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Tari E, Frim L, Stolcz T, Teutsch B, Veres DS, Hegyi P, Erőss B. At admission hemodynamic instability is associated with increased mortality and rebleeding rate in acute gastrointestinal bleeding: a systematic review and meta-analysis. Therap Adv Gastroenterol 2023; 16:17562848231190970. [PMID: 37655056 PMCID: PMC10467304 DOI: 10.1177/17562848231190970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/13/2023] [Indexed: 09/02/2023] Open
Abstract
Background Acute gastrointestinal bleeding (GIB) is a life-threatening event. Around 20-30% of patients with GIB will develop hemodynamic instability (HI). Objectives We aimed to quantify HI as a risk factor for the development of relevant end points in acute GIB. Design A systematic search was conducted in three medical databases in October 2021. Data sources and methods Studies of GIB patients detailing HI as a risk factor for the investigated outcomes were selected. For the overall results, pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated based on a random-effects model. Subgroups were formed based on the source of bleeding. The Quality of Prognostic Studies tool was used to assess the risk of bias. Results A total of 62 studies were eligible, and 39 were included in the quantitative synthesis. HI was found to be a risk factor for both in-hospital (OR: 5.48; CI: 3.99-7.52) and 30-day mortality (OR: 3.99; CI: 3.08-5.17) in upper GIB (UGIB). HI was also associated with higher in-hospital (OR: 3.68; CI: 2.24-6.05) and 30-day rebleeding rates (OR: 4.12; 1.83-9.31) among patients with UGIB. The need for surgery was also more frequent in hemodynamically compromised UGIB patients (OR: 3.65; CI: 2.84-4.68). In the case of in-hospital mortality, the risk of bias was high for 1 (4%), medium for 13 (48%), and low for 13 (48%) of the 27 included studies. Conclusion Hemodynamically compromised patients have increased odds of all relevant untoward end points in GIB. Therefore, to improve the outcomes, adequate emergency care is crucial in HI. Registration PROSPERO registration number: CRD42021285727.
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Affiliation(s)
- Edina Tari
- Centre for Translational Medicine, Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Levente Frim
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Tünde Stolcz
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Brigitta Teutsch
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dániel Sándor Veres
- Department of Biophysics and Radiation Biology, Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Centre for Translational Medicine, Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Tömő u. 25.-29., Budapest, 1083, Hungary
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Kanno T, Yuan Y, Tse F, Howden CW, Moayyedi P, Leontiadis GI. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 2022; 1:CD005415. [PMID: 34995368 PMCID: PMC8741303 DOI: 10.1002/14651858.cd005415.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Upper gastrointestinal (GI) bleeding is a common reason for emergency hospital admission. Proton pump inhibitors (PPIs) reduce gastric acid production and are used to manage upper GI bleeding. However, there is conflicting evidence regarding the clinical efficacy of proton pump inhibitors initiated before endoscopy in people with upper gastrointestinal bleeding. OBJECTIVES To assess the effects of PPI treatment initiated prior to endoscopy in people with acute upper GI bleeding. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase and CINAHL databases and major conference proceedings to October 2008, for the previous versions of this review, and in April 2018, October 2019, and 3 June 2021 for this update. We also contacted experts in the field and searched trial registries and references of trials for any additional trials. SELECTION CRITERIA We selected randomised controlled trials (RCTs) that compared treatment with a PPI (oral or intravenous) versus control treatment with either placebo, histamine-2 receptor antagonist (H2RA) or no treatment, prior to endoscopy in hospitalised people with uninvestigated upper GI bleeding. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed study eligibility, extracted study data and assessed risk of bias. Outcomes assessed at 30 days were: mortality (our primary outcome), rebleeding, surgery, high-risk stigmata of recent haemorrhage (active bleeding, non-bleeding visible vessel or adherent clot) at index endoscopy, endoscopic haemostatic treatment at index endoscopy, time to discharge, blood transfusion requirements and adverse effects. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included six RCTs comprising 2223 participants. No new studies have been published after the literature search performed in 2008 for the previous version of this review. Of the included studies, we considered one to be at low risk of bias, two to be at unclear risk of bias, and three at high risk of bias. Our meta-analyses suggest that pre-endoscopic PPI use may not reduce mortality (OR 1.14, 95% CI 0.76 to 1.70; 5 studies; low-certainty evidence), and may reduce rebleeding (OR 0.81, 95% CI 0.62 to 1.06; 5 studies; low-certainty evidence). In addition, pre-endoscopic PPI use may not reduce the need for surgery (OR 0.91, 95% CI 0.65 to 1.26; 6 studies; low-certainty evidence), and may not reduce the proportion of participants with high-risk stigmata of recent haemorrhage at index endoscopy (OR 0.80, 95% CI 0.52 to 1.21; 4 studies; low-certainty evidence). Pre-endoscopic PPI use likely reduces the need for endoscopic haemostatic treatment at index endoscopy (OR 0.68, 95% CI 0.50 to 0.93; 3 studies; moderate-certainty evidence). There were insufficient data to determine the effect of pre-endoscopic PPI use on blood transfusions (2 studies; meta-analysis not possible; very low-certainty evidence) and time to discharge (1 study; very low-certainty evidence). There was no substantial heterogeneity amongst trials in any analysis. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that PPI treatment initiated before endoscopy for upper GI bleeding likely reduces the requirement for endoscopic haemostatic treatment at index endoscopy. However, there is insufficient evidence to conclude whether pre-endoscopic PPI treatment increases, reduces or has no effect on other clinical outcomes, including mortality, rebleeding and need for surgery. Further well-designed RCTs that conform to current standards for endoscopic haemostatic treatment and appropriate co-interventions, and that ensure high-dose PPIs are only given to people who received endoscopic haemostatic treatment, regardless of initial randomisation, are warranted. However, as it may be unrealistic to achieve the optimal information size, pragmatic multicentre trials may provide valuable evidence on this topic.
