects associated with PPIs, which made them reluctant to prescribe them. For cardiologists, prevention of bleeding was usually a priority, but they sometimes deferred prescribing to others. For the other 3 specialties, PPI gastroprotection was a low priority. There was unclear delineation of responsibility for prescribing gastroprotection between specialties. CONCLUSIONS Major barriers to PPI gastroprotection relate to knowledge, decision processes, and professional role, which operate differentially across specialties. Multicomponent interventions will likely be necessary to improve guideline-based use of PPIs to prevent upper GI bleeding.VISUAL ABSTRACT.
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Affiliation(s)
- Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan
| | - Danielle Helminski
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Alex N Kokaly
- UCLA Health Department of Medicine, Los Angeles, California
| | - Caroline R Richardson
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | - Raymond De Vries
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sameer D Saini
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan
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14
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Lee D, Kim JS, Kim BJ, Shin SY, Kim DB, Ahn HS. Influence of individual proton pump inhibitors on clinical outcomes in patients receiving clopidogrel following percutaneous coronary intervention. Medicine (Baltimore) 2021; 100:e27411. [PMID: 34967346 PMCID: PMC8718184 DOI: 10.1097/md.0000000000027411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 09/17/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Data are conflicting on whether proton pump inhibitors (PPIs) diminish the efficacy of clopidogrel. We investigated individual PPIs and adverse cardiovascular events in postpercutaneous coronary intervention (PCI) patients on dual antiplatelet therapy with clopidogrel. METHODS We searched Ovid-MEDLINE, EMBASE, and Cochrane from inception to March 2020 to identify studies that evaluated the efficacy and safety of clopidogrel added PPIs versus clopidogrel only in post-PCI patient. We extracted data from 28 studies for major adverse cardiovascular endpoints (MACE), myocardial infarction (MI), cardiovascular death, and gastrointestinal bleeding. Risk ratios (RR) and hazard ratios (HR) were pooled separately. RESULTS Data were extracted on 131,412 patients from the 28 studies included. Concomitant use of PPI with clopidogrel was associated with increased risk of MACE (RR 1.30; 95% confidence interval [CI] 1.15-1.48; P < .001) and MI (RR 1.43; 95% CI 1.25-1.64; P < .001). Random-effects meta-analyses with individual PPIs demonstrated an increased risk of MACE in those taking pantoprazole (RR 1.31; 95% CI 1.07-1.61, P = .01) or lansoprazole (RR 1.35; 95% CI 1.19-1.54, P < .0001) compared with patients not on PPIs. Likewise, in adjusted analyses, the pooled HR of adjusted events for MACEs showed that the increased risk of MACEs was similar for 4 classes of PPIs but not for rabeprazole (HR: 1.32; 95% CI 0.69-2.53, P = .40). CONCLUSION The post-PCI patients on dual antiplatelet therapy with clopidogrel in the PPI group were associated with higher risk of MACE and MI. Although the results for rabeprazole were not robust, it was the only PPI that did not yield a significantly increased risk of MACE.
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Affiliation(s)
- Dongyoung Lee
- Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea
| | - Je Sang Kim
- Cardiovascular Center, Dongguk University College of Medicine and Ilsan Hospital, Goyang, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Seung Yong Shin
- Cardiovascular and Arrhythmia Center, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Dong Bin Kim
- Department of Internal Medicine, Bucheon St. Mary's Hospital, Catholic University College of Medicine, Seoul, Korea
| | - Hyung Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
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15
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Li X, Wang Y, Zhu X, Zheng L. Clinical study of drug-drug interaction between omeprazole and pyrotinib after meal. Br J Clin Pharmacol 2021; 88:2349-2358. [PMID: 34873745 DOI: 10.1111/bcp.15169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/10/2021] [Accepted: 11/19/2021] [Indexed: 02/05/2023] Open
Abstract
AIMS We aimed to investigate the effect of omeprazole on the pharmacokinetics (PK) of pyrotinib and determine the safety of this combination in healthy Chinese volunteers. METHODS Eighteen healthy volunteers were enrolled in this single-dose and self-controlled study. Pyrotinib (400 mg per oral) was administered 30 minutes after the standard meal. Omeprazole was administered from day 6 (D6) to D10 (40 mg, per oral). On D10, the subjects took omeprazole under fasting conditions, followed by pyrotinib 30 minutes after the standard meal. Blood samples for PK analyses in each phase were collected for analysing the drug concentration. Safety was assessed via clinical laboratory tests and physical examinations. RESULTS Compared with a single dose of pyrotinib, pyrotinib coadministered with omeprazole showed no significant difference in exposure, elimination, half-life and apparent clearance rate. The mixed-effects model revealed that the least-squares geometric mean ratios of area under the concentration-time curve (AUC)0-t , AUC0-∞ and maximum plasma concentration (Cmax, 90% confidence intervals) of pyrotinib alone and pyrotinib coadministered with omeprazole were 0.94 (0.82, 1.08), 0.94 (0.83, 1.08) and 0.91 (0.806, 1.038), respectively, indicating the absence of significant differences in AUC0-t , AUC0-∞ and Cmax . During the treatment period, 6 subjects (33.3%) reported 8 adverse events during pyrotinib monotherapy and omeprazole administration, respectively; 10 subjects (55.6%) reported 34 adverse events in the combined administration phase. CONCLUSION Omeprazole, a proton-pump inhibitor, did not significantly impact the PK properties of pyrotinib, and a good safety profile was observed on coadministration.
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Affiliation(s)
- Xiaoyu Li
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Wang
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaohong Zhu
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital, Sichuan University, Chengdu, China
| | - Li Zheng
- Clinical Trial Center, National Medical Products Administration Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, West China Hospital, Sichuan University, Chengdu, China
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16
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Catapano JS, Srinivasan VM, Wakim AA, Lundberg JN, Rutledge C, Cole TS, Baranoski JF, Fredrickson VL, Rahmani R, Albuquerque FC, Ducruet AF. Omeprazole-clopidogrel interaction and neurovascular complications after flow-diverter device placement. J Neurointerv Surg 2021; 14:380-383. [PMID: 34083398 DOI: 10.1136/neurintsurg-2021-017397] [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: 02/03/2021] [Accepted: 05/10/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Omeprazole is a common proton pump inhibitor that interferes with the hepatic activation of clopidogrel and potentially reduces its platelet-inhibitory effect. Omeprazole has been shown to increase P2Y12 levels and adverse cardiovascular outcomes in patients treated with drug-eluting stents. However, omeprazole use among patients treated with flow-diverting stents for intracranial aneurysms has not been evaluated. METHODS All patients with placement of a flow-diverting device for treatment of an intracranial aneurysm at a tertiary institution from January 1, 2014, to December 31, 2018, were retrospectively analyzed. Inclusion criteria included documented clopidogrel administration, available P2Y12 levels, and thorough documentation of administration of other medications, including omeprazole. RESULTS A total of 138 patients met the inclusion criteria. Sixteen patients (12%) were receiving omeprazole and clopidogrel at treatment. P2Y12 reactivity was significantly greater in the omeprazole cohort (mean P2Y12 level, 250 P2Y12 reaction units (PRU)) than in the control cohort (mean P2Y12 level, 112PRU) (P<0.001). Furthermore, a greater proportion of patients had a P2Y12 level >180 PRU in the omeprazole cohort (14 of 16 [88%] vs 24 of 122 [20%]; P<0.001; OR [95% CI], 29 [6-134]). CONCLUSION Omeprazole was associated with a significant increase in the mean P2Y12 reactivity level among patients with intracranial aneurysms treated with flow-diverting devices who received clopidogrel. However, receipt of omeprazole was not associated with an increased risk of ischemic events or stent stenosis. For neuroendovascular patients who are treated with a flow diverter while receiving clopidogrel, alternative gastrointestinal medication regimens should be considered.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andre A Wakim
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jaclyn N Lundberg
- Department of General Medicine, Creighton University School of Medicine, Phoenix Health Sciences Campus, Phoenix, Arizona, USA
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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17
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Hashash JG, Aoun R, El-Majzoub N, Khamis A, Rockey D, Akl EA, Barada K. Resuming aspirin in patients with non-variceal upper gastrointestinal bleeding: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34:344-353. [PMID: 33948059 PMCID: PMC8079865 DOI: 10.20524/aog.2021.0617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background Our primary and secondary aims were to analyze the evidence surrounding mortality and re-bleeding risks in patients on aspirin with non-variceal upper gastrointestinal bleeding (NVUGIB) as a function of whether or not aspirin was resumed after the bleeding episode, and to determine whether aspirin intake upon admission affected the outcomes. Methods A search for randomized controlled trials (RCTs) and prospective observational studies was performed. Data extraction and risk of bias assessment were done. Generic inverse variance and random-effects model were employed. Heterogeneity across studies was assessed using the I2 test. Certainty of evidence was assessed using the GRADE approach for each comparison and outcome, and an evidence profile was created. Results Evidence from 1 RCT and 4 observational studies suggests that early aspirin resumption reduced mortality (hazard ratio [HR] 0.20, 95% confidence interval [CI] 0.06-0.63) while increasing re-bleeding risk (HR 1.90, 95%CI 0.60-6.00); moderate certainty of evidence. The observational evidence was inconsistent for both mortality (HR 0.84, 95%CI 0.54-1.33) and re-bleeding (HR 0.85, 95%CI 0.47-1.55); very low certainty of evidence. Nine observational studies addressed our secondary aim: 6 provided inconsistent results regarding mortality (pooled odds ratio [OR] 1.1, 95%CI 0.80-1.50) and 4 provided inconsistent results regarding re-bleeding risk (pooled OR 0.92, 95%CI 0.53-1.59); very low certainty of evidence for both outcomes. Conclusion Evidence supporting a protective effect of aspirin resumption soon after NVUGIB is of low-to-moderate certainty, and is not informative as to the optimal timing of aspirin resumption.
