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Sato Y, Aoki T, Sadashima E, Nakamoto Y, Kobayashi K, Yamauchi A, Yamada A, Omori J, Ikeya T, Aoyama T, Tominaga N, Kishino T, Ishii N, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Fujita M, Sato H, Suzuki S, Narasaka T, Hayasaka J, Funabiki T, Kinjo Y, Mizuki A, Kiyotoki S, Mikami T, Gushima R, Fujii H, Fuyuno Y, Gunji N, Toya Y, Narimatsu K, Manabe N, Nagaike K, Kinjo T, Sumida Y, Funakoshi S, Kobayashi K, Matsuhashi T, Komaki Y, Maehata T, Tateishi K, Kaise M, Nagata N. Long-term Risks of Recurrence After Hospital Discharge for Acute Lower Gastrointestinal Bleeding: A Large Nationwide Cohort Study. Clin Gastroenterol Hepatol 2023; 21:3258-3269.e6. [PMID: 37276989 DOI: 10.1016/j.cgh.2023.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 05/11/2023] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND & AIMS Currently, large, nationwide, long-term follow-up data on acute lower gastrointestinal bleeding (ALGIB) are scarce. We investigated long-term risks of recurrence after hospital discharge for ALGIB using a large multicenter dataset. METHODS We retrospectively analyzed 5048 patients who were urgently hospitalized for ALGIB at 49 hospitals across Japan (CODE BLUE-J study). Risk factors for the long-term recurrence of ALGIB were analyzed by using competing risk analysis, treating death without rebleeding as a competing risk. RESULTS Rebleeding occurred in 1304 patients (25.8%) during a mean follow-up period of 31 months. The cumulative incidences of rebleeding at 1 and 5 years were 15.1% and 25.1%, respectively. The mortality risk was significantly higher in patients with out-of-hospital rebleeding episodes than in those without (hazard ratio, 1.42). Of the 30 factors, multivariate analysis showed that shock index ≥1 (subdistribution hazard ratio [SHR], 1.25), blood transfusion (SHR, 1.26), in-hospital rebleeding (SHR, 1.26), colonic diverticular bleeding (SHR, 2.38), and thienopyridine use (SHR, 1.24) were significantly associated with increased rebleeding risk. Multivariate analysis of colonic diverticular bleeding patients showed that blood transfusion (SHR, 1.20), in-hospital rebleeding (SHR, 1.30), and thienopyridine use (SHR, 1.32) were significantly associated with increased rebleeding risk, whereas endoscopic hemostasis (SHR, 0.83) significantly decreased the risk. CONCLUSIONS These large, nationwide follow-up data highlighted the importance of endoscopic diagnosis and treatment during hospitalization and the assessment of the need for ongoing thienopyridine use to reduce the risk of out-of-hospital rebleeding. This information also aids in the identification of patients at high risk of rebleeding.
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Affiliation(s)
- Yoshinori Sato
- Division of Gastroenterology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Eiji Sadashima
- Department of Medical Research Institute, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Yusuke Nakamoto
- Division of Gastroenterology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St Luke's International University, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Sho Suzuki
- Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan; Division of Endoscopic Center, University of Tsukuba Hospital, Ibaraki, Japan
| | | | - Tomohiro Funabiki
- Department of Emergency Medicine, Fujita Health University Hospital, Aichi, Japan; Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Yuzuru Kinjo
- Department of Gastroenterology, Naha City Hospital, Okinawa, Japan
| | - Akira Mizuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yamaguchi, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Naohiko Gunji
- Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | - Kazuyuki Narimatsu
- Department of Internal Medicine, National Defense Medical College, Saitama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Tetsu Kinjo
- Department of Endoscopy, University of the Ryukyus Hospital, Okinawa, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Sadahiro Funakoshi
- Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan
| | - Kiyonori Kobayashi
- Department of Gastroenterology, Kitasato University, School of Medicine, Kanagawa, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan; Hygiene and Health Promotion Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Tadateru Maehata
- Division of Gastroenterology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Keisuke Tateishi
- Division of Gastroenterology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan; Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan.
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Saven H, Zhong L, McFarlane IM. Co-prescription of Dual-Antiplatelet Therapy and Proton Pump Inhibitors: Current Guidelines. Cureus 2022; 14:e21885. [PMID: 35273851 PMCID: PMC8901154 DOI: 10.7759/cureus.21885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/13/2022] Open
Abstract
Dual-antiplatelet therapy (DAPT) prevents thrombotic complications associated with coronary artery disease, acute coronary syndrome, and stent thrombosis following the percutaneous coronary intervention or coronary artery bypass grafting. When initiating DAPT, the risk of thrombosis must be balanced with the increased risk of upper gastrointestinal bleed (UGIB). Proton-pump inhibitors (PPIs) are concurrently prescribed with DAPT to reduce bleeding risk. In this review, we discuss the benefits and potential complications of DAPT/PPI co-prescription. The only large international randomized control trial (RCT), Clopidogrel and the Optimization of Gastrointestinal Events Trial (COGENT), shows robust evidence that PPIs are a safe and effective method to reduce the risk of bleeding in patients on DAPT. However, more large-scale RCTs are needed to study potential long-term effects and draw a stronger conclusion on this topic.
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Affiliation(s)
- Hannah Saven
- Internal Medicine, State University of New York (SUNY) Downstate College of Medicine, New York, USA
| | - Lynna Zhong
- Internal Medicine, State University of New York (SUNY) Downstate College of Medicine, New York, USA
| | - Isabel M McFarlane
- Internal Medicine, State University of New York (SUNY) Downstate Medical Center, New York, USA
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3
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Bedene A, van Dorp ELA, Rosendaal FR, Dahan A, Lijfering WM. Risk of drug-related upper gastrointestinal bleeding in the total population of the Netherlands: a time-trend analysis. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000733. [PMID: 35012975 PMCID: PMC8753354 DOI: 10.1136/bmjgast-2021-000733] [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: 06/30/2021] [Accepted: 11/17/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Many prescribed and over-the-counter medications, for example, non-steroidal anti-inflammatory drugs (NSAIDs) are associated with upper gastrointestinal bleeding (UGIB). Recently, a decrease in prescribing of NSAIDs was observed in the Netherlands, but whether a similar decreasing trend could be observed in the incidence of severe UGIB (either fatal or requiring hospitalisation), contingent on medication prescription, is unknown. Design We conducted a cohort study using Dutch national statistics on pharmacy claims, hospitalisation and mortality between 2013 and 2018. We explored the incidence of sex-specific and age-specific severe UGIB in four (sub)populations: (A) total population, (B) without a filled prescrption for NSAIDs, (C) without filled prescriptions for NSAIDs and antithrombotic agents, (D) without any risk factors for UGIB. Results The cumulative incidence of severe UGIB did not decrease throughout the study period, regardless of the subgroup analysis. In the total population, it was 199 per 100 000 inhabitants (95% CI 197 to 201) in 2013–2014 and 260 (95% CI 258 to 263) in 2017–2018. The absolute risk of severe UGIB was 50% lower in the subgroup B than in the full cohort. It decreased further by 50% in the subgroup D when compared with subgroup B. The risk of severe UGIB was 1.5–1.9 fold higher in young women than in young men; an indication of over-the-counter NSAIDs use being more prevalent in women than men in this age group. Conclusion We found no evidence to support a relationship between reduced prescribing of NSAIDs and the incidence of severe UGIB in the Netherlands since 2013. The relationship was also not observed when we removed the effect of risk factors.