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Affiliation(s)
- Takeshi Kanno
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yuhong Yuan
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Frances Tse
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee, Memphis, TN, USA
| | - Paul Moayyedi
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
| | - Grigorios I Leontiadis
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada
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Csiki E, Szabó H, Hanák L, Szakács Z, Kiss S, Vörhendi N, Pécsi D, Hegyi E, Hegyi P, Erőss B. Oral Proton Pump Inhibitors May Be as Effective as Intravenous in Peptic Ulcer Bleeding: A Systematic Review and Meta-analysis. Clin Transl Gastroenterol 2021; 12:e00341. [PMID: 33988530 PMCID: PMC8049165 DOI: 10.14309/ctg.0000000000000341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 03/05/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Current guidelines recommend intravenous (IV) proton pump inhibitor (PPI) therapy in peptic ulcer bleeding (PUB). We aimed to compare the efficacy of oral and IV administration of PPIs in PUB. METHODS We performed a systematic search in 4 databases for randomized controlled trials, which compared the outcomes of oral PPI therapy with IV PPI therapy for PUB. The primary outcomes were 30-day recurrent bleeding and 30-day mortality. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for dichotomous outcomes, while weighted mean differences (WMDs) with CI were calculated for continuous outcomes in meta-analysis. The protocol was registered a priori onto PROSPERO (CRD42020155852). RESULTS A total of 14 randomized controlled trials reported 1,951 peptic ulcer patients, 977 and 974 of which were in the control and intervention groups, respectively. There were no statistically significant differences between oral and IV administration regarding 30-day rebleeding rate (OR = 0.96, CI: 0.65-1.44); 30-day mortality (OR = 0.70, CI: 0.35-1.40); length of hospital stay (WMD = -0.25, CI: -0.93 to -0.42); transfusion requirements (WMD = -0.09, CI: -0.07 to 0.24); need for surgery (OR = 0.91, CI: 0.40-2.07); further endoscopic therapy (OR = 1.04, CI: 0.56-1.93); and need for re-endoscopy (OR = 0.81, CI: 0.52-1.28). Heterogeneity was negligible in all analysis, except for the analysis on the length of hospitalization (I2 = 82.3%, P = 0.001). DISCUSSION Recent evidence suggests that the oral administration of PPI is not inferior to the IV PPI treatment in PUB after endoscopic management, but further studies are warranted.
