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Nguyen CM, Barletta JF, Devlin JW. Use of Acid Suppression Agents following Acute, Nonvariceal, Upper Gastrointestinal Bleeding. Hosp Pharm 2017. [DOI: 10.1177/001857870403901008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Cindy M. Nguyen
- Detroit Receiving Hospital, Department of Pharmacy Services, Detroit, MI
| | | | - John W. Devlin
- College of Pharmacy, Northeastern University, Boston, MA
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2
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Scarpignato C, Gatta L, Zullo A, Blandizzi C. Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression. BMC Med 2016; 14:179. [PMID: 27825371 PMCID: PMC5101793 DOI: 10.1186/s12916-016-0718-z] [Citation(s) in RCA: 247] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/14/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications. METHODS The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence. RESULTS Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile. CONCLUSIONS Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .
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Affiliation(s)
- Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy.
| | - Luigi Gatta
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy
- Gastroenterology & Endoscopy Unit, Versilia Hospital, Azienda USL Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Angelo Zullo
- Division of Gastroenterology & Digestive Endoscopy, Nuovo Regina Elena Hospital, Rome, Italy
| | - Corrado Blandizzi
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
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MacLaren R, Obritsch MD, Sherman DS, Jung R, Fish DN. Assessing Adherence to an Intravenous Pantoprazole Guideline. J Pharm Technol 2016. [DOI: 10.1177/875512250602200104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Robert MacLaren
- ROBERT MACLAREN PharmD, Assistant Professor, Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Health Sciences Center, Denver, CO
| | - Marilee D Obritsch
- MARILEE D OBRITSCH PharmD, Critical Care/Infectious Diseases Fellow, Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Health Sciences Center
| | - Deborah S Sherman
- DEBORAH S SHERMAN PharmD, Clinical Pharmacy Specialist, Critical Care, Department of Pharmacy, University of Colorado Hospital, Denver, CO
| | - Rose Jung
- ROSE JUNG PharmD BCPS, Assistant Professor, Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Health Sciences Center
| | - Douglas N Fish
- DOUGLAS N FISH PharmD BCPS FCCM, Associate Professor, Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Health Sciences Center
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4
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Inhibition of lysosomal enzyme activities by proton pump inhibitors. J Gastroenterol 2013; 48:1343-52. [PMID: 23478938 DOI: 10.1007/s00535-013-0774-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 01/26/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are pro-drugs requiring an acidic pH for activation. The specificity of PPI toward the proton pump is mainly due to the extremely low pH at the parietal cell canalicular membrane where the pump is located. Reactivity of PPIs was also observed in moderately acidic environments like the renal collecting duct. But no PPI effect on lysosomal enzymes has been observed possibly because the previous studies were performed with liver tissue, where PPIs are metabolized. METHODS The reactivity of PPIs (omeprazole, lansoprazole and pantoprazole) with a cysteine-containing peptide was analyzed by mass spectrometry, and the impact of PPIs on lysosomal enzymes was evaluated in cultured cells and mice. The effect of PPIs on the immune system was examined with a mouse tumor immunotherapy model. RESULTS Incubation of a cysteine-containing peptide with PPIs at pH5 led to the conversion of most of the peptide into PPI-peptide adducts. Dose dependent inhibition of lysosomal enzyme activities by PPIs was observed in cultured cells and mouse spleen. Further, PPI counteracted the tumor immunotherapy in a mouse model. CONCLUSIONS Our data support the hypothesis that many of the PPI adverse effects are caused by systematically compromised immunity, a result of PPI inhibition of the lysosomal enzymes. This novel mechanism complements the existing mechanisms in explaining the increased incidence of tumorigenesis and infectious diseases among PPI users and underlie the ongoing concern about the overuse of PPIs in adult and pediatric populations.
