Antacid maintenance therapy in the prevention of duodenal ulcer relapse

Magnesium for alcohol withdrawal

BACKGROUND

Patients have been given magnesium to treat or prevent alcohol withdrawal syndrome (AWS). Evidence to support this practice is limited, and is often based on the controversial link between hypomagnesaemia and AWS.

OBJECTIVES

To assess the effects of magnesium for the prevention or treatment of AWS in hospitalised adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Register of Controlled Trials (August 2012), PubMed (from 1966 to August 2012 ), EMBASE (from 1988 to August 2012), CINAHL (from 1982 to March 2010), Web of Science (1965 to August 2012). We also carried out Internet searches.

SELECTION CRITERIA

Randomised or quasi-randomised trials of magnesium for hospitalised adults with, or at risk for, acute alcohol withdrawal.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data with a standardised data extraction form, contacting the correspondence investigator if the necessary information was not available in the reports. Dichotomous outcomes were analysed by calculating the risk ratio (RR) for each trial, with the uncertainty in each result expressed with a 95% confidence interval (CI). Continuous outcomes were to be analysed by calculating the standardised mean difference (SMD) with 95% CI. For outcomes assessed by scales we compared and pooled the mean score differences from the end of treatment to baseline (post minus pre) in the experimental and control groups.

MAIN RESULTS

Four trials involving 317 people met the inclusion criteria. Three trials studied oral magnesium, with doses ranging from 12.5 mmol/day to 20 mmol/day. One trial studied parenteral magnesium (16.24 mEq q6h for 24 hours). Each trial demonstrated a high risk of bias in at least one domain. There was significant clinical and methodological variation between trials.We found no study that measured all of the identified primary outcomes and met the objectives of this review. Only one trial measured clinical symptoms of seizure, delirium tremens or components of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score. A single outcome (handgrip strength) in three trials (113 people), was amenable to meta-analysis. There was no significant increase in handgrip strength in the magnesium group (SMD 0.04; 95% CI -0.22 to 0.30). No clinically important changes in adverse events were reported.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine whether magnesium is beneficial or harmful for the treatment or prevention of alcohol withdrawal syndrome.

Antacids revisited: a review of their clinical pharmacology and recommended therapeutic use

Antacids are commonly used self-prescribed medications. They consist of calcium carbonate and magnesium and aluminum salts in various compounds or combinations. The effect of antacids on the stomach is due to partial neutralisation of gastric hydrochloric acid and inhibition of the proteolytic enzyme, pepsin. Each cation salt has its own pharmacological characteristics that are important for determination of which product can be used for certain indications. Antacids have been used for duodenal and gastric ulcers, stress gastritis, gastro-oesophageal reflux disease, pancreatic insufficiency, non-ulcer dyspepsia, bile acid mediated diarrhoea, biliary reflux, constipation, osteoporosis, urinary alkalinisation and chronic renal failure as a dietary phosphate binder. The development of histamine H2-receptor antagonists and proton pump inhibitors has significantly reduced usage for duodenal and gastric ulcers and gastro-oesophageal reflux disease. However, antacids can still be useful for stress gastritis and non-ulcer dyspepsia. The recent release of proprietary H2 antagonists has likely further reduced antacid use for non-ulcer dyspepsia. Other indications are still valid but represent minor uses. Antacid drug interactions are well noted, but can be avoided by rescheduling medication administration times. This can be inconvenient and discourage compliance with other medications. All antacids can produce drug interactions by changing gastric pH, thus altering drug dissolution of dosage forms, reduction of gastric acid hydrolysis of drugs, or alter drug elimination by changing urinary pH. Most antacids, except sodium bicarbonate, may decrease drug absorption by adsorption or chelation of other drugs. Most adverse effects from antacids are minor with periodic use of small amounts. However, when large doses are taken for long periods of time, significant adverse effects may occur especially patients with underlying diseases such as chronic renal failure. These adverse effects can be reduced by monitoring of electrolyte status and avoiding aluminum-containing antacids to bind dietary phosphate in chronic renal failure. Antacids, although effective for discussed indications of duodenal and gastric ulcer and gastro-oesophageal reflux disease, have been replaced by newer, more effective agents that are more palatable to patients. Antacids are likely to continue to be used for non-ulcer dyspepsia, minor episodes of heartburn (gastro-oesophageal reflux disease) and other clear indications. Although their wide-spread use may decline, these drugs will still be used, and clinicians should be aware of their potential drug interactions and adverse effects.