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Affiliation(s)
- Ajda Bedene
- Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Frits R Rosendaal
- Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dahan
- Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem M Lijfering
- Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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4
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Joo MK, Park CH, Kim JS, Park JM, Ahn JY, Lee BE, Lee JH, Yang HJ, Cho YK, Bang CS, Kim BJ, Jung HK, Kim BW, Lee YC. Clinical Guidelines for Drug-Related Peptic Ulcer, 2020 Revised Edition. Gut Liver 2021; 14:707-726. [PMID: 33191311 PMCID: PMC7667931 DOI: 10.5009/gnl20246] [Citation(s) in RCA: 9] [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: 08/03/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 02/06/2023] Open
Abstract
Korean guidelines for nonsteroidal anti-inflammatory drug (NSAID)-induced peptic ulcer were previously developed in 2009 with the collaboration of the Korean College of Helicobacter and Upper Gastrointestinal Research and Korean Society of Gastroenterology. However, the previous guidelines were based mainly upon a review of the relevant literature and expert opinion. Therefore, the guidelines need to be revised. We organized a guideline Development Committee for drug-related peptic ulcer under the auspices of the Korean College of Helicobacter and Upper Gastrointestinal Research in 2017 and developed nine statements, including four for NSAIDs, three for aspirin and other antiplatelet agents, and two for anticoagulants through a de novo process founded on evidence-based medicine that included a literature search and a meta-analysis, A consensus was reached through the application of the modified Delphi method. The primary target of these guidelines is adult patients undergoing long-term treatment with NSAIDs, aspirin or other antiplatelet agents and anticoagulants. The revised guidelines reflect the expert consensus and is intended to assist clinicians in the management and prevention of drug-induced peptic ulcer and associated conditions.
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Affiliation(s)
- Moon Kyung Joo
- Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Joon Sung Kim
- Department of Internal Medicine, Incheon 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
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, Seoul, Korea
| | - Bong Eun Lee
- Departments of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyo-Joon Yang
- Division of Gastroenterology, Department of Internal Medicine, 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
| | - Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, Ewha Womans 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
| | - Yong Chan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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5
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Joo MK, Park CH, Kim JS, Park JM, Ahn JY, Lee BE, Lee JH, Yang HJ, Cho YK, Bang CS, Kim BJ, Jung HK, Kim BW, Lee YC. [Clinical Guidelines for Drug-induced Peptic Ulcer, 2020 Revised Edition]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 76:108-133. [PMID: 32969360 DOI: 10.4166/kjg.2020.76.3.108] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 12/18/2022]
Abstract
The Korean guidelines for nonsteroidal anti-inflammatory drug (NSAID)-induced peptic ulcers were previously developed under co-work with the Korean College of Helicobacter and Upper Gastrointestinal Research and Korean Society of Gastroenterology at 2009. On the other hand, the previous guidelines were based mainly on a literature review and expert opinions. Therefore, the guidelines need to be revised. In this study, a guideline development committee for drug-induced peptic ulcers was organized under the Korean College of Helicobacter and Upper Gastrointestinal Research in 2017. Nine statements were developed, including four for NSAID, three for aspirin and other antiplatelet agents, and two for anticoagulants through de novo processes based on evidence-based medicine, such as a literature search, meta-analysis, and the consensus was established using the modified Delphi method. The primary target of this guideline was adult patients taking long-term NSAIDs, aspirin, or other antiplatelet agent and anticoagulants. The revised guidelines reflect the consensus of expert opinions and are intended to assist relevant clinicians in the management and prevention of drug-induced peptic ulcers and associated conditions.
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Affiliation(s)
- Moon Kyung Joo
- Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Joon Sung Kim
- Department of Internal Medicine, Incheon 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
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyo-Joon Yang
- Division of Gastroenterology, Department of Internal Medicine, 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
| | - Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, College of Medicine, Ewha Woman's University, Seoul, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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6
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Faroux L, Cruz-González I, Arzamendi D, Freixa X, Nombela-Franco L, Peral V, Caneiro-Queija B, Mangieri A, Trejo-Velasco B, Asmarats L, Regueiro A, McInerney A, Morcuende Gonzalez A, Estevez-Loureiro R, Laricchia A, O'Hara G, Rodés-Cabau J. Incidence, predictors, and clinical impact of bleeding recurrence in patients with prior gastrointestinal bleeding undergoing LAAC. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1216-1223. [PMID: 34110038 DOI: 10.1111/pace.14293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/20/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) is associated with a high recurrence rate and a prior GIB episode is common in real-world left atrial appendage closure (LAAC) recipients. The present study sought to evaluate the clinical characteristics and outcomes of patients with prior GIB undergoing LAAC, and to determine the factors associated with and clinical impact of GIB recurrence. METHODS Multicenter study including 277 consecutive patients who underwent percutaneous LAAC and had prior GIB. All-cause death, all bleeding, GIB recurrence, and clinical ischemic stroke were recorded. RESULTS After a median follow-up of 17 (interquartile range: 6-37) months post-LAAC, the rates of death, bleeding, GIB recurrence, and ischemic stroke were 14.0 per 100 person-year (PY), 29.3 per 100 PY, 17.7 per 100 PY, and 1.1 per 100 PY, respectively. GIB recurrence occurred within 3 months post-LAAC in 55.8% of patients. A previous lower GIB (vs. upper or unclassified) (HR: 1.76; 95% CI: 1.09-2.82; p = .020) and eGFR < 45 mL/min (HR: 1.70; 95% CI:1.04-2.67; p = .033) determined an increased risk of GIB recurrence. By multivariable analysis, eGFR < 45 mL/min (HR: 2.72; 95% CI: 1.70-4.34; p < .001), GIB recurrence following LAAC (HR: 2.15; 95% CI: 1.33-3.46; p = .002), diabetes mellitus (HR: 1.77; 95% CI: 1.10-2.84; p = .018), and age (HR: 1.06; 95% CI: 1.03-1.10; p < .001) were associated with an increased mortality. CONCLUSIONS Patients with prior GIB undergoing LAAC exhibited a relatively low rate of GIB recurrence, and prior lower GIB and moderate-to-severe chronic kidney disease determined an increased risk. GIB recurrence was associated with an increased mortality.