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Lu Y, Sverdén E, Ljung R, Söderlund C, Lagergren J. Use of non-steroidal anti-inflammatory drugs and proton pump inhibitors in correlation with incidence, recurrence and death of peptic ulcer bleeding: an ecological study. BMJ Open 2013; 3:bmjopen-2012-002056. [PMID: 23293249 PMCID: PMC3549209 DOI: 10.1136/bmjopen-2012-002056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) and proton pump inhibitors (PPIs) are regarded as two types of drugs that respectively increase and decrease the risk of peptic ulcer bleeding. However, their relation to occurrence, recurrence and death of bleeding in the population level is not clear. STUDY OBJECTIVE To clarify recent calendar-time correlations between sales of NSAIDs and PPIs and the occurrence of peptic ulcer bleeding, re-bleeding and death. DESIGN Ecological study. RESULTS The time trend of peptic ulcer bleeding did not correlate with PPI sales but did correlate with NSAIDs in mem (R(male)=0.6571, P(male)=0.05). Sales of PPIs (inverse) and NSAIDs correlated with re-bleeding in women (R(male)=-0.8754, P(male)=0.002 and R(female)=0.7161, P(female)=0.03, respectively), but not in men. An inverse correlation between PPI sales and 30-day death after bleeding was found (R(male)=-0.9392, P(male)=0.0002 and R(female)=-0.8561, P(female)=0.003), and NSAID sales were found to correlate with increased death after bleeding ((R(male)=0.7278, P(male)=0.03, R(female)=0.7858, P(female)=0.01). CONCLUSIONS The sales of NSAIDs and PPIs correlate with recurrence of peptic ulcer bleeding in women and death after peptic ulcer bleeding in both genders in the population level.
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Affiliation(s)
- Yunxia Lu
- Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Emma Sverdén
- Section of Upper Gastrointestinal Surgery, Department of Surgery, South General Hospital, Stockholm, Sweden
| | - Rickard Ljung
- Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Centre for Epidemiology, The National Board of Health and Welfare, Stockholm, Sweden
| | - Claes Söderlund
- Section of Upper Gastrointestinal Surgery, Department of Surgery, South General Hospital, Stockholm, Sweden
| | - Jesper Lagergren
- Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- King's College London, London, UK
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6
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Primer consenso español sobre el tratamiento de la hemorragia digestiva por úlcera péptica. Med Clin (Barc) 2010; 135:608-16. [DOI: 10.1016/j.medcli.2010.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 07/09/2010] [Accepted: 07/13/2010] [Indexed: 01/26/2023]
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7
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Prevalencia de nueva hemorragia por úlcera péptica en pacientes tratados con inhibidores de la bomba de protones por vía intravenosa. Med Clin (Barc) 2010; 134:577-82. [DOI: 10.1016/j.medcli.2009.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 11/12/2009] [Accepted: 11/12/2009] [Indexed: 11/18/2022]
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The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc 2010; 71:663-8. [PMID: 20363407 DOI: 10.1016/j.gie.2009.11.026] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 11/13/2009] [Indexed: 12/13/2022]
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Laine L, McQuaid KR. Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clin Gastroenterol Hepatol 2009; 7:33-47; quiz 1-2. [PMID: 18986845 DOI: 10.1016/j.cgh.2008.08.016] [Citation(s) in RCA: 212] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Revised: 08/06/2008] [Accepted: 08/08/2008] [Indexed: 02/07/2023]
Abstract
The aim of this study was to determine appropriate endoscopic treatment of patients with bleeding ulcers by synthesizing results of randomized controlled trials. We performed dual independent bibliographic database searches to identify randomized trials of thermal therapy, injection therapy, or clips for bleeding ulcers with active bleeding, visible vessels, or clots, focusing on results from studies without second-look endoscopy and re-treatment. The primary end point was further (persistent plus recurrent) bleeding. Compared with epinephrine, further bleeding was reduced significantly by other monotherapies (relative risk [RR], 0.58 [95% CI, 0.36-0.93]; number-needed-to-treat [NNT], 9 [95% CI, 5-53]), and epinephrine followed by another modality (RR, 0.34 [95% CI, 0.23-0.50]; NNT, 5 [95% CI, 5-7]); epinephrine was not significantly less effective in studies with second-look and re-treatment. Compared with no endoscopic therapy, further bleeding was reduced by thermal contact (heater probe, bipolar electrocoagulation) (RR, 0.44 [95% CI, 0.36-0.54]; NNT, 4 [95% CI, 3-5]) and sclerosant therapy (RR, 0.56 [95% CI, 0.38-0.83]; NNT, 5 [95% CI, 4-13]). Clips were more effective than epinephrine (RR, 0.22 [95% CI, 0.09-0.55]; NNT, 5 [95% CI, 4-9]), but not different than other therapies, although the latter studies were heterogeneous, showing better and worse results for clips. Endoscopic therapy was effective for active bleeding (RR, 0.29 [95% CI, 0.20-0.43]; NNT, 2 [95% CI, 2-2]) and a nonbleeding visible vessel (RR, 0.49; [95% CI, 0.40-0.59]; NNT, 5 [95% CI, 4-6]), but not for a clot. Bolus followed by continuous-infusion proton pump inhibitor after endoscopic therapy significantly improved outcome compared with placebo/no therapy (RR, 0.40 [95% CI, 0.28-0.59]; NNT, 12 [95% CI, 10-18]), but not compared with histamine(2)-receptor antagonists. Thermal devices, sclerosants, clips, and thrombin/fibrin glue appear to be effective endoscopic hemostatic therapies. Epinephrine should not be used alone. Endoscopic therapy should be performed for ulcers with active bleeding and nonbleeding visible vessels, but efficacy is uncertain for clots. Bolus followed by continuous-infusion intravenous proton pump inhibitor should be used after endoscopic therapy.