Prescribing policy for antiulcer treatment in the elderly

In the short and long term treatment of peptic ulcer in the elderly some problems have yet to be resolved, mainly concerning the physiology and pathophysiology of the aging stomach, the pharmacokinetic and pharmacodynamic properties of antiulcer drugs, and the presence of different risk factors compared with young patients. The available data from controlled trials of peptic ulcer in the general population and from the limited experience in geriatrics, show that the clinical efficacy and tolerability of the anti-secretory drugs (e.g. cimetidine, ranitidine and famotidine) and of cytoprotective compounds are similar to that observed in younger patients. However, more data are necessary concerning the optimal dosage in relation to physiological age-related changes of liver and kidney function, the duration of prophylactic treatment, and importantly, the assurance of adequate patient compliance.

Maintenance therapy for duodenal ulcer: a randomized controlled comparison of seven forms of treatment

PURPOSE

We performed a randomized controlled trial to compare the efficacy of seven forms of maintenance treatment of duodenal ulcer, including a mealtime regimen of antacids.

PATIENTS AND METHODS

We randomized 785 patients with healed duodenal ulcer to receive: (1) no treatment; (2) mealtime antacids with an acid-neutralizing capacity of 80 mmol/day; (3) an antidepressant, trimipramine 25 mg; (4) an anticholinergic, pirenzepine 50 mg; (5) cimetidine 200 mg; (6) cimetidine 400 mg; (7) ranitidine 150 mg; or (8) sucralfate 1 g twice a day. Symptomatology and side effects were assessed every 2 months and endoscopy was performed every 4 months up to 1 year.

RESULTS

The patients were comparable in the majority of clinical characteristics before entry. The cumulative percentages of patients with relapse of ulcers at 12 months by life-table analysis were 61% with no treatment, 38% with mealtime antacids, 60% with trimipramine, 52% with pirenzepine, 46% with cimetidine 200 mg, 44% with cimetidine 400 mg, 30% with ranitidine 150 mg, and 40% with sucralfate. Cimetidine 400 mg, antacids, ranitidine 150 mg, and sucralfate were significantly better than no treatment and the other forms of treatment. Ranitidine was significantly better than antacids, cimetidine, and sucralfate in preventing endoscopically documented duodenal ulcer relapse by multiple comparison at 12 months, but not by life-table analysis nor when symptomatic relapses were compared. No significant difference was detected among antacids, cimetidine, and sucralfate. No major side effects occurred with the seven forms of treatment, but those receiving antacids had the highest incidence of minor adverse events (26%).

CONCLUSION

This study suggests that mealtime antacids are as effective as H2-receptor antagonists and sucralfate in the maintenance treatment of duodenal ulcer disease, but have to be taken three times a day and had the highest incidence of reported minor adverse events. The relapse rate was lower with ranitidine than with cimetidine, sucralfate, and antacids, but the difference was small and may not be clinically important.

Review article: maintenance treatment with H2-receptor antagonists for peptic ulcer disease

In recent years a number of different strategies for managing patients with peptic ulcer disease have become available. The present review discusses the relative merits of each form of treatment. Intermittent treatment (whether given in response to symptoms or as a prophylactic regimen prescribed seasonally or at weekends) fails to prevent ulcer recurrence and leaves patients at risk of haemorrhage and perforation. Anti-Helicobacter pylori therapy, although useful in certain circumstances, cannot be recommended for all patients with ulcer disease because of side effects and, in any case, requires further assessment of efficacy. Gastric surgery reduces ulcer recurrence and complications, but operations which have a low incidence of side effects are associated with higher rates of ulcer recurrence, particularly when patients are followed up for more than 10 years. Long-term continuous maintenance treatment with H2-receptor antagonists for 5 or more years effectively prevents ulcer recurrence in the majority of patients and significantly reduces the risk of ulcer complications. In addition, maintenance treatment has proved to be safe and is well tolerated by patients. Maintenance treatment with H2-receptor antagonists is the preferred option for the management of patients with peptic ulcer disease.