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Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology, American University of Beirut, Riad El Solh, Beirut, Lebanon (Jana G. Hashash, Roni Aoun, Kassem Barada)
| | - Roni Aoun
- Division of Gastroenterology, American University of Beirut, Riad El Solh, Beirut, Lebanon (Jana G. Hashash, Roni Aoun, Kassem Barada)
| | - Nadim El-Majzoub
- American University of Beirut, Riad El Solh, Beirut, Lebanon (Nadim El-Majzoub)
| | - Assem Khamis
- Clinical Research Institute, American University of Beirut, Riad El Solh, Beirut, Lebanon (Assem Khamis, Elie A. Akl)
| | - Don Rockey
- Division of Gastroenterology, Medical University of South Carolina, USA (Don Rockey)
| | - Elie A Akl
- Clinical Research Institute, American University of Beirut, Riad El Solh, Beirut, Lebanon (Assem Khamis, Elie A. Akl)
| | - Kassem Barada
- Division of Gastroenterology, American University of Beirut, Riad El Solh, Beirut, Lebanon (Jana G. Hashash, Roni Aoun, Kassem Barada)
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18
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Elkafrawy AA, Ahmed M, Alomari M, Elkaryoni A, Kennedy KF, Clarkston WK, Campbell DR. Safety of gastrointestinal endoscopy in patients with acute coronary syndrome and concomitant gastrointestinal bleeding. World J Clin Cases 2021; 9:1048-1057. [PMID: 33644168 PMCID: PMC7896652 DOI: 10.12998/wjcc.v9.i5.1048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/01/2020] [Accepted: 01/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is a major concern in patients hospitalized with acute coronary syndrome (ACS) due to the common use of both antiplatelet medications and anticoagulants. Studies evaluating the safety of gastrointestinal endoscopy (GIE) in ACS patients with GIB are limited by their relatively small size, and the focus has generally been on upper GIB and esophago-gastroduod-enoscopy (EGD) only.
AIM To evaluate the safety profile and the hospitalization outcomes of undergoing GIE in patients with ACS and concomitant GIB using the national database for hospitalized patients in the United States.
METHODS The Nationwide Inpatient Sample database was queried to identify patients hospitalized with ACS and GIB during the same admission between 2005 and 2014. The International Classification of Diseases Code, 9th Revision Clinical Modification was utilized for patient identification. Patients were further classified into two groups based on undergoing endoscopic procedures (EGD, small intestinal endoscopy, colonoscopy, or flexible sigmoidoscopy). Both groups were compared regarding demographic information, outcomes, and comorbi-dities. Multivariate analysis was conducted to identify factors associated with mortality and prolonged length of stay. Chi-square test was used to compare categorical variables, while Student’s t-test was used to compare continuous variables. All analyses were performed using SAS 9.4 (Cary, NC, United States).
RESULTS A total of 35612318 patients with ACS were identified between January 2005 and December 2014. 269483 (0.75%) of the patients diagnosed with ACS developed concomitant GIB during the same admission. At least one endoscopic procedure was performed in 68% of the patients admitted with both ACS and GIB. Patients who underwent GIE during the index hospitalization with ACS and GIB had lower mortality (3.8%) compared to the group not undergoing endoscopy (8.6 %, P < 0.001). A shorter length of stay (LOS) was observed in patients who underwent GIE (mean 6.59 ± 7.81 d) compared to the group not undergoing endoscopy (mean 7.84 ± 9.73 d, P < 0.001). Multivariate analysis showed that performing GIE was associated with lower mortality (odds ratio: 0.58, P < 0.001) and shorter LOS (-0.36 factor, P < 0.001).
CONCLUSION Performing GIE during the index hospitalization of patients with ACS and GIB was correlated with a better mortality rate and a shorter LOS. Approximately two-thirds of patients with both ACS and GIB undergo GIE during the same hospitalization.
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Affiliation(s)
- Ahmed A Elkafrawy
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, MO 64108, United States
| | - Mohamed Ahmed
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, MO 64108, United States
| | - Mohammad Alomari
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FL 33331, United States
| | - Ahmed Elkaryoni
- Division of Cardiovascular Medicine, Loyola University Medical Center and Stritch School of Medicine, Maywood, IL 60153, United States
| | - Kevin F Kennedy
- Mid America Heart Institute, Saint Luke's Health System, Kansas City, MO 64111, United States
| | - Wendell K Clarkston
- Department of Gastroenterology, Saint Luke's Hospital/University of Missouri Kansas City, Kansas City, MO 64111, United States
| | - Donald R Campbell
- Department of Gastroenterology, Saint Luke's Hospital/University of Missouri Kansas City, Kansas City, MO 64111, United States
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19
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Singh-Franco D, Mastropietro DR, Metzner M, Dressler MD, Fares A, Johnson M, De La Rosa D, Wolowich WR. Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis. PLoS One 2020; 15:e0243134. [PMID: 33270710 PMCID: PMC7714117 DOI: 10.1371/journal.pone.0243134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
Objective Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST). Methods To identify studies, the following databases were systematically searched on October 14th, 2018 and repeated on September 12th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review. Results Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I2 = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I2 = 36%). Conclusion This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.
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Affiliation(s)
- Devada Singh-Franco
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
- * E-mail:
| | - David R. Mastropietro
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Miriam Metzner
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Michael D. Dressler
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Amneh Fares
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Melinda Johnson
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Daisy De La Rosa
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - William R. Wolowich
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
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Bang CS, Joo MK, Kim BW, Kim JS, Park CH, Ahn JY, Lee JH, Lee BE, Yang HJ, Cho YK, Park JM, Kim BJ, Jung HK. The Role of Acid Suppressants in the Prevention of Anticoagulant-Related Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. Gut Liver 2020; 14:57-66. [PMID: 30974930 PMCID: PMC6974330 DOI: 10.5009/gnl19009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/01/2019] [Accepted: 02/13/2019] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Although acid suppressants are widely used for the prevention or treatment of drug-induced upper gastrointestinal bleeding (GIB), evidence regarding the prevention of anticoagulant-related GIB is scarce. The aim of this study was to evaluate the protective effect of acid suppressants against anticoagulant-related GIB. Methods A systematic review was conducted of studies that evaluated the protective effect of acid suppressants against anticoagulant-related GIB found in PubMed, the Cochrane library, Embase, and KoreaMed from the date of database inception to April 2018. Random effect model meta-analyses with sensitivity analyses were conducted. The methodological quality of each included publication was evaluated using the Risk of Bias Assessment Tool for Nonrandomized Studies. Publication bias was assessed. Results In total, six nested case-control or cohort studies were identified and analyzed. Proton-pump inhibitors (PPI) had a protective effect against upper GIB in patients on dicumarinics (risk ratio [RR], 0.56; 95% confidence interval [CI], 0.38 to 0.83; I2, 0%); however, the histamine-2 receptor antagonist did not have the same effect (RR, 0.97; 95% CI, 0.52 to 1.81; I2, 0%). Acid suppressants did not have a protective effect against GIB in patients on dabigatran (hazard ratio, 0.78; 95% CI, 0.44 to 1.37; I2, 81.8%). Conclusions The protective effect of PPIs against dicumarinics-related upper GIB was clear, while there was no evidence supporting the protective effect of acid suppressants against dabigatran-related GIB. However, in the absence of randomized trials demonstrating a lack of bias, solid conclusions cannot be drawn.