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Affiliation(s)
- Endre Csiki
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Department of Gastroenterology, Mureş County Clinical Hospital, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu-Mureş, Faculty of Medicine, Târgu-Mureş, Romania
| | - Hanna Szabó
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
- George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Faculty of Medicine, Târgu-Mureş, Romania
| | - Lilla Hanák
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Szabolcs Kiss
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Nóra Vörhendi
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Dániel Pécsi
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Eszter Hegyi
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, Szentágothai Research Center, University of Pécs, Pécs, Hungary
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Zhu Z, Lai Y, Ouyang L, Lv N, Chen Y, Shu X. High-Dose Proton Pump Inhibitors Are Superior to Standard-Dose Proton Pump Inhibitors in High-Risk Patients With Bleeding Ulcers and High-Risk Stigmata After Endoscopic Hemostasis. Clin Transl Gastroenterol 2021; 12:e00294. [PMID: 33448708 PMCID: PMC7810506 DOI: 10.14309/ctg.0000000000000294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/23/2020] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION To define the best cutoff of the Glasgow-Blatchford score (GBS) for identifying high- and low-risk rebleeding patients with bleeding ulcers and high-risk stigmata after endoscopic hemostasis and compare the efficacy of high-dose and standard-dose intravenous proton pump inhibitors (HD-IVPs and SD-IVPs, respectively) in this patient population. METHODS We retrospectively reviewed the data of 346 patients with bleeding ulcers and high-risk stigmata who underwent endoscopic hemostasis between March 2014 and September 2018 in our center and were divided into an HD-IVP group and an SD-IVP group. Propensity score-matching analysis was performed to control for selection bias and other potential confounders. Recurrent bleeding rates were calculated according to the GBS. RESULTS Overall, 346 patients meeting the inclusion criteria were enrolled, with 89 patients in the SD-IVP group and 89 patients in the HD-IVP group after matching with all baseline characteristics balanced (P > 0.05). GBS = 8 was the best cutoff for identifying high-risk rebleeding patients (GBS ≥ 8) with a significant difference (P = 0.015) in recurrence rate between the SD-IVP (17/61, 27.9%) and HD-IVP (7/65, 10.8%) groups and low-risk rebleeding patients (GBS < 8) with no difference (P = 1) in recurrence rate between the SD-IVP (2/28, 7.1%) and HD-IVP (2/24, 8.3%) groups. DISCUSSION The best cutoff for identifying high-risk and low-risk rebleeding patients with bleeding ulcers and high-risk stigmata after endoscopic hemostasis was GBS = 8. Although HD-IVP is more effective than SD-IVP in high-risk patients, they are equally effective in low-risk patients.
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Affiliation(s)
- Zhenhua Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Yongkang Lai
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Liu Ouyang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Nonghua Lv
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Youxiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Xu Shu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
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Comparison of three risk scores to predict outcomes in upper gastrointestinal bleeding; modifying Glasgow-Blatchford with albumin. ACTA ACUST UNITED AC 2020; 57:322-333. [PMID: 31268861 DOI: 10.2478/rjim-2019-0016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Management of upper gastrointestinal bleeding (UGIB) is of great importance. In this way, we aimed to evaluate the performance of three well known scoring systems of AIMS65, Glasgow-Blatchford Score (GBS) and Full Rockall Score (FRS) in predicting adverse outcomes in patients with UGIB as well as their ability in identifying low risk patients for outpatient management. We also aimed to assess whether changing albumin cutoff in AIMS65 and addition of albumin to GBS add predictive value to these scores. METHODS This was a retrospective study on adult patients who were admitted to Razi hospital (Rasht, Iran) with diagnosis of upper gastrointestinal bleeding between March 21, 2013 and March 21, 2017. Patients who didn't undergo endoscopy or had incomplete medical data were excluded. Initially, we calculated three score systems of AIMS65, GBS and FRS for each patient by using initial Vital signs and lab data. Secondary, we modified AIMS65 and GBS by changing albumin threshold from <3.5 to <3.0 in AIMS65 and addition of albumin to GBS, respectively. Primary outcomes were defined as in hospital mortality, 30-day rebleeding, need for blood transfusion and endoscopic therapy. Secondary outcome was defined as composition of primary outcomes excluding need for blood transfusion. We used AUROC to assess predictive accuracy of risk scores in primary and secondary outcomes. For albumin-GBS model, the AUROC was only calculated for predicting mortality and secondary outcome. The negative predictive value for AIMS65, GBS and modified AIMS65 was then calculated. RESULT Of 563 patients, 3% died in hospital, 69.4% needed blood transfusion, 13.1% needed endoscopic therapy and 3% had 30-day rebleeding. The leading cause of UGIB was erosive disease. In predicting composite of adverse outcomes all scores had statistically significant accuracy with highest AUROC for albumin-GBS. However, in predicting in hospital mortality, only albumin-GBS, modified AIMS65 and AIMS65 had acceptable accuracy. Interestingly, albumin, alone, had higher predictive accuracy than other original risk scores. None of the four scores could predict 30-day rebleeding accurately; on the contrary, their accuracy in predicting need for blood transfusion was high enough. The negative predictive value for GBS was 96.6% in score of ≤2 and 85.7% and 90.2% in score of zero in AIMS65 and modified AIMS65, respectively. CONCLUSION Neither of risk scores was highly accurate as a prognostic factor in our population; however, modified AIMS65 and albumin-GBS may be optimal choice in evaluating risk of mortality and general assessment. In identifying patient for safe discharge, GBS ≤ 2 seemed to be advisable choice.