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Affiliation(s)
- Laurent Faroux
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Vicente Peral
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | | | | | | | | | - Ander Regueiro
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Angela McInerney
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Antonio Morcuende Gonzalez
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | | | | | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
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7
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Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, Laursen SB, Radaelli F, Papanikolaou IS, Cúrdia Gonçalves T, Dinis-Ribeiro M, Awadie H, Braun G, de Groot N, Udd M, Sanchez-Yague A, Neeman Z, van Hooft JE. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:300-332. [PMID: 33567467 DOI: 10.1055/a-1369-5274] [Citation(s) in RCA: 173] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - A John Morris
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Marine Camus
- Sorbonne University, Endoscopic Unit, Saint Antoine Hospital Assistance Publique Hopitaux de Paris, Paris, France
| | - James Lau
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Angel Lanas
- Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain
| | - Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- School of Medicine, University of Minho, Braga/Guimarães, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Mario Dinis-Ribeiro
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal
| | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Georg Braun
- Medizinische Klinik 3, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Marianne Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andres Sanchez-Yague
- Gastroenterology Unit, Hospital Costa del Sol, Marbella, Spain
- Gastroenterology Department, Vithas Xanit International Hospital, Benalmadena, Spain
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Diagnostic Imaging and Nuclear Medicine Institute, Emek Medical Center, Afula, Israel
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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8
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Tang J, Sharma U, Desai S, Molnar J, Perlmuter L, Feller A, Shah P. A Study of Proton Pump Inhibitors and Other Risk Factors in Warfarin-Associated Gastrointestinal Bleeding. Cureus 2021; 13:e12624. [PMID: 33585113 PMCID: PMC7872495 DOI: 10.7759/cureus.12624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Warfarin users are at increased risk for gastrointestinal bleeding (GIB). History of GIB, stroke, cardiovascular or chronic kidney disease, age greater than 65 years, and drug interaction with proton pump inhibitors (PPI) have previously been identified as risk factors for GIB in warfarin users. We hypothesized that concomitant use of warfarin and PPI would increase the incidence of GIB relative to warfarin use alone. Methods We did a retrospective review of medical records of 626 patients taking warfarin for at least two weeks. Parameters including age, concomitant medication use (non-steroidal anti-inflammatory drugs (NSAID), aspirin, selective serotonin reuptake inhibitors (SSRIs), PPI, and anti-platelet drug), history of GIB, chronic renal failure (CRF), and peptic ulcer disease (PUD) prior to warfarin use were analyzed. Results Variables that increase the likelihood of bleeding in warfarin users included aspirin, PPI, history of PUD, history of previous GIB, CRF, and elevated prothrombin time (PT)/international normalized ratio (INR) values. Concomitant antiplatelet use showed a slight increase in GIB but this was not statistically significant (p=0.082). NSAID use and SSRI use were not associated with a higher risk of GIB among warfarin users. Patients who are on PPI and warfarin simultaneously are more likely to be on acetylsalicylic acid (ASA) or have a history of PUD, GIB, or CRF, all of which are associated with increased incidences of GIB. Conclusions Although concomitant use of warfarin and PPI appears to be associated with an increased incidence of GIB, these patients are more likely to have other risk factors that also increase the risk of a GIB outcome. Therefore, the interaction between PPI and warfarin is clinically insignificant.
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Affiliation(s)
- Jevon Tang
- Gastroenterology, Captain James A. Lovell Federal Health Care Center, North Chicago, USA
| | - Umesh Sharma
- Gastroenterology, Captain James A. Lovell Federal Health Care Center, North Chicago, USA
| | - Shreya Desai
- Internal Medicine, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Janos Molnar
- Cardiology, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Lawrence Perlmuter
- Internal Medicine, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | - Axel Feller
- Gastroenterology, Captain James A. Lovell Federal Health Care Center, North Chicago, USA
| | - Pallavi Shah
- Gastroenterology, Captain James A. Lovell Federal Health Care Center, North Chicago, USA.,Internal Medicine, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, USA
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Hemostatic spray powder TC-325 in the primary endoscopic treatment of peptic ulcer-related bleeding: multicenter international registry. Endoscopy 2021; 53:36-43. [PMID: 32459000 DOI: 10.1055/a-1186-5360] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity and is associated with a 2 % - 17 % mortality rate in the UK and USA. Bleeding peptic ulcers account for 50 % of UGIB cases. Endoscopic intervention in a timely manner can improve outcomes. Hemostatic spray is an endoscopic hemostatic powder for GI bleeding. This multicenter registry was created to collect data prospectively on the immediate endoscopic hemostasis of GI bleeding in patients with peptic ulcer disease when hemostatic spray is applied as endoscopic monotherapy, dual therapy, or rescue therapy. METHODS Data were collected prospectively (January 2016 - March 2019) from 14 centers in the UK, France, Germany, and the USA. The application of hemostatic spray was decided upon at the endoscopist's discretion. RESULTS 202 patients with UGIB secondary to peptic ulcers were recruited. Immediate hemostasis was achieved in 178/202 patients (88 %), 26/154 (17 %) experienced rebleeding, 21/175 (12 %) died within 7 days, and 38/175 (22 %) died within 30 days (all-cause mortality). Combination therapy of hemostatic spray with other endoscopic modalities had an associated lower 30-day mortality (16 %, P < 0.05) compared with monotherapy or rescue therapy. There were high immediate hemostasis rates across all peptic ulcer disease Forrest classifications. CONCLUSIONS This is the largest case series of outcomes of peptic ulcer bleeding treated with hemostatic spray, with high immediate hemostasis rates for bleeding peptic ulcers.