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Affiliation(s)
- Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Sung Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Ji Yong Ahn
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hyo-Joon Yang
- Division of Gastroenterology, Department of Internal Medicine and Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yu Kyung Cho
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Myung Park
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
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21
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Kim WY, Lee S, Jun K, Ah YM, Lee JY. Underutilization of gastrointestinal prophylaxis in high-risk chronic nonsteroidal anti-inflammatory drug users in Korea. Int J Clin Pharm 2020; 43:645-653. [PMID: 33147346 DOI: 10.1007/s11096-020-01176-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/09/2020] [Indexed: 11/28/2022]
Abstract
Background The increasing use of antithrombotic therapies in older patients has led to an increased risk of gastrointestinal (GI) bleeding in chronic nonsteroidal anti-inflammatory drug (NSAID) users. Therefore, there is a pressing need for GI prophylaxis in these high-risk patients. Objective To analyze prescribing patterns and factors associated with the use of gastroprotective agents (GPAs) among high-risk, chronic NSAID users. Setting National claims database including 20% of the total Korean population aged ≥ 65 years. Method In this cross-sectional study, we identified older adults prescribed traditional NSAIDs for > 90 days and classified them into high- and ultra-high-risk groups if they had one or two or more GI risk factors, respectively. Proton pump inhibitors or misoprostol prescribed for more than 80% of traditional NSAID treatment days was regarded as appropriate GI prophylaxis. Main outcome measure Prevalence and associated factors with appropriate GI prophylaxis. Results Among 69,992 chronic traditional NSAID users, 38.8% and 9.4% belonged to the high and ultra-high-risk groups; 13.2% and 19.9% received appropriate GI prophylaxis, respectively. The most frequently used GPA was histamine H2 antagonists. Multiple NSAID use, concomitant antiplatelets and anticoagulants, and prior GI ulcer history increased the likelihood of receiving appropriate GI prophylaxis. Advanced age (≥ 85 years), indications other than arthritis, and neurology specialists negatively affected appropriate GI prophylaxis use. Conclusion Approximately one in five chronic NSAID users, considered ultra-high risk, are prescribed appropriate GI prophylaxis in Korea. Advanced age, indications, and specialties of the prescriber all need to be considered when selecting target populations for interventions.
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Affiliation(s)
- Woo-Youn Kim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1, Gwanak-ro, Seoul, 08826, Republic of Korea
| | - Suhyun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1, Gwanak-ro, Seoul, 08826, Republic of Korea
| | - Kwanghee Jun
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1, Gwanak-ro, Seoul, 08826, Republic of Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsangbuk-do, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1, Gwanak-ro, Seoul, 08826, Republic of Korea.
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22
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Lee MW, Katz PO. Nonsteroidal Antiinflammatory Drugs, Anticoagulation, and Upper Gastrointestinal Bleeding. Clin Geriatr Med 2020; 37:31-42. [PMID: 33213773 DOI: 10.1016/j.cger.2020.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Advanced age, history of peptic ulcer disease, Helicobacter pylori, coadministration of nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, anticoagulation, and antiplatelets are risk factors for gastrointestinal bleeding in the elderly. Awareness of these risks and appropriate use of NSAIDs, particularly in those needing antiplatelet or anticoagulant therapy, is critical to optimal management. Careful selection of elderly patients requiring antiplatelet, anticoagulation, or chronic NSAID therapy for cotherapy with proton pump inhibitors can significantly reduce morbidity and mortality from gastrointestinal bleeding.
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Affiliation(s)
- Mindy Winghin Lee
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1315 York Avenue, First Floor, New York, NY 10021, USA
| | - Philip O Katz
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1315 York Avenue, First Floor, New York, NY 10021, USA.
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23
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Medication-related factors associated with proton pump inhibitor prescription beyond official guidelines in older adults. Eur Geriatr Med 2020; 11:1051-1061. [DOI: 10.1007/s41999-020-00380-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 08/04/2020] [Indexed: 12/14/2022]
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24
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Kurlander JE, Rubenstein JH, Richardson CR, Krein SL, De Vries R, Zikmund-Fisher BJ, Yang YX, Laine L, Weissman A, Saini SD. Physicians' Perceptions of Proton Pump Inhibitor Risks and Recommendations to Discontinue: A National Survey. Am J Gastroenterol 2020; 115:689-696. [PMID: 32091419 PMCID: PMC7196016 DOI: 10.14309/ajg.0000000000000558] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To provide contemporary estimates of internists' perceptions of adverse effects associated with proton pump inhibitors (PPIs) and self-reported clinical use. METHODS We invited 799 internists, including specialists and postgraduate trainees, to complete an online survey. Topics included perceptions of PPI adverse effects (AEs) and effectiveness for upper gastrointestinal bleeding (UGIB) prevention, changes in prescribing, and management recommendations for patients using PPIs for gastroesophageal reflux disease or UGIB prevention. We used logistic regression to identify factors associated with appropriate PPI continuation in the scenario of a patient at high risk for UGIB. RESULTS Among 437 respondents (55% response rate), 10% were trainees and 72% specialized in general medicine, 70% were somewhat/very concerned about PPI AEs, and 76% had somewhat/very much changed their prescribing. A majority believed PPIs increase the risk for 6 of 12 AEs queried. Fifty-two percent perceived PPIs to be somewhat/very effective for UGIB prevention. In a gastroesophageal reflux disease scenario in which PPI can be safely discontinued, 86% appropriately recommended PPI discontinuation. However, in a high-risk UGIB prevention scenario in which long-term PPI use is recommended, 79% inappropriately recommended discontinuation. In this latter scenario, perceived effectiveness for bleeding prevention was strongly associated with continuing PPI (odds ratio 7.68, P < 0.001 for moderately; odds ratio 17.3, P < 0.001 for very effective). Other covariates, including concern about PPI AEs, had no significant association. DISCUSSION Most internists believe PPIs cause multiple AEs and recommend discontinuation even in patients at high risk for UGIB. Future interventions should focus on ensuring that PPIs are prescribed appropriately according to individual risks and benefits.
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Affiliation(s)
- Jacob E Kurlander
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Joel H Rubenstein
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Caroline R Richardson
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah L Krein
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Raymond De Vries
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Brian J Zikmund-Fisher
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Yu-Xiao Yang
- Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- The Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- Veterans Affair Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Arlene Weissman
- Research Center, American College of Physicians, Philadelphia, Pennsylvania, USA
| | - Sameer D Saini
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
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Milivojevic V, Milosavljevic T. Burden of Gastroduodenal Diseases from the Global Perspective. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2020; 18:148-157. [PMID: 31993967 DOI: 10.1007/s11938-020-00277-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW We reviewed the recent medical literature to show global burden of gastroduodenal disease, potential strategies, and further perspectives. RECENT FINDINGS Gastrointestinal and liver diseases are growing health problems, and cause more than 8 million deaths per year worldwide; encompass a range of long-term health conditions, such as digestive cancers, gastroesophageal reflux disease, Helicobacter pylori infection, peptic ulcer disease, liver diseases, inflammatory bowel disease, coeliac disease, and functional gastrointestinal disorders. Scientific knowledge demonstrates that the noncommunicable disease burden can be greatly reduced if cost-effective preventive and curative actions, along with interventions for prevention and control of noncommunicable diseases already available, are implemented in an effective and balanced manner. SUMMARY Future research will have to elaborate on simple methods for preselection of patients at high risk to allow their implementation in strategies and respect all demand of cost-effectiveness. Understanding trends in GI illnesses could be helpful to meet the needs of patients and decrease the disease burden.
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Affiliation(s)
- Vladimir Milivojevic
- Clinic of Gastroenterology and Hepatology, Clinical Center of Serbia, School of Medicine, Belgrade University, Koste Todorovic N 2, Belgrade, Serbia.
- School of Medicine, Belgrade University, Belgrade, Serbia.