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Sgourakis G, Chatzidakis G, Poulou A, Malliou P, Argyropoulos T, Ravanis G, Vagia A, Kpogho I, Briki A, Tsuruhara H, Stankovičová T. High-dose vs. Low-dose Proton Pump Inhibitors post-endoscopic hemostasis in patients with bleeding peptic ulcer. A meta-analysis and meta-regression analysis. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2018; 29:22-31. [PMID: 29391304 PMCID: PMC6322613 DOI: 10.5152/tjg.2018.17143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 09/01/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND/AIMS Present meta-analysis aims to evaluate studies of low- versus high-dose proton pump Inhibitors (PPI) post-endoscopic hemostasis, including the newly published randomized controlled trials (RCTs) and to conclude whether low-dose PPI can generate the comparable results as high-dose PPI. MATERIALS AND METHODS To identify suitable trials, the electronic databases PubMed, Medline, Cochrane Library, and the Embase were used. All RCTs concerning low- versus high-dose PPI administration post-endoscopic hemostasis published until December 2016 were identified. Primary outcomes were rebleeding rates, need for surgical intervention, and mortality. RESULTS Studies included a total of 1.651 participants. There were significantly less cases of rebleeding in the low-dose PPI treatment arm (p=0.003). All but one study provided data concerning need for Surgical Intervention and Mortality. The respective effect sizes were [odds ratio (OR), 95% confidence intervals (CI): 1.35, 0.72-2.53] and [OR, 95% CI: 1.20, 0.70-2.05]. Both treatment arms were comparable considering the aforementioned outcomes (p=0.35 and p=0.51, respectively). Meta-regression analysis likewise unveiled comparable outcomes between studies using pantoprazole versus lansoprazole concerning all three outcomes [rebleeding (p=0.944), surgical intervention (p=0.884), and mortality (p=0.961)]. CONCLUSION A low-dose PPI treatment is equally effective as a high-dose PPI treatment following endoscopic arresting of bleeding. However, we anticipate the completion of more high-quality RCTs that will embrace distinct ethnicities, standardized endoscopic diagnosis and management, double-blind strategies, and appraisal of results working specific standards over clear-cut follow-up periods.
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Affiliation(s)
- George Sgourakis
- Department of Surgery, Furness General Hospital, Barrow-in-Furness, United Kingdom
| | - George Chatzidakis
- Department of Pharmacology and Toxicology, Comenius University Faculty of Pharmacy, Bratislava, Slovakia
| | - Androniki Poulou
- Department of Gastroenterology, Korgialenio-Benakio Red Cross Hospital, Athens, Greece
| | - Panagiota Malliou
- Department of Gastroenterology, Korgialenio-Benakio Red Cross Hospital, Athens, Greece
| | | | - George Ravanis
- Department of Gastroenterology, Korgialenio-Benakio Red Cross Hospital, Athens, Greece
| | - Aphroditi Vagia
- Department of Gastroenterology, Korgialenio-Benakio Red Cross Hospital, Athens, Greece
| | - Itseoritse Kpogho
- Department of Surgery, Furness General Hospital, Barrow-in-Furness, United Kingdom
| | - Adam Briki
- Department of Surgery, Furness General Hospital, Barrow-in-Furness, United Kingdom
| | - Hana Tsuruhara
- Department of Surgery, Furness General Hospital, Barrow-in-Furness, United Kingdom
| | - Tatiana Stankovičová
- Department of Pharmacology and Toxicology, Comenius University Faculty of Pharmacy, Bratislava, Slovakia
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Value of Oral Proton Pump Inhibitors in Acute, Nonvariceal Upper Gastrointestinal Bleeding: A Network Meta-Analysis. J Clin Gastroenterol 2017; 51:707-719. [PMID: 27505402 DOI: 10.1097/mcg.0000000000000625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Intravenous (IV) proton pump inhibitors (PPI) are the standard medical treatment in acute nonvariceal upper gastrointestinal bleeding (ANVGIB). Optimal route of PPI delivery has been questioned. AIM The aim was to perform a systematic review and network meta-analysis for the endpoints of risk of rebleeding, length of stay (LOS), surgery (ROS), mortality, and total units of blood transfused (UBT) among trials evaluating acid suppressive medications in ANVGIB. METHODS A total of 39 studies using IV PPI drip, IV scheduled PPI, oral PPI, H2-receptor antagonists, and placebo were identified. Network meta-analysis was used for indirect comparisons and Bayesian Markov Chain Monte Carlo methods for calculation of probability superiority. RESULTS No difference was observed between IV PPI drip and scheduled IV PPI for mortality (relative risk=1.11; 95% credibility interval, 0.56-2.21), LOS (0.04, -0.49 to 0.44), ROS (1.27, 0.64-2.35) and risk of rebleeding within 72 hours, 1 week, and 1 month [(0.98, 0.48-1.95), (0.59, 0.13-2.03), (0.82, 0.28-2.16)]. Oral PPIs were as effective as IV scheduled PPIs and IV PPI drip for LOS (0.22, -0.61 to 0.79 and 0.16, -0.56 to 0.80) and UBT (-0.25, -1.23 to 0.65 and -0.06, -0.71 to 0.65) and superior to IV PPI drip for ROS (0.30, 0.10 to 0.78). CONCLUSION Scheduled IV PPIs were as effective as IV PPI drip for most outcomes. Oral PPIs were comparable to scheduled IV for LOS and UBT and superior to IV PPI drip for ROS. Conclusions should be tempered by low frequency endpoints such as ROS, but question the need for IV PPI drip in ANVGIB.