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10
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Mizokami Y, Yamamoto T, Atarashi H, Yamashita T, Akao M, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Kaburagi J, Takita A, Inoue H. Current status of proton pump inhibitor use in Japanese elderly patients with non-valvular atrial fibrillation: A subanalysis of the ANAFIE Registry. PLoS One 2020; 15:e0240859. [PMID: 33151969 PMCID: PMC7644054 DOI: 10.1371/journal.pone.0240859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/04/2020] [Indexed: 01/16/2023] Open
Abstract
The real-world status of proton pump inhibitor (PPI) use in patients with atrial fibrillation (AF) receiving antithrombotic treatment is largely unknown. The All Nippon AF In the Elderly (ANAFIE) Registry, a prospective, multicenter, observational study, aimed to determine treatment patterns, risk factors, and outcomes among elderly (aged ≥75 years) Japanese non-valvular AF (NVAF) patients in the real-world clinical setting. The present subanalysis of the ANAFIE Registry determined the PPI prescription status of 32,490 elderly Japanese NVAF patients. Patients were stratified by PPI use (PPI+) or no PPI use (PPI−). Risk scores for stroke (CHADS2, CHA2DS2-VASc) and bleeding (HAS-BLED), anticoagulant use, time in therapeutic range (TTR) for warfarin, and anticoagulant/antiplatelet combination use were evaluated. PPIs were used in 11,981 (36.9%) patients. Compared with the PPI− group, the PPI+ group included a greater proportion of female patients (45.2% vs 41.3%; P <0.0001) and had significantly higher CHADS2, CHA2DS2-VASc, and HAS-BLED scores (P <0.0001 for each) as well as higher prevalences of several comorbidities. In the PPI+ group, 54.6% of patients did not have gastrointestinal (GI) disorders and were likely prescribed a PPI to prevent GI bleeding events. Most of the patients with a GI disorder in the PPI+ group had reflux esophagitis. Compared with patients not receiving anticoagulants, a significantly higher proportion of patients receiving anticoagulants received PPIs. For patients receiving anticoagulants, antiplatelet drugs, and both drugs, rates of PPI use were 34.1%, 44.1%, and 53.5%, respectively (P <0.01). Although the rate of PPI use was the highest for NVAF patients receiving both antiplatelet and anticoagulants, no clear differences were observed in the anticoagulants used. These data suggest that PPIs were actively prescribed in high-risk cases and may have been used to prevent GI bleeding among elderly NVAF patients receiving antithrombotic drugs. Trial registration:UMIN000024006
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Affiliation(s)
- Yuji Mizokami
- Department of Gastroenterology, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Takatsugu Yamamoto
- Department of Medicine, Teikyo University, Itabashi City, Tokyo, Japan
- * E-mail:
| | | | | | - Masaharu Akao
- National Hospital Organization Kyoto Medical Center, Fushimi Ward, Kyoto, Japan
| | - Takanori Ikeda
- Toho University Omori Medical Center, Ota City, Tokyo, Japan
| | - Yukihiro Koretsune
- National Hospital Organization Osaka National Hospital, Chuo Ward, Osaka, Japan
| | - Ken Okumura
- Saiseikai Kumamoto Hospital, Minami Ward, Kumamoto, Japan
| | | | | | - Kazunori Toyoda
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | - Masahiro Yasaka
- National Hospital Organization Kyushu Medical Center, Chuo Ward, Fukuoka, Japan
| | | | - Satoshi Teramukai
- Kyoto Prefectural University of Medicine, Kamigyo Ward, Kyoto, Japan
| | - Tetsuya Kimura
- Medical Science Department, Daiichi Sankyo Co., Ltd., Chuo City, Tokyo, Japan
| | - Jumpei Kaburagi
- Medical Science Department, Daiichi Sankyo Co., Ltd., Chuo City, Tokyo, Japan
| | - Atsushi Takita
- Biostatistics and Data Management Department, Daiichi Sankyo Co., Ltd., Shinagawa-ku, Tokyo, Japan
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11
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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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12
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Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, Leontiadis GI, Abraham NS, Calvet X, Chan FKL, Douketis J, Enns R, Gralnek IM, Jairath V, Jensen D, Lau J, Lip GYH, Loffroy R, Maluf-Filho F, Meltzer AC, Reddy N, Saltzman JR, Marshall JK, Bardou M. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med 2019; 171:805-822. [PMID: 31634917 PMCID: PMC7233308 DOI: 10.7326/m19-1795] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
DESCRIPTION This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations. METHODS An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional. RECOMMENDATIONS Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
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Affiliation(s)
- Alan N Barkun
- McGill University, Montreal, Quebec, Canada (A.N.B.)
| | - Majid Almadi
- McGill University, Montreal, Quebec, Canada, and King Saud University, Riyadh, Saudi Arabia (M.A.)
| | - Ernst J Kuipers
- Erasmus University Medical Center, Rotterdam, the Netherlands (E.J.K.)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, and VA Connecticut Healthcare System, West Haven, Connecticut (L.L.)
| | - Joseph Sung
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Frances Tse
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | | | | | - Xavier Calvet
- Hospital Parc Taulí de Sabadell, University of Barcelona, Sabadell, Spain, and CiberEHD (Instituto de Salud Carlos III), Madrid, Spain (X.C.)
| | - Francis K L Chan
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - James Douketis
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Robert Enns
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada (R.E.)
| | - Ian M Gralnek
- Technion-Israel Institute of Technology, Emek Medical Center, Afula, Israel (I.M.G.)
| | | | - Dennis Jensen
- University of California, Los Angeles, Los Angeles, California (D.J.)
| | - James Lau
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Gregory Y H Lip
- University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom, and Aalborg University, Aalborg, Denmark (G.Y.L.)
| | - Romaric Loffroy
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
| | | | | | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Hyderabad, India (N.R.)
| | - John R Saltzman
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.R.S.)
| | - John K Marshall
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Marc Bardou
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
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13
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Miyamoto S, Tsuda M, Kato M, Mabe K, Muto S, Ono S, Shimizu Y, Sakamoto N. Evaluation of gastric acid suppression with vonoprazan using calcium carbonate breath test. J Clin Biochem Nutr 2018; 64:174-179. [PMID: 30936631 PMCID: PMC6436034 DOI: 10.3164/jcbn.18-75] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/21/2018] [Indexed: 12/18/2022] Open
Abstract
Vonoprazan, a potassium-competitive acid blocker, is a new class of acid-suppressing agent. The acid-inhibitory effect of vonoprazan has been well-documented. However, there is no report on the extent to which the amount of gastric acid secretion is suppressed, not pH measurement, by the use of vonoprazan. The aim of this study was to evaluate this suppression effect. This was a single-arm, interventional pilot study involving 7 healthy Japanese men. The subjects were administered 20 mg vonoprazan for 6 days. The amount of gastric acid secretion was determined using the calcium carbonate breath test. The acid outputs were defined as the maximum Δ13C‰ (Δ13C max) and area under the curve (AUC) during the 30 min sampling period. The Δ13C max and AUC values significantly decreased on the administration of 20 mg vonoprazan. The AUC dropped by approximately 78% on day 1 and by 84% on day 6 and subsequently returned to the control level after cessation of vonoprazan therapy (reduction by 68% on day 7 and by 42% on day 8). In conclusion, the amount of gastric acid secretion rapidly decreased by the administration of vonoprazan; this inhibitory effect was found to be potent and long-lasting. (UMIN ID: UMIN000025469).
