1
|
Abstract
Purpose of review Peptic ulcer disease (PUD) is a recognized complication of non-steroidal anti-inflammatory drugs (NSAIDs). Stress ulcers are a concern for intensive care unit (ICU) patients; PUD is also an issue for patients taking anticoagulation. Helicobacter pylori test and treat is an option for patients starting NSAID therapy, and proton pump inhibitors (PPIs) may reduce PUD in NSAID patients and other high-risk groups. Recent findings There are a large number of trials that demonstrate that Helicobacter pylori eradication reduces PUD in NSAID patients. PPI is also effective at reducing PUD in this group and is also effective in ICU patients and those on anticoagulants. The effect is too modest for PPI to be recommended in everyone, and more research is needed as to which groups would benefit the most. Increasing age, past history of PUD, and comorbidity are the most important risk factors. Summary H. pylori test and treat should be offered to older patients starting NSAIDS, while PPIs should be prescribed to patients that are at high risk of developing PUD and at risk of dying from PUD complications.
Collapse
|
2
|
Thorat MA, Cuzick J. Prophylactic use of aspirin: systematic review of harms and approaches to mitigation in the general population. Eur J Epidemiol 2015; 30:5-18. [PMID: 25421783 DOI: 10.1007/s10654-014-9971-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 10/30/2014] [Indexed: 12/26/2022]
Abstract
A careful assessment of benefits and harms is required to assess suitability of aspirin as a prophylactic public health measure. However, comprehensive population-level data on harms are lacking. We collected and synthesized age and sex-specific data on harms relevant to aspirin use in average-risk individuals aged 50 years or older. We conducted systematic literature searches to identify baseline rates of gastrointestinal (GI) bleeding, peptic ulcer, major extra-cranial bleeding, and case-fatality rates due to GI bleeding or peptic ulcer in general population. The magnitude of aspirin-associated increase, the prevalence and attributable risk of Helicobacter pylori infection on these events in aspirin users was also assessed. Baseline rates of major extracranial bleeding events and GI complications increase with age; an almost threefold to fourfold increase is observed from age 50-54 to 70-74 years. Low or standard-dose aspirin use increases GI bleeding events by 60% leading to an annual excess of 0.45 and 0.79 GI bleeding events per 1,000 women and men aged 50-54 years respectively. 5-10% of major GI complications are fatal; a clear age dependence--higher fatality in older individuals, is seen. Eradication of H. pylori infection before aspirin use could reduce the incidence of upper GI complications by 25-30%. GI complications are increased by about 60% due to aspirin use but are fatal only in a very small proportion of individuals younger than 70 years of age. Major bleeding events that are comparable in severity to cancer or CVD, are infrequent. Screening and eradication of H. pylori infection could substantially lower aspirin-related GI harms.
Collapse
Affiliation(s)
- Mangesh A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK,
| | | |
Collapse
|
3
|
Thorat MA, Cuzick J. Reply to the letter to the editor 'the harms of low-dose aspirin prophylaxis are overstated' by P. Elwood and G. Morgan. Ann Oncol 2014; 26:442-3. [PMID: 25403580 DOI: 10.1093/annonc/mdu546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- M A Thorat
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - J Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| |
Collapse
|
4
|
|
5
|
Abstract
OBJECTIVES To estimate the rates of peptic ulcer bleeding (PUB) incidence and the association of demographic factors with 30-day mortality after PUB. METHODS Diagnostic algorithms for PUB were derived and validated on the basis of 115 true PUB patients at one tertiary hospital in 2005, followed by estimation of age-specific PUB incidence and 30-day mortality rates, using the Korean National Health Insurance claim database. A Cox proportional hazard model was used to determine the impact of demographic factors on the 30-day mortality rate ratio (MRR) after PUB. RESULTS The diagnostic algorithm showed 89 and 88% positive predictive value and sensitivity, respectively. On the basis of this algorithm, the rate of PUB incidence was 22.1 per 100 000 during 2006-2007 and the age-specific incidence rate increased with advanced age. This incidence rate was more than three times higher among men than women. Among 21 107 PUB patients, the overall 30-day mortality rate was 2.15%, but it ranged from 0.83% for patients younger than 60 years to 7.65% for patients older than 80 years. The adjusted 30-day mortality rate ratio for patients older than 80 was 8.13 (95% confidence interval 6.10-10.8) compared with those younger than 60 and 7.09 (95% confidence interval 2.78-4.51) for patients with a high level of comorbidity compared with a low level of comorbidity. CONCLUSION PUB incidence was higher among men and increased with advanced age. Increased 30-day mortality was observed in association with increasing age, after adjusting for comorbidity.