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Liang CM, Hsu CN, Tai WC, Yang SC, Wu CK, Shih CW, Ku MK, Yuan LT, Wang JW, Tseng KL, Sun WC, Hung TH, Nguang SH, Hsu PI, Wu DC, Chuah SK. Risk factors influencing the outcome of peptic ulcer bleeding in chronic kidney disease after initial endoscopic hemostasis: A nationwide cohort study. Medicine (Baltimore) 2016; 95:e4795. [PMID: 27603387 PMCID: PMC5023910 DOI: 10.1097/md.0000000000004795] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Patients with chronic kidney disease (CKD) who had peptic ulcer bleeding (PUB) may have more adverse outcomes. This population-based cohort study aimed to identify risk factors that may influence the outcomes of patients with CKD and PUB after initial endoscopic hemostasis. Data from 1997 to 2008 were extracted from the National Health Insurance Research Database in Taiwan. We included a cohort dataset of 1 million randomly selected individuals and a dataset of patients with CKD who were alive in 2008. A total of 18,646 patients with PUB were screened, and 1229 patients admitted for PUB after endoscopic hemostasis were recruited. The subjects were divided into non-CKD (n = 1045) and CKD groups (n = 184). We analyzed the risks of peptic ulcer rebleeding, sepsis events, and mortality among in-hospital patients, and after discharge. Results showed that the rebleeding rates associated with repeat endoscopic therapy (11.96% vs 6.32%, P = 0.0062), death rates (8.7%, vs 2.3%, P < 0.0001), hospitalization cost (US$ 5595±7200 vs US$2408 ± 4703, P < 0.0001), and length of hospital stay (19.6 ± 18.3 vs 11.2 ± 13.1, P < 0.0001) in the CKD group were higher than those in the non-CKD group. The death rate in the CKD group was also higher than that in the non-CKD group after discharge. The independent risk factor for rebleeding during hospitalization was age (odds ratio [OR], 1.02; P = 0.0063), whereas risk factors for death were CKD (OR, 2.37; P = 0.0222), shock (OR, 2.99; P = 0.0098), and endotracheal intubation (OR, 5.31; P < 0.0001). The hazard ratio of rebleeding risk for aspirin users after discharge over a 10-year follow-up period was 0.68 (95% confidence interval [CI]: 0.45-0.95, P = 0.0223). On the other hand, old age (P < 0.0001), CKD (P = 0.0090), diabetes (P = 0.0470), and congestive heart failure (P = 0.0013) were the independent risk factors for death after discharge. In-hospital patients with CKD and PUB after endoscopic therapy had higher recurrent bleeding, infection, and mortality rates, and the need for second endoscopic therapy. Age was the independent risk factor for recurrent bleeding during hospitalization. After being discharged with a 10-year follow-up period, nonaspirin user was a significant factor for recurrent bleeding.
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Affiliation(s)
- Chih-Ming Liang
- Division of Hepatogastroenterology, Department of Internal Medicine
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Gang Gung Memorial Hospital, Kaohsiung
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung
| | - Wei-Chen Tai
- Division of Hepatogastroenterology, Department of Internal Medicine
- Chang Gung University, College of Medicine, Kaohsiung
| | - Shih-Cheng Yang
- Division of Hepatogastroenterology, Department of Internal Medicine
| | - Cheng-Kun Wu
- Division of Hepatogastroenterology, Department of Internal Medicine
| | - Chih-Wei Shih
- Division of Hepatogastroenterology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi
| | - Ming-Kun Ku
- Division of Gastroenterology, Fu-Ying University Hospital, Pin-Tung
| | - Lan-Ting Yuan
- Divisions of Gastroenterology, Yuan General Hospital, Kaohsiung
| | - Jiunn-Wei Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, and Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Kuo-Lun Tseng
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, and Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
| | - Wei-Chih Sun
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, National Yang-Ming University, Kaohsiung
| | - Tsung-Hsing Hung
- Division of Gastroenterology; Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi
| | - Seng-Howe Nguang
- Division of Gastroenterology; Pin-Tung Christian Hospital, Pin-Tung, Taiwan
| | - Pin-I Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, National Yang-Ming University, Kaohsiung
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, and Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung
- Correspondence: Seng-Kee Chuah and Deng-Chyang Wu, Division of Hepatogastroenterology, Kaohsiung Chang Gung Memorial Hospital, 123, Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung 833, Taiwan (e-mails: and )
| | - Seng-Kee Chuah
- Division of Hepatogastroenterology, Department of Internal Medicine
- Chang Gung University, College of Medicine, Kaohsiung
- Correspondence: Seng-Kee Chuah and Deng-Chyang Wu, Division of Hepatogastroenterology, Kaohsiung Chang Gung Memorial Hospital, 123, Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung 833, Taiwan (e-mails: and )