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Affiliation(s)
- Shuichi Miyamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido 060-8648, Japan
| | - Momoko Tsuda
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido 060-8648, Japan
| | - Mototsugu Kato
- Department of Gastroenterology, National Hospital Organization Hakodate Hospital, 16-gou, 18-banchi, Kawahara-cho, Hakodate, Hokkaido 041-8512, Japan
| | - Katsuhiro Mabe
- Department of Gastroenterology, National Hospital Organization Hakodate Hospital, 16-gou, 18-banchi, Kawahara-cho, Hakodate, Hokkaido 041-8512, Japan
| | - Shuichi Muto
- Department of Gastroenterology, National Hospital Organization Hokkaido Medical Center, 1-banchi, 1-gou, 5-jo, 7-chome, Yamanote, Nishi-ku, Sapporo, Hokkaido 063-0005, Japan
| | - Shoko Ono
- Division of Endoscopy, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido 060-8648, Japan
| | - Yuichi Shimizu
- Division of Endoscopy, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido 060-8648, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido 060-8648, Japan
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14
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Goldstein JL, Whellan DJ, Scheiman JM, Cryer BL, Eisen GM, Lanas A, Fort JG. Long-Term Safety of a Coordinated Delivery Tablet of Enteric-Coated Aspirin 325 mg and Immediate-Release Omeprazole 40 mg for Secondary Cardiovascular Disease Prevention in Patients at GI Risk. Cardiovasc Ther 2017; 34:59-66. [PMID: 26725920 PMCID: PMC5069577 DOI: 10.1111/1755-5922.12172] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction In two, 6‐month, randomized, double‐blind Phase 3 trials, PA32540 (enteric‐coated aspirin 325 mg and immediate‐release omeprazole 40 mg) compared to aspirin alone was associated with fewer endoscopic gastric and duodenal ulcers in patients requiring aspirin therapy for secondary cardiovascular disease (CVD) prevention who were at risk for upper gastrointestinal (UGI) events. Aims In this 12‐month, open‐label, multicenter Phase 3 study, we evaluated the long‐term cardiovascular and gastrointestinal safety of PA32540 in subjects who were taking aspirin 325 mg daily for ≥3 months for secondary CVD prevention and were at risk for aspirin‐associated UGI events. Enrolled subjects received PA32540 once daily for up to 12 months and were assessed at baseline, month 1, month 6, and month 12. Results The overall safety population consisted of 379 subjects, and 290 subjects (76%) were on PA32540 for ≥348 days (12‐month completers). Adverse events (AEs) caused study withdrawal in 13.5% of subjects, most commonly gastroesophageal reflux disease (1.1%). Treatment‐emergent AEs occurred in 76% of the safety population (11% treatment‐related) and 73% of 12‐month completers (8% treatment‐related). The most common treatment‐related AE was dyspepsia (2%). One subject had a gastric ulcer observed on for‐cause endoscopy. There were five cases of adjudicated nonfatal myocardial infarction, one nonfatal stroke, and one cardiovascular death, but none considered treatment‐related. Conclusions Long‐term treatment with PA32540 once daily for up to 12 months in subjects at risk for aspirin‐associated UGI events is not associated with any new or unexpected safety events.
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Affiliation(s)
| | | | | | - Byron L Cryer
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Glenn M Eisen
- Oregon Health and Science University, Portland, OR, USA
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15
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Ray WA, Chung CP, Murray KT, Smalley WE, Daugherty JR, Dupont WD, Stein CM. Association of Proton Pump Inhibitors With Reduced Risk of Warfarin-Related Serious Upper Gastrointestinal Bleeding. Gastroenterology 2016; 151:1105-1112.e10. [PMID: 27639805 PMCID: PMC5124401 DOI: 10.1053/j.gastro.2016.08.054] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/29/2016] [Accepted: 08/31/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Proton pump inhibitors (PPIs) might reduce the risk of serious warfarin-related upper gastrointestinal bleeding, but the evidence of their efficacy for this indication is limited. A gastroprotective effect of PPIs would be particularly important for patients who take warfarin with antiplatelet drugs or nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), which further increase the risk of gastrointestinal bleeding. METHODS This retrospective cohort study of patients beginning warfarin treatment in Tennessee Medicaid and the 5% National Medicare Sample identified 97,430 new episodes of warfarin treatment with 75,720 person-years of follow-up. The study end points were hospitalizations for upper gastrointestinal bleeding potentially preventable by PPIs and for bleeding at other sites. RESULTS Patients who took warfarin without PPI co-therapy had 119 hospitalizations for upper gastrointestinal bleeding per 10,000 person-years of treatment. The risk decreased by 24% among patients who received PPI co-therapy (adjusted hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.63-0.91). There was no significant reduction in the risk of other gastrointestinal bleeding hospitalizations (HR, 1.07; 95% CI, 0.94-1.22) or non-gastrointestinal bleeding hospitalizations (HR, 0.98; 95% CI, 0.84-1.15) in this group. Among patients concurrently using antiplatelet drugs or NSAIDs, those without PPI co-therapy had 284 upper gastrointestinal bleeding hospitalizations per 10,000 person-years of warfarin treatment. The risk decreased by 45% (HR, 0.55; 95% CI, 0.39-0.77) with PPI co-therapy. PPI co-therapy had no significant protective effect for warfarin patients not using antiplatelet drugs or NSAIDs (HR, 0.86; 95% CI, 0.70-1.06). Findings were similar in both study populations. CONCLUSIONS In an analysis of patients beginning warfarin treatment in Tennessee Medicaid and the 5% National Medicare Sample, PPI co-therapy was associated with reduced risk of warfarin-related upper gastrointestinal bleeding; the greatest reduction occurred in patients also taking antiplatelet drugs or NSAIDs.