Antacids and ulcer healing. A review of the evidence

There have been a number of controlled trials of antacids in the treatment of patients with peptic ulcer disease. As a general rule the size of studies has been small and there have been difficulties ensuring adequate binding, because of the formulation and taste of the antacids. Despite these difficulties, antacids appear to be effective ulcer healing agents with efficacies resembling those of other antiulcer drugs. Definite dose relationships are unclear but high doses of buffering capacity over 200 mmol/day appear unnecessary and are associated with increasingly frequent adverse effects. Low dose maintenance treatment is effective at limiting duodenal ulcer relapse.

Double-blind randomized multicenter study comparing Maalox TC tablets and ranitidine in healing of duodenal ulcers

The efficacy of ranitidine 150 mg twice daily and Maalox TC three tablets four times daily were compared in patients with endoscopically confirmed duodenal ulcer. Seventy-nine patients were randomly allocated to double-blind, double-dummy treatment, stratified for smokers. Endoscopy was repeated after four weeks. Those unhealed continued treatment for a further two weeks before final endoscopy. Per protocol analysis in 53 patients showed ulcer healing rates at week 4 and at weeks 4 and 6 combined of 78 and 89% on Maalox TC, and of 81 and 91% on ranitidine, respectively. The same analysis gave overall healing rates of 81% in smokers and 100% in nonsmokers, irrespective of treatment. Both treatments provided early ulcer pain relief. Diarrhea was a commoner side effect in patients on Maalox TC. The study showed Maalox TC and ranitidine were equally effective in healing duodenal ulceration.

Long term treatment of duodenal ulcer. A review of management options

Duodenal ulcer is a chronic disease characterised by remission and relapses. The duration of this relapsing tendency is unpredictable for the individual patient, but in most cases it lasts for many years and perhaps the entire lifetime. Various therapeutic strategies have been suggested to maintain the disease in remission: continuous, intermittent and on-demand treatment with H2-antagonists, or surgery. Continuous maintenance treatment with the currently available H2-blockers has proved to be superior to all the other strategies in terms of efficacy, and should therefore be regarded as the long term treatment of choice for duodenal ulcer patients. The duration of maintenance treatment is still uncertain, but probably it should not be less than a few years. Intermittent treatment or surgery could be proposed to patients unsuitable for continuous maintenance, depending on whether they have mild or aggressive disease, respectively.

Oxygen-derived free radicals and the prevention of duodenal ulcer relapse: a new approach

This study investigated whether or not oxygen-derived free radicals are implicated in the mechanism of recurrence of duodenal ulceration. To this end, allopurinol (50 mg qds)--a hydroxyl scavenger and an inhibitor of xanthine oxidase which forms superoxide radicals--and dimethyl sulphoxide (DMSO, 500 mg qds)--a hydroxyl scavenger--were given orally. Three hundred and two consecutive patients with previous symptomatic, endoscopy-proven duodenal ulceration which had been shown endoscopically to have healed and who were smokers and social drinkers, were randomized to receive for one year either placebo, cimetidine 400 mg at bedtime, allopurinol, or DMSO. In two hundred and twenty patients evaluable for efficacy, the cumulative relapse at one year was: placebo 65%, cimetidine 30%, allopurinol 12% and DMSO 13%. Cimetidine was significantly effective (p less than 0.01); however, allopurinol and DMSO were equally efficacious and superior to cimetidine (p less than 0.05). In patients who relapsed, the ulcer recurrence tended to occur early on placebo and to be evenly distributed over the year on active therapy. In all the groups, the relative frequency of symptomatic to silent relapses was similar in the first and second halves of the year and was comparable among the groups. The results suggest that oxygen-derived free radicals are directly implicated in the mechanism of duodenal ulcer relapse and that removing the radicals reduces recurrence of this ulceration.