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Chwiesko A, Charkiewicz R, Niklinski J, Luczaj W, Skrzydlewska E, Milewski R, Baniukiewicz A, Wroblewski E, Rosolowski M, Dabrowski A. Effects of different omeprazole dosing on gastric pH in non-variceal upper gastrointestinal bleeding: A randomized prospective study. J Dig Dis 2016; 17:588-599. [PMID: 27518195 DOI: 10.1111/1751-2980.12393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/15/2016] [Accepted: 08/08/2016] [Indexed: 01/10/2023]
Abstract
OBJECTIVE We aimed to identify the best method of omeprazole (OME) application with respect to intragastric pH, cytochrome P450 2C19 (CYP2C19) genotype and phenotype. METHODS The patients with non-variceal upper gastrointestinal bleeding (NVUGIB) were prospectively enrolled. After the achievement of endoscopic hemostasis, the patients were randomized to 40-mg intravenous (i.v.) OME bolus injection every 12 h or 8-mg/h continuous i.v. infusion for 72 h after an 80-mg i.v. OME bolus administration. The intragastric pH was recorded for 72 h. The CYP2C19 variant alleles (*2, *3, *17) were analyzed and the serum concentrations of OME and 5-hydroxyomeprazole (5-OH OME) were determined. RESULTS Altogether 41 Caucasians (18 in the OME infusion [OI] group and 23 in the OME bolus [OB] group) were analyzed. The median percentage of time with an intragastric pH > 4.0 was higher in the infusion group than in the OB group over 48 h (100% vs 96.6%, P = 0.009) and 72 h (100% vs 87.6%, P = 0.006), and that at an intragastric pH >6.0 was higher in the OI group than the OB group over 72 h (97.9% vs 63.5%, P = 0.04). Helicobacter pylori infection was correlated with the fastest increase in intragastric pH, especially in the OI group. In both groups, CYP2C19 genotypes (*1/*1, *1/*17, *17/*17) had no essential effect on intragastric pH. CONCLUSIONS In patients with NVUGIB, OME i.v. bolus followed by continuous infusion is more effective than OME i.v. bolus every 12 h in maintaining higher intragastric pH, regardless of CYP2C19 genetic polymorphisms. H. pylori infection accelerates the initial elevation of intragastric pH.
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Affiliation(s)
- Adam Chwiesko
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Radoslaw Charkiewicz
- Department of Clinical Molecular Biology, Medical University of Bialystok, Bialystok, Poland
| | - Jacek Niklinski
- Department of Clinical Molecular Biology, Medical University of Bialystok, Bialystok, Poland
| | - Wojciech Luczaj
- Department of Inorganic and Analytical Chemistry, Medical University of Bialystok, Bialystok, Poland
| | - Elzbieta Skrzydlewska
- Department of Inorganic and Analytical Chemistry, Medical University of Bialystok, Bialystok, Poland
| | - Robert Milewski
- Department of Statistics and Medical Informatics, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Baniukiewicz
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Eugeniusz Wroblewski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Mariusz Rosolowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Dabrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
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Outcome of holiday and nonholiday admission patients with acute peptic ulcer bleeding: a real-world report from southern Taiwan. BIOMED RESEARCH INTERNATIONAL 2014; 2014:906531. [PMID: 25093189 PMCID: PMC4100444 DOI: 10.1155/2014/906531] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 06/18/2014] [Indexed: 01/18/2023]
Abstract
Background. Recent findings suggest that patients admitted on the weekend with peptic ulcer bleeding might be at increased risk of adverse outcomes. However, other reports found that there was no “holiday effect.” The purpose of this study was to determine if these findings hold true for a real-life Taiwanese medical gastroenterology practice. Materials and Methods. We reviewed the medical files of hospital admissions for patients with peptic ulcer bleeding who received initial endoscopic hemostasis between January 2009 and March 2011. A total of 744 patients were enrolled (nonholiday group, n = 615; holiday group, n = 129) after applying strict exclusion criteria. Holidays were defined as weekends and national holidays in Taiwan. Results. Our results showed that there was no significant difference in baseline characteristics between the two groups. We also observed that, compared to the nonholiday group, patients in the holiday group received earlier endoscopy treatment (12.20 hours versus 16.68 hours, P = 0.005), needed less transfused blood (4.8 units versus 6.6 units, P = 0.02), shifted from intravenous to oral proton-pump inhibitors (PPIs) more quickly (5.3 days versus 6.9 days, P = 0.05), and had shorter hospital stays (13.05 days versus 17.36 days, P = 0.005). In the holiday and nonholiday groups, the rebleeding rates were 17.8% and 23.41% (P = 0.167), the mortality rates were 11.63% versus 13.66% (P = 0.537), and surgery was required in 2.11% versus 4.66% (P = 0.093), respectively. Conclusions. Patients who presented with peptic ulcer bleeding on holidays did not experience delayed endoscopy or increased adverse outcomes. In fact, patients who received endoscopic hemostasis on the holiday had shorter waiting times, needed less transfused blood, switched to oral PPIs quicker, and experienced shorter hospital stays.