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Affiliation(s)
- Wayne A Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Cecilia P Chung
- Department of Medicine, Division of Rheumatology, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee; Veterans' Administration Tennessee Valley Health Care System, Nashville, Tennessee
| | - Katherine T Murray
- Department of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Medicine, Division of Cardiology, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Walter E Smalley
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee; Veterans' Administration Tennessee Valley Health Care System, Nashville, Tennessee; Department of Gastroenterology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James R Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - C Michael Stein
- Department of Medicine, Division of Rheumatology, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
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Characteristics of gastrointestinal bleeding after placement of continuous-flow left ventricular assist device: a case series. Dig Dis Sci 2015; 60:1859-67. [PMID: 25616611 DOI: 10.1007/s10620-015-3538-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 01/12/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Medical management of patients with continuous-flow left ventricular assist devices (LVADs) remains challenging for the gastroenterologist given their high risk of gastrointestinal bleeding (GIB) and need for continuous anticoagulation. AIMS Our aim was to better characterize LVAD patients who presented with a GIB at our facility and delineate the prevalence, presentation, time to diagnosis, management, and therapeutic endoscopic interventions, including small bowel tools that may offer additional benefit. METHODS We retrospectively reviewed adult patients (>18 years) who underwent LVAD implantation at our tertiary care facility between October 2011 and October 2013. Electronic medical records were reviewed for presenting symptoms, average days to initial and repeat GIB, hospital course, and techniques that led to diagnosis and hemostasis. RESULTS Eighteen patients underwent LVAD implantation, of which 61 % presented with a GIB for a total of 20 presentations (1.8 per patient). Mean time to initial GIB was 154 days. Patients required an average of 1.8 endoscopic procedures per admission. Esophagogastroduodenoscopy (EGD) and push enteroscopy (PE) were more likely to lead to a diagnosis, and EGD was the most commonly used diagnostic tool at initial presentation. Sixty percent of patients who initially received EGD presented with a recurrent GIB and required PE, which was diagnostic and therapeutic for small bowel angiodysplasias in 80 % of cases. CONCLUSION We found a higher GIB rate compared with prior studies. Bleeding events were associated with multiple procedures and interventions. We recommend an algorithmic approach to LVAD patients who bleed. Our experience suggests that PE is warranted at initial presentation in order to achieve hemostasis, prevent recurrent GIB, and decrease subsequent readmission rates.
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Sáez ME, González-Pérez A, Johansson S, Nagy P, García Rodríguez LA. Patterns in the use of low-dose acetylsalicylic acid and other therapies following upper gastrointestinal bleeding. Am J Cardiovasc Drugs 2014; 14:443-50. [PMID: 25119521 DOI: 10.1007/s40256-014-0088-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Anticoagulants and/or antiplatelet agents such as acetylsalicylic acid (ASA) are important in prevention of cardiovascular (CV) events, but may be associated with upper gastrointestinal bleeding (UGIB). However, discontinuing these agents may leave patients at risk of CV events. OBJECTIVES This study aimed to assess patterns of therapy after UGIB in routine clinical practice. METHODS The Health Improvement Network UK primary care database was used to identify a cohort of patients aged 40-84 years with a UGIB event between 2000 and 2007 (n = 2,036). Patients were followed up for 1 year from the recorded UGIB. Re-prescription rates for antithrombotics and drugs that can modify the risk of UGIB were estimated at 30, 90, 180, and 365 days. RESULTS At 365 days, the re-prescription rate was 43 % for ASA, 66 % for warfarin, 69 % for clopidogrel, and 49 % for dipyridamole. The re-prescription rate of gastroprotective agents at 365 days for current users of histamine H2-receptor antagonists was 36 % and that of proton pump inhibitors (PPIs) was 97 %. In patients who were prescribed ASA before UGIB (n = 572), only 24 % were prescribed a PPI in the previous year. In patients who were prescribed ASA in the year after UGIB (n = 337), 92 % were prescribed a PPI. CONCLUSIONS Antiplatelet use fell after UGIB events. In patients who were prescribed a PPI after a UGIB event, there was increased re-prescription of antiplatelet agents and antithrombotics.
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Affiliation(s)
- María E Sáez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), c/Almirante 28, 2°, 28004, Madrid, Spain
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de Groot NL, van Haalen HGM, Spiegel BMR, Laine L, Lanas A, Focks JJ, Siersema PD, van Oijen MGH. Gastroprotection in low-dose aspirin users for primary and secondary prevention of ACS: results of a cost-effectiveness analysis including compliance. Cardiovasc Drugs Ther 2014; 27:341-57. [PMID: 23417566 DOI: 10.1007/s10557-013-6448-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Low-dose aspirin (ASA) increases the risk of upper gastrointestinal (GI) complications. Proton pump inhibitors (PPIs) reduce these upper GI side effects, yet patient compliance to PPIs is low. We determined the cost-effectiveness of gastroprotective strategies in low-dose ASA users considering ASA and PPI compliance. METHODS Using a Markov model we compared four strategies: no medication, ASA monotherapy, ASA+PPI co-therapy and a fixed combination of ASA and PPI for primary and secondary prevention of ACS. The risk of acute coronary syndrome (ACS), upper GI bleeding and dyspepsia was modeled as a function of compliance and the relative risk of developing these events while using medication. Costs, quality adjusted life years and number of ACS events were evaluated, applying a variable risk of upper GI bleeding. Probabilistic sensitivity analyses were performed. RESULTS For our base case patients using ASA for primary prevention of ACS no medication was superior to ASA monotherapy. PPI co-therapy was cost-effective (incremental cost-effectiveness ratio [ICER] €10,314) compared to no medication. In secondary prevention, PPI co-therapy was cost-effective (ICER €563) while the fixed combination yielded an ICER < €20,000 only in a population with elevated risk for upper GI bleeding or moderate PPI compliance. PPI co-therapy had the highest probability to be cost-effective in all scenarios. PPI use lowered the overall number of ACS. CONCLUSIONS Considering compliance, PPI co-therapy is likely to be cost-effective in patients taking low dose ASA for primary and secondary prevention of ACS, given low PPI prices. In secondary prevention, a fixed combination seems cost-effective in patients with elevated risk for upper GI bleeding or in those with moderate PPI compliance. Both strategies reduced the number of ACS compared to ASA monotherapy.
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Affiliation(s)
- N L de Groot
- Department Gastroenterology and Hepatology, University Medical Center Utrecht, PO Box (85500 internal code F02.618), 3508 GA Utrecht, The Netherlands.
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Dall M, dePont Christensen R, Schaffalitzky de Muckadell OB, Lassen AT, Hallas J. Re-prescribing of causative drugs in persons discharged after serious drug-induced upper gastrointestinal bleeding. Aliment Pharmacol Ther 2012; 35:948-54. [PMID: 22313346 DOI: 10.1111/j.1365-2036.2012.05006.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 12/12/2011] [Accepted: 01/11/2012] [Indexed: 01/28/2023]
Abstract
BACKGROUND Several drug classes are known to be associated with serious upper gastrointestinal bleeding (UGIB), among others NSAID, low-dose acetylsalicylic acid (ASA), vitamin K antagonists (VKA), clopidogrel and selective serotonin reuptake inhibitors (SSRIs). There are few data on how and to what extent these drugs are reintroduced in patients who have been discharged after a bleeding episode related to any of them. AIM To assess if physicians re-prescribed potential causative drugs after an episode of UGIB and to explore whether drugs with antihaemostatic action (DAHA) are re-prescribed without a gastro-protective agent. METHODS By use of the Kaplan-Meyer method, we estimated the time from UGIB to re-prescribing for 3652 cases who were all admitted to hospital with a diagnosis of serious upper gastrointestinal bleeding from 1995 to 2006. Data on drug exposure were retrieved from a Danish prescription database, a recent study on drug-related UGIB, and The National Board of Health in Denmark. RESULTS One-year rates of re-prescribing after UGIB were; 82%, 25%, 43%, 68%, 55%, 71% for SSRIs, NSAID, low-dose ASA, VKA, clopidogrel and dipyridamol, respectively. However, re-prescribing rates without proton pump inhibitors (PPIs) were markedly lower 25%, 3%, 5%, 1%, 17% and 6%, respectively. Non-users of DAHA had a prevalence of PPI use of about 30% a few months after an UGIB. CONCLUSIONS Drugs with antihaemostatic action are re-prescribed to a large extent after an episode of upper gastrointestinal bleeding, but usually covered by PPIs. This use of PPI is specific for users of drugs with antihaemostatic action.