Collapse
|
6
|
Wilcox CM, Cryer BL, Henk HJ, Zarotsky V, Zlateva G. Mortality associated with gastrointestinal bleeding events: Comparing short-term clinical outcomes of patients hospitalized for upper GI bleeding and acute myocardial infarction in a US managed care setting. Clin Exp Gastroenterol 2009; 2:21-30. [PMID: 21694823 PMCID: PMC3108636 DOI: 10.2147/ceg.s4936] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To compare the short-term mortality rates of gastrointestinal (GI) bleeding to those of acute myocardial infarction (AMI) by estimating the 30-, 60-, and 90-day mortality among hospitalized patients. METHODS United States national health plan claims data (1999-2003) were used to identify patients hospitalized with a GI bleeding event. Patients were propensity-matched to AMI patients with no evidence of GI bleed from the same US health plan. RESULTS 12,437 upper GI-bleed patients and 22,847 AMI patients were identified. Propensity score matching yielded 6,923 matched pairs. Matched cohorts were found to have a similar Charlson Comorbidity Index score and to be similar on nearly all utilization and cost measures (excepting emergency room costs). A comparison of outcomes among the matched cohorts found that AMI patients had higher rates of 30-day mortality (4.35% vs 2.54%; p < 0.0001) and rehospitalization (2.56% vs 1.79%; p = 0.002), while GI bleed patients were more likely to have a repeat procedure (72.38% vs 44.95%; p < 0.001) following their initial hospitalization. The majority of the difference in overall 30-day mortality between GI bleed and AMI patients was accounted for by mortality during the initial hospitalization (1.91% vs 3.58%). CONCLUSIONS GI bleeding events result in significant mortality similar to that of an AMI after adjusting for the initial hospitalization.
Collapse
Affiliation(s)
| | - Byron L Cryer
- University of Texas Southwestern Medical School, Dallas, TX
| | | | | | | |
Collapse
|
7
|
van der Velde G, Hogg-Johnson S, Bayoumi AM, Cassidy JD, Côté P, Boyle E, Llewellyn-Thomas H, Chan S, Subrata P, Hoving JL, Hurwitz E, Bombardier C, Krahn M. Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis. J Manipulative Physiol Ther 2009; 32:S209-18. [PMID: 19251067 DOI: 10.1016/j.jmpt.2008.11.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
STUDY DESIGN Decision analysis. OBJECTIVE To identify the best treatment for nonspecific neck pain. SUMMARY OF BACKGROUND DATA In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects. METHODS (Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decisionanalytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial. RESULTS There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days. CONCLUSION When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior.
Collapse
|
8
|
van der Velde G, Hogg-Johnson S, Bayoumi AM, Cassidy JD, Côté P, Boyle E, Llewellyn-Thomas H, Chan S, Subrata P, Hoving JL, Hurwitz E, Bombardier C, Krahn M. Identifying the Best Treatment Among Common Nonsurgical Neck Pain Treatments. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2008. [DOI: 10.1007/s00586-008-0635-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
9
|
Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis. Spine (Phila Pa 1976) 2008; 33:S184-91. [PMID: 18204391 DOI: 10.1097/brs.0b013e31816454f8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Decision analysis. OBJECTIVE To identify the best treatment for nonspecific neck pain. SUMMARY OF BACKGROUND DATA In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects. METHODS (Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decision-analytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial. RESULTS There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days. CONCLUSION When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior.