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11
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Masjedizadeh AR, Hajiani E, Alavinejad P, Hashemi SJ, Shayesteh AA, Jamshidian N. High Dose versus Low Dose Intravenous Pantoprazole in Bleeding Peptic Ulcer: A Randomized Clinical Trial. Middle East J Dig Dis 2014; 6:137-43. [PMID: 25093061 PMCID: PMC4119670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 06/11/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The appropriate dose of proton pump inhibitors for treatment of patients with upper (GI) bleeding remains controversial. This study compares high-dose versus low-dose intravenous proton pump inhibitor (PPI) infusion for prevention of GI bleeding complications. METHODS A total of 166 patients with bleeding peptic ulcers underwent therapeutic endoscopy using concomitant therapy by argon plasma coagulation (APC) and diluted epinephrine injection. Patients were randomly divided into two groups: high-dose pantoprazole (80 mg bolus, 8 mg per hour) and low-dose pantoprazole (40 mg bolus, 4 mg per hour) infused for three days. Initial outcomes were rebleeding, need for surgery, hemoglobin drop more than two units, and hospitalization for more than five days. Secondary outcome included mortality rate. RESULTS Overall, 166 patients (83 patients per group) enrolled in the study. The average age of patients in the high-dose group was 59.5±15.6 years and 52.3±13.3 years in the low-dose group (p=0.58). Males comprised 69.7% of patients. In the high-dose group, the mean number of units of transfused blood was 3.3±1.71 and in the low-dose group, it was 2.82±1.73 (p=0.50). There were 36 (43.37%) patients in the high-dose group and 40 (48.19%) in the low-dose group who were hospitalized for more than 5 days (p=0.53). Rebleeding was observed in 27 (32.53%) patients in the high-dose group and in 21 (25.30%) in the low-dose group (p=0.30). There were no significant differences observed in drop in hemoglobin of more than two units (p=0.15), mortality (p=0.99) and surgery (p=0.75) between the two groups. CONCLUSION For controlling peptic ulcer bleeding, there is no difference between high dose and low dose pantoprazole infusion.
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Affiliation(s)
- Abdol Rahim Masjedizadeh
- 1 Research Institute for Infectious Diseases of the Digestive System, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
,2 Division of Gastroenterology and Hepatology,Ahvaz Jundishapur University of Medical Sciences, Ahwaz, Iran
,Corresponding Author: Abdol Rahim Masjedizadeh, MD Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ahvaz Jundishapur University of Medical Sciences, Imam Hospital, P.O. Box 89, Ahvaz, Iran Tel: +98 611 3910643 Fax:+98 611 3910642
| | - Eskandar Hajiani
- 1 Research Institute for Infectious Diseases of the Digestive System, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
,2 Division of Gastroenterology and Hepatology,Ahvaz Jundishapur University of Medical Sciences, Ahwaz, Iran
| | - Pezhman Alavinejad
- 1 Research Institute for Infectious Diseases of the Digestive System, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
,2 Division of Gastroenterology and Hepatology,Ahvaz Jundishapur University of Medical Sciences, Ahwaz, Iran
| | - Seyed Jalal Hashemi
- 1 Research Institute for Infectious Diseases of the Digestive System, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
,2 Division of Gastroenterology and Hepatology,Ahvaz Jundishapur University of Medical Sciences, Ahwaz, Iran
| | - Ali Akbar Shayesteh
- 1 Research Institute for Infectious Diseases of the Digestive System, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
,2 Division of Gastroenterology and Hepatology,Ahvaz Jundishapur University of Medical Sciences, Ahwaz, Iran
| | - Noordin Jamshidian
- 3 Department of Internal Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahwaz, Iran
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Oh JH. Pharmacological Therapy of Peptic Ulcer. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2014. [DOI: 10.7704/kjhugr.2014.14.1.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Jung Hwan Oh
- Department of Internal Medicine, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea
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13
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Stressläsionen im oberen Gastrointestinaltrakt. Anaesthesist 2012; 61:647-56; quiz 657-8. [DOI: 10.1007/s00101-012-2048-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Chiu YC, Lu LS, Wu KL, Tam W, Hu ML, Tai WC, Chiu KW, Chuah SK. Comparison of argon plasma coagulation in management of upper gastrointestinal angiodysplasia and gastric antral vascular ectasia hemorrhage. BMC Gastroenterol 2012; 12:67. [PMID: 22681987 PMCID: PMC3439282 DOI: 10.1186/1471-230x-12-67] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 06/09/2012] [Indexed: 01/10/2023] Open