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26
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Komagamine J, Yabuki T, Kobayashi M. Association between potentially inappropriate medications at discharge and unplanned readmissions among hospitalised elderly patients at a single centre in Japan: a prospective observational study. BMJ Open 2019; 9:e032574. [PMID: 31699748 PMCID: PMC6858212 DOI: 10.1136/bmjopen-2019-032574] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To determine the prevalence of potentially inappropriate medication (PIM) use at admission and discharge among hospitalised elderly patients and evaluate the association between PIMs at discharge and unplanned readmission in Japan. DESIGN A prospective observational study conducted by using electronic medical records. PARTICIPANTS All consecutive patients aged 65 years or older who were admitted to the internal medicine ward were included. Patients who were electively admitted for diagnostic procedures were excluded. MAIN OUTCOME MEASURES The primary outcome was 30-day unplanned readmissions. The secondary outcome was the prevalence of any PIM use at admission and discharge. PIMs were defined based on the Beers Criteria. The association between any PIM use at discharge and the primary outcome was evaluated by using logistic regression. RESULTS Seven hundred thirty-nine eligible patients were included in this study. The median patient age was 82 years (IQR 74-88); 389 (52.6%) were women, and the median Charlson Comorbidity Index was 2 (IQR 0-3). The proportions of patients taking any PIMs at admission and discharge were 47.2% and 32.2%, respectively. Of all the patients, 39 (5.3%) were readmitted within 30 days after discharge for the index hospitalisation. The use of PIMs at discharge was not associated with an increased risk of 30-day readmission (OR 0.93; 95% CI 0.46 to 1.87). This result did not change after adjusting for patient age, sex, number of medications, duration of hospital stay and comorbidities (OR 0.78; 95% CI 0.36 to 1.66). CONCLUSION The prevalence of any PIM use at discharge was high among hospitalised elderly patients in a Japanese hospital. Although the use of PIMs at discharge was not associated with an increased risk of unplanned readmission, given a lack of power of this study due to a low event rate, further studies investigating this association are needed. TRIAL REGISTRATION NUMBER UMIN000027189.
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Affiliation(s)
- Junpei Komagamine
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
| | - Taku Yabuki
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
| | - Masaki Kobayashi
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
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Abstract
The purpose of this study was to mask the bitter taste of nizatidine (NZD) using cation-exchange resins. Amberlite IRP-69 and Dowex-50 containing cross-linked polystyrene backbones were used. The drug resin complexes were prepared by batch process using drug: resin ratios of 1:1, 1:3, and 1:5. The optimum drug: resin ratio and the time required for maximum percentage drug loading into the complexes were determined. The selected drug-resin complexes were evaluated for morphology, drug release, and taste. The NZD-Dowex complex was obtained at a drug: resin ratio of 1:5 using a stirring time of 1 h in order to get 100% loading of NZD. The NZD-Dowex complex had a spherical shape and smooth texture similar to Dowex resin. The NZD-Dowex complex with a ratio of 1:5 showed that in vitro drug release of 4.27% at 5 min in simulated salivary fluid of pH 6.8 and 99.67% at 1 h in simulated gastric fluid of pH 1.2. NZD’s bitter taste was effectively masked when it formed a complex with Dowex at a ratio of 1:5. This was proved by an electronic tongue and human test panel.
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Sostres C, Marcén B, Laredo V, Alfaro E, Ruiz L, Camo P, Carrera-Lasfuentes P, Lanas Á. Risk of rebleeding, vascular events and death after gastrointestinal bleeding in anticoagulant and/or antiplatelet users. Aliment Pharmacol Ther 2019; 50:919-929. [PMID: 31486121 DOI: 10.1111/apt.15441] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 02/19/2019] [Accepted: 07/06/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with gastrointestinal bleeding during anticoagulant and/or antiplatelet therapy represent a clinical challenge. AIM To determine the risk/rates of rebleeding, vascular events and death in patients treated with antiplatelet or anticoagulant agents who developed major gastrointestinal bleeding METHODS: This was an observational cohort study of patients who developed gastrointestinal bleeding while on antiplatelet and/or anticoagulant therapy. Drug use information was collected prospectively during bleeding events. Cox proportional hazards models were used to evaluate rebleeding, vascular events and death. RESULTS Among 871 patients (mean age 78.9 ± 8.6 years), 38.9% used an anticoagulant, 52.5% used an antiplatelet and 8.6% used both; 93.1% interrupted treatment after gastrointestinal bleeding and 80.5% restarted therapy within 7.6 ± 36.4 days; 38.7% had upper gastrointestinal bleeds, 46.7% lower gastrointestinal bleeds and 14.6% gastrointestinal bleeds of unknown origin. Median follow-up was 24.9 months (IQR: 7.0-38.0). Resumption of both therapies was associated with a higher risk of rebleeding, lower risk of ischaemic events or death and a similar risk for upper and lower gastrointestinal events. Resumption of therapy ≤ 7 days after bleeding showed a similar pattern with no differences in death. Rebleeding rates were higher in anticoagulant vs antiplatelet patients (138.0 vs 99.0 events per 1000 patient-years), and the bleeding location was identical in 61.8% of cases. CONCLUSIONS Resumption of anticoagulant or antiplatelet therapy after a gastrointestinal bleeding event was associated with a lower risk of vascular events and death and a higher rebleeding risk. The benefits of early reinstitution of anticoagulant/antiplatelet therapy outweigh the gastrointestinal-related risks.
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Affiliation(s)
- Carlos Sostres
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.,IIS Aragón, Zaragoza, Spain.,CIBERehd, Zaragoza, Spain
| | - Beatriz Marcén
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Viviana Laredo
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Enrique Alfaro
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Lara Ruiz
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Patricia Camo
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Ángel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.,IIS Aragón, Zaragoza, Spain.,CIBERehd, Zaragoza, Spain.,University of Zaragoza, Zaragoza, Spain
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Newberry C, Saha A, Siddique SM, Metz DC, Domenico C, Choi K, Gitelman E, Mehta S. A Novel Clinical Decision Support System for Gastrointestinal Bleeding Risk Stratification in the Critically Ill. Jt Comm J Qual Patient Saf 2019; 45:440-445. [PMID: 30833110 DOI: 10.1016/j.jcjq.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 01/17/2019] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Acid suppression therapy can reduce the development of stress and medication-related mucosal disease when prescribed appropriately. Suboptimal inpatient prescribing of acid suppression therapy therefore may lead to increased development of gastrointestinal hemorrhage in high-risk populations. The aim of this quality improvement study was to improve appropriate acid suppression therapy in patients admitted to ICUs in an academic medical center. INTERVENTION DEVELOPMENT, IMPLEMENTATION, AND ADAPTATION An adaptable, multifaceted implementation strategy guided by unit-based root cause analysis was initially developed in a single ICU with a high-risk population. Identifiable targets of intervention, including provider awareness, unstructured rounding protocols, and electronic communication tools, were augmented by the development of an automated alert system. This electronic dashboard risk-stratified patients based on information derived from the electronic medical record (EMR). The dashboard then offered clinical decision support. Use of the dashboard and percentage of appropriate acid suppression therapy prescriptions were tracked over time. RESULTS Appropriate acid suppression therapy prescribing was improved from 72.9% to 86.0% (p < 0.001). CONCLUSION Automated technology including an EMR-supported electronic dashboard was the foundation of successful intervention. Considering the deleterious effects of both under- and overprescribing of acid suppression therapy, particularly in high-risk patient populations, this type of technology may lead to enhanced patient outcomes.
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Youn SH, Lim H, Ju Y, Soh JS, Park JW, Kang HS, Kim SE, Moon SH, Kim JH, Park CK, Seo SI, Shin WG. Effect of gastroprotective agents on upper gastrointestinal bleeding in patients receiving direct oral anticoagulants. Scand J Gastroenterol 2018; 53:1490-1495. [PMID: 30509124 DOI: 10.1080/00365521.2018.1541478] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Direct oral anticoagulants (DOACs) are effective in the prevention and treatment of thromboembolism; however, they are associated with upper gastrointestinal bleeding (UGIB). In this study, we evaluated the efficacy of gastroprotective agents (GPAs) in reducing the risk of UGIB in patients receiving DOACs. METHODS We retrospectively reviewed the medical records of 2076 patients who received DOACs for the prevention or treatment of thromboembolic events between January 2008 and July 2016. A cumulative incidence analysis using the Kaplan-Meier method was performed to determine the rate of UGIB and its association with GPAs administration. RESULTS Of the 2076 patients, 360 received GPAs. Over the follow-up period (1160 person-years), one patient in the GPA group (0.7 per 100 person-years) and 29 patients in the non-GPA group (2.8 per 100 person-years) developed UGIB (p = .189). In the multivariate analysis, UGIB was associated with older age (hazard ratio (HR), 1.041; p = .048), a history of peptic ulcer or UGIB (HR, 5.931; p < .001), and concomitant use of antiplatelet agents (HR, 3.121; p = .014). GPAs administration did not reduce the risk of UGIB (p = .289). However, based on the subgroup analysis of 225 patients with concomitant use of antiplatelet agents or a history of peptic ulcer or UGIB, the GPA group (0 per 100 person-years) showed reduced incidence of UGIB compared with the non-GPA group (11.3 per 100 person-years) (p = .065). CONCLUSIONS The prophylactic use of GPAs could reduce the risk of UGIB in patients receiving DOACs who have risk factors, such as concomitant use of antiplatelet agents or a history of peptic ulcer or UGIB.