Collapse
|
10
|
Varas-Lorenzo C, Maguire A, Castellsague J, Perez-Gutthann S. Quantitative assessment of the gastrointestinal and cardiovascular risk-benefit of celecoxib compared to individual NSAIDs at the population level. Pharmacoepidemiol Drug Saf 2007; 16:366-76. [PMID: 16897817 DOI: 10.1002/pds.1299] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE To estimate the net cardiovascular (CV) (coronary heart disease, stroke, congestive heart failure), and gastrointestinal (GI) (peptic ulcer complications) risk-benefit public health impact of the use of celecoxib compared to non-selective NSAIDs in the arthritis population. METHODS We applied discrete event simulation models to data from the US National Health Surveys, CV risk-prediction models from the Framingham Heart Study, and population-based studies. Models took into account the multifactorial effect of risk factors, comorbidity, and competing risk of mortality. We simulated the natural history of CV and GI disease in the U.S. arthritis population over 1 year, through the individual baseline cardiovascular and gastrointestinal risk profile. This model was modified with relative risks associated with the use of each treatment. The mean number of events was estimated for each end-point in each model: natural history, celecoxib, diclofenac, ibuprofen, naproxen. The number of events for celecoxib was compared with each NSAID. RESULTS The evaluation included 1% of the U.S. population with arthritis. Celecoxib, when applied to 100 000 patients over 1 year, resulted in 570 (range from sensitivity analysis: 440-691), 226 (124-313), and 746 (612-868) fewer ulcer complications than diclofenac, ibuprofen, and naproxen, respectively. There were 20 (16-25), 8 (4-12), and 27 (22-32) fewer deaths from ulcer complications, respectively. No increase in cardiovascular events or all cause mortality was observed for celecoxib versus the other individual NSAIDs. CONCLUSION Results from these simulations suggest a gastrointestinal benefit for celecoxib not offset by increased cardiovascular events or mortality. The methodology used here provides a risk-benefit assessment framework for evaluating the public heath impact of drugs.
Collapse
Affiliation(s)
- Cristina Varas-Lorenzo
- Global Epidemiology, Safety and Risk Management, Pfizer Worldwide Development, Barcelona, Spain.
| | | | | | | |
Collapse
|
11
|
Ohmann C, Imhof M, Ruppert C, Janzik U, Vogt C, Frieling T, Becker K, Neumann F, Faust S, Heiler K, Haas K, Jurisch R, Wenzel EG, Normann S, Bachmann O, Delgadillo J, Seidel F, Franke C, Lüthen R, Yang Q, Reinhold C. Time-trends in the epidemiology of peptic ulcer bleeding. Scand J Gastroenterol 2005; 40:914-20. [PMID: 16165708 DOI: 10.1080/00365520510015809] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Despite the introduction of effective medical treatment of peptic ulcer disease, bleeding is still a frequent complication. The aim of this study was to investigate whether the incidence and the risk profile of peptic ulcer haemorrhage have changed within a 10-year period. MATERIAL AND METHODS In a prospective epidemiological and observational study the incidence and risk profile of peptic ulcer haemorrhage in Düsseldorf, Germany were compared between two time periods (period A: 1.3.89-28.2.90 and period B: 1.4.99-31.3.2000), involving nine hospitals with both surgical and medical departments. Patients with proven peptic ulcer haemorrhage at endoscopy or operation were included in the study; those with bleeding under defined severe stress conditions were excluded. RESULTS No differences in bleeding ulcer incidence were observed between periods A and B (51.4 per 100,000 person-years versus 48.7), or for duodenal ulcer (24.9 versus 25.7) or for gastric ulcer bleeding (26.5 versus 23.0). A marked increase in incidence rates was observed with increasing age. In period B, patients with bleeding ulcers were older (56% versus 41% 70 years or older), were usually taking non-steroidal anti-inflammatory drugs (NSAIDs) (45% versus 27%) and were less likely to have a history of ulcer (25% versus 59%) compared with patients in period A. CONCLUSIONS The persisting high incidence of peptic ulcer disease is a superimposing of two trends: a higher incidence in the growing population of elderly patient with a higher intake of NSAIDs and a lower incidence among younger patients due to a decrease in incidence and improved medical treatment.