Abstract
Background Vascular ectasias, including gastric antral vascular ectasia (GAVE) and angiodysplasia, are increasingly recognized as important sources of gastrointestinal bleeding. This study investigated and compared the efficacies and outcomes of treatment of upper gastrointestinal (UGI) angiodysplasia and GAVE hemorrhage by endoscopic argon plasma coagulation (APC). Methods From January 2006 to December 2009, 46 patients diagnosed with upper GI bleeding caused by angiodysplasia or GAVE at a tertiary hospital were recruited into this study. They included 26 males and 20 females with an average age of 65.6 years (range, 45–90 years). All patients underwent APC for hemostasis during an endoscopic procedure. Parameters such as underlying co-morbidities, number of endoscopic treatment sessions, recurrent bleeding, and clinical outcomes during follow-up were analyzed. Results The 46 patients with UGI vascular ectasia hemorrhage included 27 patients with angiodysplasia and 19 with GAVE. The patients with angiodysplasia were older than those with GAVE (71.6 ± 10.2 years versus 61.8 ± 11.9 years, P = 0.005). More GAVE patients than angiodysplasia patients had co-existing liver cirrhosis (63.2% versus 25.9%, P = 0.012). The patients with GAVE had a higher rate of recurrent bleeding (78.9% versus 7.4%, P < 0.001) and required more treatment sessions to achieve complete hemostasis (2.4 ± 1.4 versus 1.1 ± 0.1, P < 0.001) than those with angiodysplasia. Univariate analysis demonstrated that age greater than 60 years (odds ratio (OR) = 8.929, P = 0.003), GAVE (OR = 0.021, P < 0.001), and previous radiation therapy (OR = 11.667, P = 0.032) were associated with higher rates of recurrent bleeding. Further multivariate analysis revealed that GAVE was the only independent risk factor for recurrent bleeding after APC treatment (OR = 0.027, P < 0.001). Conclusion Endoscopic hemostasis with APC is a safe treatment modality for both angiodysplasia and vascular ectasia bleeding. The efficacy of APC treatment is greater for angiodysplasia than for vascular ectasia bleeding. GAVE patients have a higher recurrent bleeding rate and may require multiple treatment sessions for sustained hemostasis.
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Affiliation(s)
- Yi-Chun Chiu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung City 833, Taiwan
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Seo KA, Lee SJ, Kim KB, Bae SK, Liu KH, Kim DH, Shin JG. Ilaprazole, a new proton pump inhibitor, is primarily metabolized to ilaprazole sulfone by CYP3A4 and 3A5. Expert Opin Ther Pat 2011. [PMID: 22022918 DOI: 10.1517/13543776.2013.741121] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Ilaprazole is a new proton pump inhibitor, designed for treatment of gastric ulcers, and developed by Il-Yang Pharmaceutical Co (Seoul, Korea). It is extensively metabolised to the major metabolite ilaprazole sulfone. In the present study, several in vitro approaches were used to identify the cytochrome P450 (CYP) enzymes responsible for ilaprazole sulfone formation. Concentrations of ilaprazole sulfone were determined by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Incubation of ilaprazole with cDNA-expressed recombinant CYPs indicated that CYP3A was the major enzyme that catalyses ilaprozole to ilaprazole sulfone. This reaction was inhibited significantly by ketoconazole, a CYP3A inhibitor, and azamulin, a mechanism-based inhibitor of CYP3A, while no substantial effect was observed using selective inhibitors for eight other P450s (CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, and CYP2E1). In addition, the formation of ilaprazole sulfone correlated well with CYP3A-catalysed testosterone 6β-hydroxylation and midazolam 1'-hydroxylation in 20 different human liver microsome panels. The intrinsic clearance of the formation of ilaprazole sulfone by CYP3A4 was 16-fold higher than that by CYP3A5. Collectively, these results indicate that the formation of the major metabolite of ilaprazole, ilaprazole sulfone, is predominantly catalysed by CYP3A4/5.
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Affiliation(s)
- Kyung-Ah Seo
- Department of Pharmacology and PharmacoGenomics Research Center, Inje University College of Medicine, Busan, Korea
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