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Affiliation(s)
- Loren Laine
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Law JK, Andrews CN, Enns R. Intravenous proton pump inhibition utilization and prescribing patterns escalation: a comparison between early and current trends in use. Gastrointest Endosc 2009; 69:3-9. [PMID: 18718583 DOI: 10.1016/j.gie.2008.04.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Accepted: 04/19/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Approved indications of intravenous (i.v.) proton pump inhibition (PPI) are limited to treatment of reflux esophagitis in patients unable to tolerate oral medications and for patients with pathologic hypersecretory states. OBJECTIVES i.v. PPIs are commonly used after endoscopic evaluation of patients with high-risk endoscopic stigmata (HRES) of nonvariceal upper GI bleeding (NVUGIB). There appears to have been an expansion of indications of this drug at many centers. DESIGN All consecutive patients receiving i.v. PPI (pantoprazole) between 2 study periods, (1) when pantoprazole was restricted to the gastroenterology service and (2) when it was unrestricted, were reviewed. SETTING Tertiary care university hospital. PATIENTS All receiving i.v. PPI. INTERVENTIONS i.v. PPI utilization. MAIN OUTCOME MEASUREMENTS Percentage of patients receiving i.v. PPI for indications other than bleeding during 2 time periods. RESULTS In the early period, 217 patients (67.30% male) received i.v. PPI on 218 occasions compared with 516 patients (65.31% male, P= .61) in the later period on 613 occasions. In the early group, 93.12% of 217 patients received i.v. PPI for NVUGIB compared with 56.12% of 516 patients (P< .0001) with 18% of patients receiving i.v. PPI for nothing by mouth status and 13% for abdominal pain in the later group. A total of 153 (70.18%) patients in the early group underwent upper endoscopy compared with only 275 (44.86%) patients in the later group; 84 of these 153 patients (54.90%) were already on i.v. PPI at the time of endoscopy in the early group compared with 253 (92.00%, P< .0001). CONCLUSIONS i.v. PPI use has escalated at our hospital and is being prescribed in patients before endoscopy with fewer patients noted to have HRES on endoscopy.
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Affiliation(s)
- Joanna K Law
- Division of Gastroenterology, Department of Medicine, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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11
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Tsoi KKF, Lau JYW, Sung JJY. Cost-effectiveness analysis of high-dose omeprazole infusion before endoscopy for patients with upper-GI bleeding. Gastrointest Endosc 2008; 67:1056-63. [PMID: 18407271 DOI: 10.1016/j.gie.2007.11.056] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Accepted: 11/29/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND The use of intravenous (i.v.) proton pump inhibitors (PPI) before an endoscopy in upper-GI bleeding (UGIB) was shown to reduce the need of endoscopic therapy and shorten hospital stay. OBJECTIVE To investigate whether preemptive use of a PPI in UGIB is a cost-effective strategy. DESIGN A decision analysis model that represents treatment pathways for patients with UGIB was constructed and structuralized by 30-day outcomes. Direct costs of medical treatment, diagnostic and therapeutic endoscopy, endoscopic re-treatment, surgery, and hospitalization were analyzed. SETTING Prince of Wales Hospital, Hong Kong. PATIENTS A total of 631 patients were recruited. Sixty patients (19.1%) in the PPI group and 90 patients (28.4%) in the placebo group required endoscopic hemostasis at index endoscopy. MAIN OUTCOME MEASUREMENTS The primary measurements were cost-effectiveness ratios and incremental cost-effectiveness ratios (ICER) to avert endoscopic therapy between PPI and placebo treatment. Sensitivity analyses were conducted by varying the cost of endoscopy, hospitalization, the incidence rate of endoscopic therapy, and the proportion of bleeding peptic ulcers. RESULTS The overall direct cost per patient was U.S. dollars (USD) $2813 for PPI treatment and USD $2948 for the placebo. A PPI reduced endoscopic therapy by 7.4% and resulted in a lower cost-effectiveness ratio per endoscopic therapy averted (USD $3561) than the placebo (USD $4117). The ICER value was USD -$1843, which indicated that preemptive PPI treatment is more effective and less costly for UGIB. When the proportions of patients with peptic ulcer bleeding were greater than 8.3%, the preemptive PPI treatment remained cost saving. CONCLUSIONS Preemptive use of IV PPI before an endoscopy is a cost-effective strategy in the management of UGIB.