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Affiliation(s)
- Sung Hee Youn
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Hyun Lim
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Yeonmi Ju
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Jae Seung Soh
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Ji Won Park
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Ho Suk Kang
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Sung Eun Kim
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Sung Hoon Moon
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Jong Hyeok Kim
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Choong Kee Park
- a Department of Internal Medicine, Hallym University Sacred Heart Hospital , University of Hallym College of Medicine , Anyang , Republic of Korea
| | - Seung In Seo
- b Department of Internal Medicine, Kangdong Sacred Heart Hospital , University of Hallym College of Medicine , Seoul , Republic of Korea
| | - Woon Geon Shin
- b Department of Internal Medicine, Kangdong Sacred Heart Hospital , University of Hallym College of Medicine , Seoul , Republic of Korea
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Trends in concomitant clopidogrel and proton pump inhibitor treatment among ACS inpatients, 2000-2016. Eur J Clin Pharmacol 2018; 75:227-235. [PMID: 30324301 DOI: 10.1007/s00228-018-2564-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The US Food and Drug Administration (FDA) issued three safety announcements between January 2009 and October 2010 warning against concomitant use of clopidogrel and proton pump inhibitors (PPIs) due to a potential drug-drug interaction that may attenuate clopidogrel's antiplatelet activity. This primary objective of this study was to examine trends in concomitant clopidogrel/PPI use among acute coronary syndrome (ACS) inpatients in the US between 2000 and 2016, in relation to the FDA safety communications. METHODS Adult inpatients with a primary diagnosis of ACS were identified from the Cerner Health Facts® database. The standardized (age, sex, race, and census region) prevalence of clopidogrel use with PPIs was calculated yearly and quarterly. Findings were stratified by PPIs' potential to inhibit clopidogrel's activity and by age. RESULTS A total of 204,533 inpatients were identified. In 2008, the prevalence of concomitant clopidogrel and PPI treatment was 34.9%, decreasing to 24.4 and 16.4% in 2009 and 2010, respectively, with the decline being similar across age groups. Treatment with inhibiting PPIs (omeprazole and esomeprazole) and clopidogrel has continued to decrease since 2010, with a prevalence of 0.8% in 2016. A similar reduction was not observed with clopidogrel and non-inhibiting PPIs (pantoprazole, lansoprazole, rabeprazole, and dexlansoprazole). During the FDA warning period, the combined treatment with clopidogrel and H2 receptor antagonists, an alternative to PPIs suggested by the FDA, temporarily increased from 7.8% in 2008 to 12.8 and 14.5% in 2009 and 2010, respectively. CONCLUSIONS Findings suggest that clinical practice recommendations made by the FDA were followed. Further research is needed to determine how changes in drug labels and the availability of new drugs may have influenced the observed trends.
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Frampton J, Devries JT, Welch TD, Gersh BJ. Modern Management of ST-Segment Elevation Myocardial Infarction. Curr Probl Cardiol 2018; 45:100393. [PMID: 30660333 DOI: 10.1016/j.cpcardiol.2018.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 08/31/2018] [Indexed: 12/31/2022]
Abstract
Disruption of intracoronary plaque with thrombus formation resulting in severe or total occlusion of the culprit coronary artery provides the pathophysiologic foundation for ST-segment elevation myocardial infarction (STEMI). Management of STEMI focuses on timely restoration of coronary blood flow along with antithrombotic therapies and secondary prevention strategies. The purpose of this review is to discuss the epidemiology, pathophysiology, and diagnosis of STEMI. In addition, the review will focus on guideline-directed therapy for these patients and review potential associated complications.
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Komagamine J. Prevalence of potentially inappropriate medications at admission and discharge among hospitalised elderly patients with acute medical illness at a single centre in Japan: a retrospective cross-sectional study. BMJ Open 2018; 8:e021152. [PMID: 30030316 PMCID: PMC6059264 DOI: 10.1136/bmjopen-2017-021152] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To determine the prevalence of potentially inappropriate medications (PIMs) at admission and discharge among hospitalised elderly patients with acute medical illness in Japan. DESIGN A retrospective single-centre cross-sectional study. PARTICIPANTS Hospitalised patients aged 65 years or older admitted for pneumonia, heart failure, ischaemic stroke, acute coronary syndrome, chronic obstructive pulmonary disease or asthma, gastrointestinal bleeding, urinary tract infection or epilepsy from September 2014 to June 2016 who were still alive at discharge. MAIN OUTCOME MEASURES The primary outcome was the proportion of patients taking at least one PIM at admission and discharge. PIMs were defined based on the 2015 American Geriatric Society Beers Criteria. Temporal changes in the proportion of patients taking at least one PIM from admission to discharge were also evaluated. RESULTS During the study period, 689 eligible patients were identified. The median patient age was 82.0 years (IQR 76.0-88.0), 348 (50.5%) were men and the median number of medications at admission was 5.0 (IQR 3.0-8.0). The proportions of patients taking any PIMs at admission and discharge were 47.9% (95% CI 44.2% to 51.6%) and 25.1% (95% CI 21.9% to 28.4%), respectively. The proportion of patients taking any PIMs was significantly lower at discharge than at admission (reduction rate 0.48, 95%, CI 0.41 to 0.53). CONCLUSIONS A substantial proportion of hospitalised elderly patients with acute medical illness took PIMs at admission and discharge. These findings should be confirmed at other hospitals in Japan.
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Affiliation(s)
- Junpei Komagamine
- Department of Internal Medicine, National Hospital Organisation Tochigi Medical Centre, Utsunomiya, Japan
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Nakamura S, Watanabe T, Shimada S, Nadatani Y, Otani K, Tanigawa T, Miyazaki T, Iimuro M, Fujiwara Y. Does discontinuation of antithrombotics affect the diagnostic yield of small bowel capsule endoscopy in patients demonstrating obscure gastrointestinal bleeding? J Clin Biochem Nutr 2018; 63:149-153. [PMID: 30279627 PMCID: PMC6160721 DOI: 10.3164/jcbn.17-142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 01/12/2018] [Indexed: 12/22/2022] Open
Abstract
A large proportion of patients demonstrating obscure gastrointestinal bleeding (OGIB) are antithrombotic users and need to undergo small bowel capsule endoscopy (SBCE). We examined the effect of discontinuation of antithrombotics on the diagnostic yield of SBCE. Additionally, we assessed predictive factors associated with positive SBCE findings. Our study included 130 patients using antithrombotics who underwent SBCE for overt OGIB. The primary endpoint was the difference in the rate of positive SBCE findings between patients who continued and those who discontinued antithrombotics. Secondary endpoints were to investigate the effect of discontinuation of antithrombotics using a propensity score analysis, and to assess predictive factors associated with a positive SBCE. Among the 73 patients who continued use of antithrombotics, 36 (49.3%) patients demonstrated positive findings, while among the 57 patients who discontinued antithrombotics, 35 (61.4%) patients showed positive findings. Rates of positive SBCE findings didn't differ between the two groups. After we performed propensity score matching, discontinuation didn't affect the rate of positive SBCE findings. The lowest hemoglobin level was the only independent predictive factor associated with positive SBCE findings. In conclusion, discontinuation of antithrombotic therapy didn't affect the diagnostic yield of SBCE in patients presenting with overt OGIB.