Collapse
Affiliation(s)
- Christian Ohmann
- Koordinierungszentrum für Klinische Studien, Heinrich-Heine-Universität.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Brooks CL. Clinical resources: we need to monitor quality and costs. Abstracts & commentary. CURRENT SURGERY 2000; 57:112-5. [PMID: 16093040 DOI: 10.1016/s0149-7944(00)00192-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- C L Brooks
- University Health Systems of Eastern North Carolina, Greenville, North Carolina, USA
| |
Collapse
|
13
|
Ruigómez A, García Rodríguez LA, Hasselgren G, Johansson S, Wallander MA. Overall mortality among patients surviving an episode of peptic ulcer bleeding. J Epidemiol Community Health 2000; 54:130-3. [PMID: 10715746 PMCID: PMC1731615 DOI: 10.1136/jech.54.2.130] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
STUDY OBJECTIVE The authors investigated whether patients who have survived an acute episode of peptic ulcer bleeding (PUB) have an excess long term all cause mortality compared with the general population free of PUB. DESIGN Follow up study of previously identified cohort of patients with a PUB episode and a general population cohort. SETTING The source population included all people aged 30 to 89 years, registered with general practitioners in the United Kingdom. PATIENTS All patients alive one month after the PUB episode constituted the cohort of PUB patients (n = 978). A control group of 5000 people was randomly sampled from the source population. The same eligibility criteria as for patients with PUB were applied to the control series. Also, controls had to be free of PUB before start date. MAIN RESULTS Relative risk of mortality among PUB patients was 2.1, 95% CI: 1.7, 2.6) compared with the general population. This increased mortality risk occurred mainly in the patients less than 60 years old. No difference was observed between men and women. The excess mortality was not only circumscribed to deaths attributable to recurrent gastrointestinal bleed, but also cardiovascular, cancer and other causes. CONCLUSIONS People who have survived an acute episode of PUB have a reduced long term survival compared with the general population. This reduction was stronger among middle age patients than in the elderly.
Collapse
Affiliation(s)
- A Ruigómez
- Centro Español de Investigación Farmacoepidemiológica, Madrid, Spain
| | | | | | | | | |
Collapse
|
14
|
Marshall JK, Collins SM, Gafni A. Prediction of resource utilization and case cost for acute nonvariceal upper gastrointestinal hemorrhage at a Canadian community hospital. Am J Gastroenterol 1999; 94:1841-6. [PMID: 10406245 DOI: 10.1111/j.1572-0241.1999.01215.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Upper gastrointestinal hemorrhage (UGIH) is common, and thus imposes a substantial burden on health care resources. We describe resource utilization and cost for management of acute nonvariceal UGIH, and studied their variation among population subgroups. METHODS Resource utilization and direct medical case costs were extracted for consecutive admissions for nonvariceal UGIH at a large community hospital in southern Ontario through chart review and adaptation of an administrative case cost database. Univariate and multiple regression models were then developed to identify independent demographic predictors of case cost and length of stay. RESULTS Among 116 eligible admissions the average length of stay and case cost were 4.26 days and Can$2690, respectively (Can$1 = US$0.70). Both cost and length of stay demonstrated significant univariate relationships with age, comorbid illness, prior peptic ulcer disease (PUD), and prior UGIH. Age and prior PUD persisted as independent predictors in multiple regression models. An inverse transformation of total case cost allowed these variables to explain 26% of the total variance. CONCLUSIONS Resource utilization for management of acute nonvariceal UGIH at a Canadian community hospital varies substantially among population subgroups, but correlates independently with age and prior ulcer history. Careful attention must be paid to practice environments and demographic profiles before economic models of strategies to prevent or treat UGIH are applied to specific subpopulations.
Collapse
Affiliation(s)
- J K Marshall
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | |
Collapse
|