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Affiliation(s)
- Kelvin K F Tsoi
- Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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Shin JM, Vagin O, Munson K, Kidd M, Modlin IM, Sachs G. Molecular mechanisms in therapy of acid-related diseases. Cell Mol Life Sci 2008; 65:264-81. [PMID: 17928953 PMCID: PMC3081136 DOI: 10.1007/s00018-007-7249-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Inhibition of gastric acid secretion is the mainstay of the treatment of gastroesophageal reflux disease and peptic ulceration; therapies to inhibit acid are among the best-selling drugs worldwide. Highly effective agents targeting the histamine H2 receptor were first identified in the 1970s. These were followed by the development of irreversible inhibitors of the parietal cell hydrogen-potassium ATPase (the proton pump inhibitors) that inhibit acid secretion much more effectively. Reviewed here are the chemistry, biological targets and pharmacology of these drugs, with reference to their current and evolving clinical utilities. Future directions in the development of acid inhibitory drugs include modifications of current agents and the emergence of a novel class of agents, the acid pump antagonists.
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Affiliation(s)
- J. M. Shin
- Department of Physiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California USA
- VA Greater Los Angeles Healthcare System, West LA Medical Center, 11301 Wilshire Boulevard, Building 113, Los Angeles, California 90073 USA
| | - O. Vagin
- Department of Physiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California USA
- VA Greater Los Angeles Healthcare System, West LA Medical Center, 11301 Wilshire Boulevard, Building 113, Los Angeles, California 90073 USA
| | - K. Munson
- Department of Physiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California USA
- VA Greater Los Angeles Healthcare System, West LA Medical Center, 11301 Wilshire Boulevard, Building 113, Los Angeles, California 90073 USA
| | - M. Kidd
- Department of Surgery, Yale University School of Medicine, TMP202, 333 Cedar Street, New Haven Connecticut, 06520-8062 USA
| | - I. M. Modlin
- Department of Surgery, Yale University School of Medicine, TMP202, 333 Cedar Street, New Haven Connecticut, 06520-8062 USA
| | - G. Sachs
- Department of Physiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California USA
- VA Greater Los Angeles Healthcare System, West LA Medical Center, 11301 Wilshire Boulevard, Building 113, Los Angeles, California 90073 USA
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Chen VK, Wong RCK. Endoscopic Doppler ultrasound versus endoscopic stigmata-directed management of acute peptic ulcer hemorrhage: a multimodel cost analysis. Dig Dis Sci 2007; 52:149-60. [PMID: 17109216 DOI: 10.1007/s10620-006-9506-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 06/28/2006] [Indexed: 01/29/2023]
Abstract
Recurrent bleeding from acute peptic ulcer hemorrhage is problematic. Studies have shown that Doppler ultrasound (DOP-US) is useful in decreasing rebleeding. We analyzed associated costs and outcomes to better define the role of DOP-US versus Conventional (Forrest classification endoscopic stigmata) in the management of acute peptic ulcer bleeding. Two separate decision analyses were constructed. Recurrent bleeding, failed esophagogastroduodenoscopy (EGD) hemostasis, complications, and surgery rates were derived from medical literature. Costs were based on Medicare data. DOP-US is preferred over Conventional in acute peptic ulcer bleeding with average cost savings per patient ranging from 853 dollars (decision-tree modeling) to 1,160 dollars (Monte Carlo simulation). High-dose intravenous proton-pump inhibitors lowered rates of recurrent bleeding for both Conventional and DOP-US, resulting in a lower but still persistent average cost savings per patient for DOP-US (decision-tree modeling = 328 dollars, Monte Carlo simulation = 560 dollars). This decision analyses identified DOP-US as the preferred cost-minimizing strategy in acute peptic ulcer hemorrhage. Results of cost analyses were most dependent on hospitalization costs and recurrent bleeding rates.