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Affiliation(s)
- Shiro Nakamura
- Department of Inflammatory Bowel Disease, Division of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya City, Hyogo 663-8501, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Sunao Shimada
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Yuji Nadatani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Koji Otani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Takako Miyazaki
- Department of Inflammatory Bowel Disease, Division of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya City, Hyogo 663-8501, Japan
| | - Masaki Iimuro
- Department of Inflammatory Bowel Disease, Division of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya City, Hyogo 663-8501, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
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Del Giorno R, Ceschi A, Pironi M, Zasa A, Greco A, Gabutti L. Multifaceted intervention to curb in-hospital over-prescription of proton pump inhibitors: A longitudinal multicenter quasi-experimental before-and-after study. Eur J Intern Med 2018; 50:52-59. [PMID: 29274884 DOI: 10.1016/j.ejim.2017.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/03/2017] [Accepted: 11/06/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are indicated for a restricted number of clinical conditions, and their misuse can lead to several adverse effects. Despite that, the proportion of overuse is alarmingly high. OBJECTIVE To test the efficacy of a multifaceted strategy in order to achieve a significant reduction of new PPI prescriptions at discharge in hospitalized patients. DESIGN Multicenter longitudinal quasi-experimental before-and-after study conducted from July 1st, 2014 to June 30th, 2017. PARTICIPANTS 44,973 admissions in a network of 5 public teaching hospitals of the Italian-speaking region of Switzerland. INTERVENTION Multifaceted strategy consisting in a continuous transparent monitoring-benchmarking and in capillary educational interventions applied in the internal medicine departments. To confirm the causality of the results we monitored the trend of new PPI prescriptions in the, not exposed to the intervention, surgery departments of the same hospital network. MAIN MEASURES New PPI prescriptions at hospital discharge. KEY RESULTS Over the 36month study period 44,973 patient files were analyzed. At admission, comparing internal medicine vs. surgery departments, 44.9% vs. 23.3% of patients were already being treated with a PPI. The annual rate of new PPI prescriptions, for internal medicine showed a decreasing trend: 19, 19, 18, 16% in years 2014, 2015, 2016, 2017, respectively (p<0.001, 2014 vs. 2017; p-for-trend <0.001), while an increasing rate was found in the surgery departments in the same years: 30, 29, 36, 36%, respectively (p<0.001, 2014 vs. 2017; p-for-trend <0.001). The case mix was significantly associated with the probability of new PPI prescriptions in both departments (OR1.35, 95% CI 1.26-1.44 for internal medicine and 1.24, 95% CI 1.19-1.30 for surgery). CONCLUSIONS The introduction of a multifaceted intervention significantly reduced the time trend of PPI prescriptions at hospital discharge in internal medicine departments. Further studies are needed to confirm whether the strategy proposed could contribute to optimize the in-hospital drug prescription behavior in other healthcare settings as well.
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Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Bellinzona, Switzerland.
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland.
| | - Michela Pironi
- Central Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.
| | - Anna Zasa
- Quality and Patient Safety Service, La Carità Hospital, Locarno, Switzerland
| | - Angela Greco
- Quality and Patient Safety Service, La Carità Hospital, Locarno, Switzerland.
| | - Luca Gabutti
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Bellinzona, Switzerland; Institute of Biomedicine, University of Southern Switzerland, Lugano, Switzerland.
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Abstract
This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.
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Wahking RA, Steele RL, Hanners RE, Lockwood SM, Davis KW. Outcomes From a Pharmacist - led Proton Pump Inhibitor Stewardship Program at a Single Institution. Hosp Pharm 2017; 53:59-67. [PMID: 29434389 DOI: 10.1177/0018578717747192] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Proton pump inhibitors (PPIs) are effective medications for acid-related disorders; however, they are also overused and may be associated with several adverse effects. A PPI stewardship program was implemented at one institution to combat the overuse of PPIs. Objective: The purpose of this study is to evaluate the effectiveness of an inpatient PPI stewardship program in reducing PPI use, both during hospitalization and upon discharge. Methods: This was a retrospective cohort study of all patients admitted to an internal medicine service at a single institution from March 14, 2016, to August 14, 2016, with an intervention by the PPI stewardship team. The primary objective was to determine the percentage of patients who tolerated inpatient and outpatient PPI discontinuation, or dose de-escalations upon discharge. Secondary objectives included the identification of risk factors for intolerance of PPI discontinuation, the occurrence of gastrointestinal (GI) complications after PPI discontinuation, and the percentage of patients who required "as needed" acid suppressive therapy (AST) with an antacid or histamine-2 receptor antagonist (H2RA) to control their symptoms while hospitalized. Results: During the study time period, 537 patients with an active outpatient prescription for a PPI were admitted to an internal medicine team with 41.0% (n = 220) not meeting criteria for inpatient continuation. Of these patients, 95.9% (n = 211) tolerated inpatient PPI discontinuation, with 83.4% (n = 176) not requiring any "as needed" AST during hospitalization. Upon discharge, 57.1% patients (n = 24 of 42) tolerated PPI discontinuation at 3 months, while 81.8% patients (n = 18 of 22) tolerated PPI dose de-escalations at 3 months. Risk factors for intolerance of inpatient PPI discontinuation were a higher body mass index (BMI) (33.7 vs 30.3 kg/m2, P = .046) and longer length of stay (7.0 vs 4.0 days, P = .03), while longer duration of PPI use (9.0 vs 5.5 years, P = 0.03) was identified as a risk factor for intolerance of outpatient PPI discontinuation. One patient experienced reflux esophagitis 2 months after PPI discontinuation. Conclusion: A PPI stewardship program at a single institution resulted in the reduction of inappropriate PPI use in both the inpatient and outpatient settings.
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Affiliation(s)
| | - Randal L Steele
- Lexington Veterans Affairs Medical Center, Lexington, KY, USA
| | | | - Sean M Lockwood
- Lexington Veterans Affairs Medical Center, Lexington, KY, USA.,University of Kentucky College of Medicine, Lexington, KY, USA
| | - Kelly W Davis
- Lexington Veterans Affairs Medical Center, Lexington, KY, USA
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王 又. 阿司匹林治疗冠心病患者合并上消化道出血的影响因素. Shijie Huaren Xiaohua Zazhi 2017; 25:2155-2160. [DOI: 10.11569/wcjd.v25.i23.2155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
目的 研究老年冠心病患者合并上消化出血应用阿司匹林治疗的影响因素分析.
方法 选取2015-11/2016-11在湖北省汉川市人民医院采用阿司匹林口服治疗的老年冠心病患者纳入214例进行回顾性分析, 对发生上消化道出血51例患者的年龄、性别、服药时间、剂量、消化道病史、胃黏膜保护剂使用情况和吸烟史等进行分析.
结果 患者年龄随着时间逐渐增长, 上消化道出血发生率明显增高(χ2 = 11.526, P<0.01); 服药时间低于3 mo的患者上消化道出血率显著低于服药超过3 mo的患者, 差异具有统计学意义(χ2 = 8.530, P<0.01); 小剂量组患者上消化道出血率明显低于大剂量组, 差异具有统计学意义(χ2 = 5.127, P<0.01); 上消化道出血与患者年龄无相关性(P>0.05), 老年冠心病患者有消化道病史或吸烟史的服用阿司匹林肠溶片容易造成上消化道出血(P<0.05), 阿司匹林联合胃黏膜保护剂同时服用可有效降低上消化道出血发生率(P<0.05).
结论 阿司匹林肠溶片联合胃黏膜保护剂, 可降低上消化道出血发生率.
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Yamada A, Niikura R, Maki K, Nakamura M, Watabe H, Fujishiro M, Oka S, Fujimori S, Nakajima A, Ohmiya N, Matsumoto T, Tanaka S, Koike K, Sakamoto C. Proton pump inhibitor therapy did not increase the prevalence of small-bowel injury: A propensity-matched analysis. PLoS One 2017; 12:e0182586. [PMID: 28771618 PMCID: PMC5542471 DOI: 10.1371/journal.pone.0182586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/20/2017] [Indexed: 01/27/2023] Open
Abstract
Background Previous studies have reported that the suppression of acid secretion by using proton pump inhibitors (PPIs) results in dysbiosis of the small-bowel microbiota, leading to exacerbated small-bowel injuries, including erosions and ulcers. This study was designed to assess the association between PPI therapy and small-bowel lesions after adjustment for the differences in baseline characteristics between users and non-users of PPIs. Methods We retrospectively studied patients suspected to be suffering from small-bowel diseases, who underwent capsule endoscopy between 2010 and 2013. We used propensity matching to adjust for the differences in baseline characteristics between users and non-users of PPIs. The outcomes included the prevalence of small-bowel lesions: erosion, ulcer, angioectasia, varices, and tumor. Results We selected 327 patient pairs for analysis after propensity matching, and found no significant differences in the prevalence of small-bowel injuries, including erosions and ulcers, between users and non-users of PPIs. Two subgroup analyses of the effect of the type of PPI and the effect of PPI therapy in users and non-users of nonsteroidal anti-inflammatory drugs indicated no significant differences in the prevalence of small-bowel injuries in these two groups. Conclusion PPI therapy did not increase the prevalence of small-bowel injury, regardless of the type of PPI used and the use of nonsteroidal anti-inflammatory drugs.