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Affiliation(s)
- M Dall
- Research Unit of Clinical Pharmacology, University of Southern Denmark, Odense, Denmark.
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20
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Goldstein JL, Hochberg MC, Fort JG, Zhang Y, Hwang C, Sostek M. Clinical trial: the incidence of NSAID-associated endoscopic gastric ulcers in patients treated with PN 400 (naproxen plus esomeprazole magnesium) vs. enteric-coated naproxen alone. Aliment Pharmacol Ther 2010; 32:401-13. [PMID: 20497139 DOI: 10.1111/j.1365-2036.2010.04378.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gastroprotective co-therapy may reduce the risk of nonsteroidal anti-inflammatory drug (NSAID)-associated gastric ulcers, but adherence is suboptimal. AIM To compare the incidence of gastric ulcers with PN 400 [enteric-coated (EC) naproxen 500 mg and immediate-release esomeprazole 20 mg], or EC naproxen. METHODS Two randomized, double-blind, multicentre studies (PN400-301, PN400-302). Patients [stratified by low-dose aspirin (< or =325 mg) use] aged > or =50 years or 18-49 years with a history of ulcer, received PN 400 BID (301, n = 218; 302, n = 210) or EC naproxen 500 mg BID (301, n = 216; 302, n = 210) for 6 months. The primary endpoint was the cumulative incidence of endoscopic gastric ulcers. RESULTS The cumulative incidence of gastric ulcers was significantly lower with PN 400 vs. EC naproxen (301: 4.1% vs. 23.1%, P < 0.001; 302: 7.1% vs. 24.3%, P < 0.001). PN 400 was associated with a lower combined incidence of gastric ulcers vs. EC naproxen in low-dose aspirin users (n = 201) (3.0% vs. 28.4%, P < 0.001) and non-users (n = 653) (6.4% vs. 22.2%, P < 0.001). The incidence of, and discontinuations due to, upper gastrointestinal (UGI) AEs was significantly lower with PN 400 relative to EC naproxen (P < 0.01, both studies). CONCLUSIONS PN 400 significantly reduces the incidence of gastric ulcers, regardless of low-dose aspirin use, in at-risk patients, and is associated with improved UGI tolerability relative to EC naproxen (ClinicalTrials.gov, NCT00527782).
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Affiliation(s)
- J L Goldstein
- Department of Medicine, University of Illinois at Chicago, 60612, USA.
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Cryer BL, Wilcox CM, Henk HJ, Zlateva G, Chen L, Zarotsky V. The economics of upper gastrointestinal bleeding in a US managed-care setting: a retrospective, claims-based analysis. J Med Econ 2010; 13:70-7. [PMID: 20047365 DOI: 10.3111/13696990903526676] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess 12-month healthcare resource utilization and costs associated with upper gastrointestinal (UGI) bleeding events. METHODS Patients hospitalized with a UGI bleeding event were identified in US national health-plan claims data (1999-2003) and propensity matched to control patients without UGI bleeding in the same health plan. Matching criteria included age, gender, index date, Charlson Comorbidity Index score, geographic region, and prior medical utilization. RESULTS A total of 9,033 UGI-bleed patients and 579,018 control patients met the inclusion criteria, yielding 4,651 matched pairs. After matching, differences between the UGI bleed and general population cohorts remained for office visits, ER visits, and ER costs during the 6-month baseline period prior to the index date. During the 12 months following the index date, both UGI-related healthcare utilization and total healthcare, medical, and pharmacy costs incurred by the UGI-bleed cohort were significantly greater (p< 0.0001) than those incurred by the general population cohort (mean of $20,405 vs. 3,652), even after excluding the initial hospitalization costs (mean of $11,228 vs. 3,652). Costs were primarily due to inpatient hospitalizations (mean of $13,059 for the UGI-bleed cohort vs. $729 for the general population cohort) and ambulatory services (mean of $4,037 for the UGI-bleed cohort vs. $1,537 for the general population cohort). Sixteen percent of the UGI-bleed cohort had a GI-related hospitalization, and about 40% of total costs occurred after the initial hospitalization. CONCLUSIONS Patients with UGI bleeds experienced significantly higher (p< 0.0001) 12-month health-resource utilization and costs than patients without UGI bleeds. This study provides empirical evidence of the long-term economic burden associated with UGI bleeding. Interpretation of the results should take into account the lack of available information in claims data that could have an effect on study outcomes, such as particular clinical and disease-specific parameters that are not mitigated by propensity score and comorbidity index matching. In addition, this study is limited by the intensive demographic matching that was done between the two cohorts, which may have eliminated the sickest UGI patients and the healthiest general health-plan population patients.
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Affiliation(s)
- B L Cryer
- University of Texas Southwestern Medical School, Dallas, TX, USA
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Co-prescription of gastro-protectants in hospitalized patients: an analysis of what we do and what we think we do. J Clin Gastroenterol 2010; 44:e51-6. [PMID: 19609216 DOI: 10.1097/mcg.0b013e3181a9f43b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) reduce the risk of upper gastrointestinal hemorrhage (UGIH) associated with the use of many medications. GOALS To examine how clinicians perceive such risk and whether PPI co-prescribing is based on an accurate assessment. STUDY METHODS Clinicians in a single teaching hospital were asked to estimate risk of UGIH and comment on PPI co-prescription in hypothetical patients. Records of 160 hospital in-patients (median age; 74 y) were then reviewed to examine PPI prescribing and risk factors for UGIH. RESULTS In general, clinicians estimated UGIH risk accurately and reported low thresholds for PPI co-prescription. Prescribing records showed regular PPI use increased between admission and discharge of patients from 61/160 (38%) to 93/160 (58%). Ten percent had a prior history of peptic ulcer disease. Proton pump inhibitor prescription was significantly associated with the use of aspirin and clopidogrel. Half of the patients with multiple risk factors for UGIH on admission and almost a third at discharge were not co-prescribed a PPI. CONCLUSIONS Clinicians generally estimate correctly the risk of UGIH and report a low threshold for prescribing gastro-protection. Despite this, prescribing practice does not consistently take account of relative risk of UGIH. Targeted PPI co-prescribing on the basis of risk factors would lead to more rational PPI use.