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Affiliation(s)
- Victor K Chen
- Division of Gastroenterology, Department of Medicine, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, Ohio 44106-5066, USA
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14
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Ye BD, Cheon JH, Choi KD, Kim SG, Kim JS, Jung HC, Song IS. Omeprazole may be superior to famotidine in the management of iatrogenic ulcer after endoscopic mucosal resection: a prospective randomized controlled trial. Aliment Pharmacol Ther 2006; 24:837-43. [PMID: 16918888 DOI: 10.1111/j.1365-2036.2006.03050.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acid suppressing agents are widely used to treat the iatrogenic ulcers following endoscopic mucosal resection for gastric neoplasms. However, the relative merits of proton pump inhibitor or histamine(2)-receptor antagonist for endoscopic mucosal resection-induced ulcers are not known. AIM To prospectively compare omeprazole and famotidine for the healing of endoscopic mucosal resection-induced ulcers and for bleeding control. METHODS After endoscopic mucosal resection, patients were randomly assigned to omeprazole (20 mg/day) or to famotidine (40 mg/day) group for a 28-day treatment period. The ulcer sizes and stages, bleeding rates and ulcer-related symptoms were compared. RESULTS A total of 100 patients were randomized equally to each group. Forty-one patients in each group were finally compared. The two groups were comparable in terms of baseline characteristics. Twenty-eight days after treatment, the two groups were not different with respect to ulcer stage (P = 0.137) or ulcer reduction ratio (P = 0.380). No difference was observed with respect to ulcer-related symptoms (P = 0.437) and no bleeding episode occurred in any of the 82 patients. In subgroup that underwent endoscopic submucosal dissection, fewer patients in the omeprazole group showed active ulcers than those in the famotidine group (P = 0.035). CONCLUSION Our results demonstrate that omeprazole may be superior to famotidine for iatrogenic ulcers following endoscopic mucosal resection, especially for large ulcers.
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Affiliation(s)
- B D Ye
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Chongno-gu, Seoul, Korea
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15
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Jensen DM, Pace SC, Soffer E, Comer GM. Continuous infusion of pantoprazole versus ranitidine for prevention of ulcer rebleeding: a U.S. multicenter randomized, double-blind study. Am J Gastroenterol 2006; 101:1991-9; quiz 2170. [PMID: 16968504 DOI: 10.1111/j.1572-0241.2006.00773.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES No North American randomized study has compared ulcer rebleeding rates after endoscopic hemostasis in high-risk patients treated with high-dose intravenous (IV) proton pump inhibitors (PPIs) or IV histamine-2 receptor antagonists. Our hypothesis was that ulcer rebleeding with IV pantoprazole (PAN) would be lower than with IV ranitidine (RAN). METHODS This was a multicenter, randomized, double-blind, U.S. study. Patients with bleeding peptic ulcers and major stigmata of hemorrhage had endoscopic hemostasis with thermal probes with or without epinephrine injection, then were randomly assigned to IV PAN 80 mg plus 8 mg/h or IV RAN 50 mg plus 6.25 mg/h for 72 h, and subsequently had an oral PPI (1/day). Patients with signs of rebleeding had repeat endoscopy. Rebleeding rates up to 30 days were compared in an intention-to-treat analysis. RESULTS The study was stopped early because of slow enrollment (total N = 149, PAN 72, RAN 77). Demographics, APACHE II scores, ulcer type/location, stigmata, and hemostasis used were similar. The 7- and 30-day rebleeding rate was 6.9% (5 of 72 patients) with PAN and 14.3% (11 of 77) for RAN (p= 0.19). Rebleeds occurred within 72 h in 56% and between 4 and 7 days in 44% of patients. The 30-day mortality rate was 4%. Nonbleeding severe adverse events were more common in the RAN than in the PAN group (14 [18.1%]vs 7 [9.7%], p= 0.16). CONCLUSIONS Because of the small sample size of this study, there was an arithmetic but not significant difference in ulcer rebleeding rates.
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Affiliation(s)
- Dennis M Jensen
- David Geffen School of Medicine at UCLA and CURE Digestive Diseases Research Center, Los Angeles, California 90073, USA
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16
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Gisbert JP. Tratamiento farmacológico de la hemorragia digestiva por úlcera péptica. Med Clin (Barc) 2006; 127:66-75. [PMID: 16801006 DOI: 10.1157/13089992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, 28669 Boadilla del Monte, Madrid, Spain.