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Affiliation(s)
- Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- * E-mail:
| | - Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koutarou Maki
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo, Tokyo, Japan
| | - Shiro Oka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Atsushi Nakajima
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Naoki Ohmiya
- Department of Gastroenterology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Morioka, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Choitsu Sakamoto
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
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Strand DS, Kim D, Peura DA. 25 Years of Proton Pump Inhibitors: A Comprehensive Review. Gut Liver 2017; 11:27-37. [PMID: 27840364 PMCID: PMC5221858 DOI: 10.5009/gnl15502] [Citation(s) in RCA: 316] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 02/07/2016] [Indexed: 12/13/2022] Open
Abstract
Proton pump inhibitors (PPIs) were clinically introduced more than 25 years ago and have since proven to be invaluable, safe, and effective agents for the management of a variety of acid-related disorders. Although all members in this class act in a similar fashion, inhibiting active parietal cell acid secretion, there are slight differences among PPIs relating to their pharmacokinetic properties, metabolism, and Food and Drug Administration (FDA)-approved clinical indications. Nevertheless, each is effective in managing gastroesophageal reflux disease and uncomplicated or complicated peptic ulcer disease. Despite their overall efficacy, PPIs do have some limitations related to their short plasma half-lives and requirement for meal-associated dosing, which can lead to breakthrough symptoms in some individuals, especially at night. Longer-acting PPIs and technology to prolong conventional PPI activity have been developed to specifically address these limitations and may improve clinical outcomes.
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Affiliation(s)
- Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Daejin Kim
- Division of Gastroenterology, Daegu Fatima Hospital, Daegu, Korea
| | - David A Peura
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
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Belfield KD, Kuyumjian AG, Teran R, Amadi M, Blatt M, Bicking K. Impact of A Collaborative Strategy to Reduce the Inappropriate Use of Acid Suppressive Therapy in Non-Intensive Care Unit Patients. Ann Pharmacother 2017. [PMID: 28622739 DOI: 10.1177/1060028017698797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Stress ulcer prophylaxis (SUP) is inappropriately prescribed in more than 30% of non-intensive care unit (ICU) patients, leading to unnecessary adverse events as well as increases in economic burden. OBJECTIVE There was an increasing trend in the prophylactic use of acid suppressive therapy (AST) in non-critically ill patients at our institution, which prompted this initiative aimed at reducing the inappropriate use of AST in non-ICU patients. METHODS This was a retrospective interventional study that consisted of formulation of a guideline, education to the hospitalist service, and intervention by clinical pharmacists. All adult non-ICU patients admitted to the hospitalist service who were newly initiated on AST were considered for inclusion. The primary outcome was a comparison of the proportion of inpatient days with inappropriate AST. Secondary outcomes included a comparison of patients discharged on inappropriate AST and drug acquisition costs, successful pharmacy interventions, hospitalist interventions, incidence of Clostridium difficile infection (CDI) or gastrointestinal (GI) bleeding, and drug costs averted through pharmacy intervention. RESULTS There were 61 patients in the historical group and 81 patients in the interventional group. This intervention resulted in a 31% absolute reduction in inappropriate patient days of AST and a 24% absolute reduction in patients discharged on inappropriate AST. There were 23 successful interventions. There were no cases of CDI and 1 GI bleed. This intervention resulted in an 87% reduction in drug acquisition costs per patient. CONCLUSIONS A collaboration between clinical pharmacists and a hospitalist service can significantly reduce the inappropriate use of AST in non-ICU patients.
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Affiliation(s)
| | | | - Rafael Teran
- 2 Hackensack University Medical Center, Hackensack, NJ, USA
| | - Mariette Amadi
- 2 Hackensack University Medical Center, Hackensack, NJ, USA
| | - Melissa Blatt
- 2 Hackensack University Medical Center, Hackensack, NJ, USA
| | - Keri Bicking
- 2 Hackensack University Medical Center, Hackensack, NJ, USA
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Davis KW, Hanners RE, Lockwood SM. Implementation of a proton pump inhibitor stewardship program. Am J Health Syst Pharm 2017; 74:932-937. [DOI: 10.2146/ajhp160670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Kelly W. Davis
- Lexington Veterans Affairs Medical Center, Lexington, KY
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Serbin MA, Guzauskas GF, Veenstra DL. Clopidogrel-Proton Pump Inhibitor Drug-Drug Interaction and Risk of Adverse Clinical Outcomes Among PCI-Treated ACS Patients: A Meta-analysis. J Manag Care Spec Pharm 2017; 22:939-47. [PMID: 27459657 DOI: 10.18553/jmcp.2016.22.8.939] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Uncertainty regarding clopidogrel effectiveness attenuation because of a drug-drug interaction with proton pump inhibitors (PPI) has led to conflicting guidelines on concomitant therapy. In particular, the effect of this interaction in patients who undergo a percutaneous coronary intervention (PCI), a population known to have increased risk of adverse cardiovascular events, has not been systematically evaluated. OBJECTIVE To synthesize the evidence of the effect of clopidogrel-PPI drug interaction on adverse cardiovascular outcomes in a PCI patient population. METHODS We conducted a systematic literature review for studies reporting clinical outcomes in patients who underwent a PCI and were initiated on clopidogrel with or without a PPI. Studies were included in the analysis if they reported at least 1 of the clinical outcomes of interest (major adverse cardiovascular event [MACE], cardiovascular death, all-cause death, myocardial infarction, stroke, stent thrombosis, and bleed events). We excluded studies that were not exclusive to PCI patients or had no PCI subgroup analysis and/or did not report at least a 6-month follow-up. Statistical and clinical heterogeneity were evaluated and HRs and 95% CIs for adverse clinical events were pooled using the DerSimonian and Laird random-effects meta-analysis method. RESULTS We identified 12 studies comprising 50,277 PCI patients that met our inclusion and exclusion criteria. Our analysis included retrospective analyses of randomized controlled trials (2), health registries (3), claims databases (2), and institutional records (5); no prospective studies of PCI patients were identified. On average, patients were in their mid-60s, male, and had an array of comorbidities, including hyperlipidemia, diabetes, hypertension, and smoking history. Concomitant therapy following PCI resulted in statistically significant increases in composite MACE (HR = 1.28; 95% CI = 1.24-1.32), myocardial infarction (HR = 1.51; 95% CI = 1.40-1.62), and stroke (HR = 1.46; 95% CI = 1.15-1.86). However, concomitant therapy had no statistically significant effect on stent thrombosis, mortality measured by all-cause or cardiovascular death, or major bleeding before or after the grouping of studies that reported a major or minor bleed outcome. Only 1 study reported on gastrointestinal bleed, and pooled analysis could not be conducted. Statistical testing suggested heterogeneity among studies, but subgroup analysis did not reveal a clear source. CONCLUSIONS Based on the results from this meta-analysis of retrospective analyses of randomized controlled trials and observational studies, concomitant clopidogrel-PPI therapy following PCI appears to be significantly associated with adverse cardiovascular events. Further research on the effect of individual PPIs is needed. DISCLOSURES Serbin, Guzauskas, and Veenstra were supported by the NIH Common Fund and NIA (1U01AG047109-01, Veenstra, PI) via the Personalized Medicine Economics Research (PriMER) project. The authors do not report any conflicting interests. All authors contributed to the study concept and design. Serbin took the lead in data collection; data interpretation was performed primarily by Serbin, with assistance from the other authors. The manuscript was written primarily by Serbin, along with Guzauskas, and revised by Guzauskas and Veenstra, with assistance from Serbin.