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Anjiki H, Kamisawa T, Sanaka M, Ishii T, Kuyama Y. Endoscopic hemostasis techniques for upper gastrointestinal hemorrhage: A review. World J Gastrointest Endosc 2010; 2:54-60. [PMID: 21160691 PMCID: PMC2998874 DOI: 10.4253/wjge.v2.i2.54] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 09/12/2009] [Accepted: 09/19/2009] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal hemorrhage (UGIH) is an urgent disease that is often encountered in daily medical practice. Endoscopic hemostasis is currently indispensable for the treatment of UGIH. Initially, when UGIH is suspected, a cause of UGIH is presumed from the medical interview and physical findings. After ample primary treatment, urgent endoscopy is performed. Many methods of endoscopic hemostasis are in wide use, including hemoclip, injection and thermo-coagulation methods. Although UGIH develops from a wide variety of diseases, such as esophageal varices and gastric and duodenal ulcer, hemostasis is almost always possible. Identification of the causative diseases, primary treatment and characteristic features of endoscopic hemostasis are needed to allow appropriate treatment.
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Affiliation(s)
- Hajime Anjiki
- Hajime Anjiki, Terumi Kamisawa, Masaki Sanaka, Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo 113-8677, Japan
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Moore A, Bjarnason I, Cryer B, Garcia-Rodriguez L, Goldkind L, Lanas A, Simon L. Evidence for endoscopic ulcers as meaningful surrogate endpoint for clinically significant upper gastrointestinal harm. Clin Gastroenterol Hepatol 2009; 7:1156-63. [PMID: 19362611 DOI: 10.1016/j.cgh.2009.03.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Revised: 01/15/2009] [Accepted: 03/28/2009] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Surrogate endpoints are biomarkers intended to substitute for a clinical endpoint. Are endoscopic ulcers a useful surrogate endpoint for a biological progression to clinical endpoints of ulcer complications (perforation, ulcers, and bleeds), hospital admission, or death? METHODS Review of randomized trials, meta-analyses, clinical outcomes trials, and observational studies. RESULTS No large study examined both endoscopic and clinical endpoints. Endoscopic ulcers and clinically significant ulcer complications were affected in the same direction and to about the same extent in 4 distinct circumstances: (1) by risk factors-age, previous history of symptomatic ulcer or bleeding, Helicobacter pylori, aspirin; (2) in studies of antiulcer treatments with differing modes of action, especially in relation to nonsteroidal anti-inflammatory drug toxicity, and Helicobacter pylori infection; (3) in studies evaluating ulcer complications with Cox-2 selective drugs and nonsteroidal anti-inflammatory drugs; and (4) in studies of interventions in patients with high risk of recurrent ulcer bleed needing nonsteroidal anti-inflammatory drug therapy. All study designs showed consistent and reproducible effects on gastrointestinal ulcer complications paralleling endoscopy. CONCLUSIONS Consistent and plausible findings from disparate populations and designs make endoscopic ulcers a strong candidate for surrogacy, though direct progression from endoscopic ulcers to ulcer complications cannot be demonstrated. Large outcome studies are needed to establish the power of the surrogacy, absolute risk of clinical outcomes, and to identify the totality of risks and benefits of new pharmacologic therapies.
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Affiliation(s)
- Andrew Moore
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.
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Abstract
NSAIDs incur significant gastrointestinal (GI) side effects. The complication risk increases with history of peptic ulcer or older age. Helicobacter pylori infection and cardioprotective aspirin have independent and additive risks in the presence of NSAID use. NSAID enteropathy is increasingly recognized. Cardiovascular and GI risk stratification and H. pylori infection testing should be done before initiating NSAIDs. An NSAID combined with a proton pump inhibitor (PPI) is comparable to cyclooxygenase (COX)-2 inhibitors for gastroprotection, but for high-risk patients, COX-2 plus PPI should be considered. Aspirin and COX-2 inhibitors are associated with reduced colon adenoma risk, but higher dose and longer duration of treatment with aspirin appears effective. Hence, patients at high risk of colorectal cancer (with significant family or personal history of premalignant adenoma) must be identified, and cardiovascular and GI risk must be assessed before using these agents as chemopreventive drugs.
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Affiliation(s)
- Maneesh Gupta
- Division of Gastroenterology, Digestive Health Center, Center for Health and Healing, 6th Floor, Oregon Health and Science University, Portland, OR 97239, USA
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Hsu YC, Lin HJ. Proton pump inhibitors and long-term risk of recurrent upper gastrointestinal bleeding. Aliment Pharmacol Ther 2009; 29:232-3. [PMID: 20738263 DOI: 10.1111/j.1365-2036.2008.03876.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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Hauta-Aho M, Tirkkonen T, Vahlberg T, Laine K. The effect of drug interactions on bleeding risk associated with warfarin therapy in hospitalized patients. Ann Med 2009; 41:619-28. [PMID: 19711211 DOI: 10.1080/07853890903186168] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Bleeding is a serious adverse drug reaction associated with warfarin therapy, often induced by interacting co-medication. METHODS We investigated the frequency and clinical consequences of warfarin drug interactions utilizing medical records of 6,772 warfarin-treated in-patients of Turku University Hospital. RESULTS A total of 48% of warfarin-treated in-patients were exposed to interacting co-medication. Adjusted odds ratio (OR) for bleeding was highest for cytochrome P450 2C9 (CYP2C9) inhibitors (OR 3.6; 95% confidence interval (CI) 2.4-5.6). Non-selective non-steroidal anti-inflammatory drugs (NSAID) and coxibs were associated with a bleeding risk of a similar magnitude (OR 2.6; 95% CI 1.6-4.2 and OR 3.1; 95% CI 1.4-6.7, respectively). Selective serotonin re-uptake inhibitors (SSRI) were associated with a remarkably higher bleeding risk than non-SSRIs (OR 2.6; 95% CI 1.5-4.3 and OR 1.2; 95% CI 0.3-4.3, respectively). Odds ratio for bleeding in the platelet aggregation inhibitor group was 1.6 (95% CI 0.8-3.1). CONCLUSION We conclude that co-medication in warfarin-treated in-patients is common and should be carefully evaluated to decrease the bleeding risk associated with warfarin therapy.
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Affiliation(s)
- Milka Hauta-Aho
- Department of Pharmacology, Drug Development, and Therapeutics, University of Turku, Turku, Finland.
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