Omeprazole in the treatment of duodenal ulcer

Omeprazole is the most effective antisecretory agent available today. Open and dose-comparative studies have documented that at dosages of 20 mg/day or more, the drug produces duodenal ulcer healing rates of 90-100% after 4 weeks. Controlled trials show that omeprazole, 20-40 mg/day, is superior to cimetidine and ranitidine in healing duodenal ulcer, with a median therapeutic gain of 21% at 2 weeks and 15% at 4 weeks. Ulcer symptom relief is also more pronounced and faster with omeprazole than with H2-receptor antagonists. No significant side-effects attributable to treatment with omeprazole have appeared in any of these studies or in the accumulated experience from several thousand patients treated with omeprazole. No tendency to an increase in recurrence rate after discontinuation of treatment with omeprazole has been shown. In summary, omeprazole constitutes a major advance in the short-term treatment of duodenal ulcer, giving fast and pronounced healing and symptom relief.

Colloidal bismuth in the treatment of duodenal ulceration: the benefit for the patient

Colloidal bismuth subcitrate (CBS) heals gastric and duodenal ulcers better than placebo and at rates similar to those observed with the commonly used H2-antagonists. Indeed, healing of duodenal ulcers may be more rapid than with cimetidine during the first month of treatment. When treatment is withdrawn, however, relapse is slower after CBS than after the H2-antagonists. The mechanism is uncertain but may be related to the ability of CBS to suppress Campylobacter pylori infection. The clinical implications of this difference in relapse rates are discussed. Preliminary data suggest that duodenal ulcer patients who are rendered C. pylori-negative for a prolonged period may be relatively immune to relapse. If confirmed, and if a suitably effective regimen can be found, this will transform the management of this difficult clinical problem.

Use of omeprazole in the management of reflux oesophagitis resistant to H2-receptor antagonists

Severe reflux oesophagitis, which is resistant to treatment with high doses of H2-receptor antagonists, can be treated successfully with the H+,K+-ATPase inhibitor omeprazole. Experience from more than 3 years of continuous treatment with omeprazole, in doses adjusted to prevent recurrences, has demonstrated its high efficacy in the long-term management of the patients. The use of this drug emphasizes the importance of long-standing, effective, 24-hour acid inhibition for reflux oesophagitis. Fasting gastrin levels increase 2-fold during the initial treatment period but continued treatment does not induce any further elevation. Omeprazole does not induce pathological changes in the endocrine cell population of the gastric oxyntic mucosa, though in some patients an increase in the argyrophilic cell volume density during omeprazole treatment has been reported. Careful surveillance of the safety profile of this drug is continuing.

The clinical utility and safety of omeprazole

More than 13,000 individuals with duodenal ulcer, gastric ulcer or reflux oesophagitis have now taken part in controlled clinical studies with omeprazole. In duodenal ulcer, treatment with omeprazole, 20 mg daily or more, has resulted in healing rates of 58%-83% after 2 weeks and 84%-100% after 4 weeks. In all of these studies, healing rates with omeprazole have been higher than with either ranitidine or cimetidine. Omeprazole has also had a more pronounced effect on ulcer symptoms. Although the first comparative study on gastric ulcer showed only marginally higher healing rates with omeprazole than with an H2-receptor antagonist, later studies have all shown significantly higher healing rates with omeprazole. Healing rates of the order of 70% or more have been achieved within 4 weeks, rising to over 88% after 8 weeks. Symptom relief has also been faster with omeprazole. In both duodenal ulcer and gastric ulcer, almost every patient can be healed, including those resistant to treatment with H2-receptor antagonists. The influence of omeprazole on the healing of reflux oesophagitis has been investigated in several studies comparing omeprazole with ranitidine. Healing rates have been markedly higher with omeprazole in all studies. These unprecedentedly high healing rates (81%-96% at 8 weeks) have also been accompanied by rapid symptom relief. In clinical studies with omeprazole, no clinically significant side-effects which could be ascribed to treatment, nor indeed any serious side-effects, have been observed, neither have any clinically significant changes in laboratory variables been seen. Furthermore, no pathological changes of the gastric mucosa have been detected after long-term treatment with omeprazole.