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Yi ZM, Qiu TT, Zhang Y, Liu ZY, Zhai SD. Comparison of prophylactic effect of UGIB and effects on platelet function between PPIs and H 2RAs combined with DAPT: systematic review and meta-analysis. Ther Clin Risk Manag 2017; 13:367-377. [PMID: 28392699 PMCID: PMC5373835 DOI: 10.2147/tcrm.s127292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective We compared prophylactic effects of proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) on upper gastrointestinal bleeding (UGIB) associated with dual antiplatelet therapy (DAPT) and explored this influence on platelet function. Methods Randomized controlled trials and cohort studies comparing PPIs with H2RAs in adults receiving DAPT were collected from PubMed, EMBASE and Cochrane databases. Dichotomous data were pooled to obtain risk ratios (RRs) for UGIB, major adverse cardiovascular events (MACEs), poor responders to clopidogrel and rehospitalization, and continuous data were pooled to obtain mean differences (MDs) for P2Y12 reaction units (PRUs), with 95% confidence intervals (CIs). Results Twelve clinical trials (n=3,301) met the inclusion criteria. Compared to H2RAs, PPIs lessened UGIB (RR =0.16, 95% CI: 0.03–0.70), and there was no significant difference in the incidence of PRUs (MD =18.21 PRUs, 95% CI: −4.11–40.54), poor responders to clopidogrel (RR =1.21, 95% CI: 0.92–1.61), incidence of MACEs (RR =0.89, 95% CI: 0.45–1.75) or rehospitalization (RR =1.76, 95% CI: 0.79–3.92). Subgroup analysis confirmed fewer PRUs in the H2RAs group compared to the omeprazole group (2 studies, n=189, MD =31.80 PRUs, 95% CI: 11.65–51.96). However, poor responder data for clopidogrel and MACEs might be unreliable because few studies of this kind were included. Conclusion Limited evidence indicates that PPIs were better than H2RAs for prophylaxis of UGIB associated with DAPT and had no effect on platelet function. Further study is needed to confirm these observations.
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Affiliation(s)
- Zhan-Miao Yi
- Department of Pharmacy, Peking University Third Hospital, Beijing
| | - Ting-Ting Qiu
- Department of Pharmacy, Peking University Third Hospital, Beijing; Department of Pharmacy, China Pharmaceutical University, Nanjing, People's Republic of China
| | - Yuan Zhang
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Zhi-Yan Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing
| | - Suo-Di Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing
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Sumayin Ngamdu K, El Mallah W, Dwivedi A, Mohsin R, Elhanafi S, Jia Y, Alvarado LA, Mukherjee D, Zuckerman MJ. One-Year Survival is Not Affected by Gastrointestinal Bleeding After Percutaneous Coronary Interventions. Am J Med Sci 2017; 353:381-386. [DOI: 10.1016/j.amjms.2017.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/21/2017] [Accepted: 01/30/2017] [Indexed: 10/20/2022]
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Shamliyan TA, Middleton M, Borst C. Patient-centered Outcomes with Concomitant Use of Proton Pump Inhibitors and Other Drugs. Clin Ther 2017; 39:404-427.e36. [PMID: 28189362 DOI: 10.1016/j.clinthera.2017.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE We performed a systematic review of patient-centered outcomes after the concomitant use of proton pump inhibitors (PPIs) and other drugs. METHODS We searched 4 databases in July 2016 to find studies that reported mortality and morbidity after the concomitant use of PPIs and other drugs. We conducted direct meta-analyses using a random-effects model and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation working group approach. FINDINGS We included data from 17 systematic reviews and meta-analyses, 16 randomized controlled trials, and 16 observational studies that examined the concomitant use of PPIs with medications from 10 drug classes. Low-quality evidence suggests that the use of PPIs is associated with greater morbidity when administered with antiplatelet drugs, bisphosphonates, antibiotics, anticoagulants, metformin, mycophenolate mofetil, or nelfinavir. Concomitant PPIs reduce drug-induced gastrointestinal bleeding and are associated with greater docetaxel and cisplatin response rates in patients with metastatic breast cancer. For demonstrated statistically significant relative risks and benefits from concomitant PPIs, the magnitudes of the effects are small, with <100 attributable events per 1000 patients treated, and the effects are inconsistent among specific drugs. Among individual PPIs, the concomitant use of pantoprazole or esomeprazole, but not omeprazole or lansoprazole, is associated with an increased risk for all-cause mortality, nonfatal myocardial infarction, or stroke. Clopidogrel is associated with a greater risk for myocardial infarction compared with prasugrel. Conflicting results between randomized controlled trials and observational studies and high risk for bias in the body of evidence lessened our confidence in the results. IMPLICATIONS Available evidence suggests a greater risk for adverse patient outcomes after the concomitant use of PPIs and medications from 9 drug classes and warns against inappropriate drug combinations.
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Affiliation(s)
- Tatyana A Shamliyan
- Evidence-Based Medicine Center, Quality Assurance, Elsevier, Philadelphia, Pennsylvania.
| | - Maria Middleton
- Evidence-Based Medicine Center, Elsevier, Philadelphia, Pennsylvania
| | - Clarissa Borst
- Clinical Drug Information, Elsevier, Philadelphia, Pennsylvania
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Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017; 112:212-239. [PMID: 28071659 DOI: 10.1038/ajg.2016.563] [Citation(s) in RCA: 900] [Impact Index Per Article: 128.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/07/2016] [Indexed: 02/07/2023]
Abstract
Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an important cause of peptic ulcer disease and gastric cancer. H. pylori may also have a role in uninvestigated and functional dyspepsia, ulcer risk in patients taking low-dose aspirin or starting therapy with a non-steroidal anti-inflammatory medication, unexplained iron deficiency anemia, and idiopathic thrombocytopenic purpura. While choosing a treatment regimen for H. pylori, patients should be asked about previous antibiotic exposure and this information should be incorporated into the decision-making process. For first-line treatment, clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who reside in areas where clarithromycin resistance amongst H. pylori isolates is known to be low. Most patients will be better served by first-line treatment with bismuth quadruple therapy or concomitant therapy consisting of a PPI, clarithromycin, amoxicillin, and metronidazole. When first-line therapy fails, a salvage regimen should avoid antibiotics that were previously used. If a patient received a first-line treatment containing clarithromycin, bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options. If a patient received first-line bismuth quadruple therapy, clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options. Details regarding the drugs, doses and durations of the recommended and suggested first-line and salvage regimens can be found in the guideline.
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Affiliation(s)
- William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | | | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Steven F Moss
- Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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García-Iglesias P, Botargues JM, Feu Caballé F, Villanueva Sánchez C, Calvet Calvo X, Brullet Benedi E, Cánovas Moreno G, Fort Martorell E, Gallach Montero M, Gené Tous E, Hidalgo Rosas JM, Lago Macía A, Nieto Rodríguez A, Papo Berger M, Planella de Rubinat M, Saló Rich J, Campo Fernández de Los Ríos R. Management of non variceal upper gastrointestinal bleeding: position statement of the Catalan Society of Gastroenterology. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:363-374. [PMID: 28109636 DOI: 10.1016/j.gastrohep.2016.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 11/22/2016] [Accepted: 11/25/2016] [Indexed: 12/11/2022]
Abstract
In recent years there have been advances in the management of non-variceal upper gastrointestinal bleeding that have helped reduce rebleeding and mortality. This document positioning of the Catalan Society of Digestologia is an update of evidence-based recommendations on management of gastrointestinal bleeding peptic ulcer.
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Affiliation(s)
- Pilar García-Iglesias
- Servei de Digestiu, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España.
| | - Josep-Maria Botargues
- Servei de Digestiu, Hospital Universitari de Bellvitge, l'Hospitalet, Barcelona, España
| | - Faust Feu Caballé
- Servei de Gastroenterologia, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Barcelona, España
| | | | - Xavier Calvet Calvo
- Servei de Digestiu, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Departament de Medicina, Universitat Autònoma de Barcelona, España
| | - Enric Brullet Benedi
- Servei de Digestiu, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España
| | - Gabriel Cánovas Moreno
- Servei de Cirurgia, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España
| | | | - Marta Gallach Montero
- Servei de Digestiu, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España
| | - Emili Gené Tous
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Departament de Medicina, Universitat Autònoma de Barcelona, España; Servei d'Urgències, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España
| | - José-Manuel Hidalgo Rosas
- Servei de Cirurgia, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España
| | - Amelia Lago Macía
- Servei de Digestiu, Hospital de Tortosa Verge de la Cinta, Tortosa, Tarragona, España
| | | | | | | | - Joan Saló Rich
- Servei de Digestiu, Hospital de Vic, Vic, Barcelona, España
| | - Rafel Campo Fernández de Los Ríos
- Servei de Digestiu, Hospital de Sabadell-Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, España; Departament de Medicina, Universitat Autònoma de Barcelona, España
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