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Abstract
Acid suppression therapy with proton pump inhibitors is associated with well-established benefits in the management of gastro-oesophageal reflux (GERD) and other acid-related disorders. However, a number of issues still remain unsettled. Despite their clinical efficacy, when given once daily, currently available proton pump inhibitors may not adequately control intragastric acidity during the night in a significant proportion of both healthy subjects and GERD patients, in whom symptom relief remains suboptimal. Although some novel proton pump inhibitors have been synthesized, only few reached clinical testing. Amongst them, tenatoprazole represents a true advance displaying a long half-life (five to seven times longer than that of currently available drugs) and extended acid suppression covering both day and night. All the available clinical studies suggest both pharmacokinetic and pharmacodynamic advantages of tenatoprazole over esomeprazole. As this last compound provides - amongst the members of the class - the most effective control of intragastric pH whatever the parameter considered, it is conceivable that tenatoprazole could similarly be better than the other existing proton pump inhibitors. Tenatoprazole appears to be a promising proton pump inhibitor for the treatment of acid-related diseases, where it has the potential to address unmet clinical needs.
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Affiliation(s)
- C Scarpignato
- Laboratory of Clinical Pharmacology, Department of Anatomy, Pharmacology & Forensic Sciences, School of Medicine & Dentistry, University of Parma, Parma, Italy.
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Saran MK, Loewen PS, Zed PJ. Opportunities for Optimizing Pantoprazole Therapy in Patients with Acute Upper Gastrointestinal Bleeding. Hosp Pharm 2006. [DOI: 10.1310/hpj4104-354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To evaluate the appropriateness of intravenous (IV) pantoprazole in subjects presenting with signs suspicious of acute gastrointestinal bleeding (AGIB) and to identify opportunities for optimizing its use. Methods Retrospective health record review of subjects receiving IV pantoprazole for suspected or confirmed AGIB was conducted at two affiliated teaching hospitals. Results Of the 175 subjects enrolled, 157 (90%) received a diagnostic endoscopy. The median time to endoscopy was 18.5 hours, and the median time to start pantoprazole was 6.9 hours. Thirty-seven subjects (21%) did not receive the appropriate pantoprazole dose of 80 mg bolus followed by 8 mg/h infusion, and 22 high-risk subjects (33%) received less than 60 hours of IV pantoprazole. The median duration of pantoprazole following endoscopy for low-risk subjects was 21.1 hours. Conclusion Opportunities to optimize the use of IV pantoprazole include initiating therapy quickly at the appropriate dosing regimen, continuing the infusion for 72 hours in patients with high-risk bleeds, and discontinuing the infusion promptly once a high-risk AGIB is ruled out.
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Affiliation(s)
- Mandeep K. Saran
- Clinical Pharmacist, Pharmaceutical Sciences Clinical Service Unit, Vancouver Coastal Health Authority, Vancouver, BC, Canada
| | - Peter S. Loewen
- Pharmacotherapeutic Specialist, Pharmaceutical Sciences Clinical Service Unit, Vancouver Coastal Health Authority, and Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Peter J. Zed
- Pharmaceutical Sciences Clinical Service Unit, Vancouver Coastal Health Authority, Faculty of Pharmaceutical Sciences, University of British Columbia, and Division of Emergency Medicine, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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19
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Zargar SA, Javid G, Khan BA, Yattoo GN, Shah AH, Gulzar GM, Sodhi JS, Mujeeb SA, Khan MA, Shah NA, Shafi HM. Pantoprazole infusion as adjuvant therapy to endoscopic treatment in patients with peptic ulcer bleeding: prospective randomized controlled trial. J Gastroenterol Hepatol 2006; 21:716-21. [PMID: 16677158 DOI: 10.1111/j.1440-1746.2006.04292.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND AIM Following successful endoscopic therapy in patients with peptic ulcer bleeding, rebleeding occurs in 20% of patients. Rebleeding remains the most important determinant of poor prognosis. We investigated whether or not administration of pantoprazole infusion would improve the outcome in ulcer bleeding following successful endoscopic therapy. METHODS In this double-blind, placebo-controlled, prospective trial, patients who had gastric or duodenal ulcers with active bleeding or non-bleeding visible vessel received combined endoscopy therapy with injection of epinephrine and heater probe application. Patients who achieved hemostasis were randomly assigned to receive pantoprazole (80 mg intravenous bolus followed by an infusion at a rate of 8 mg per hour) or placebo for 72 h. The primary end-point was the rate of rebleeding. RESULTS Rebleeding was lower in the pantoprazole group (8 of 102 patients, 7.8%) than in the placebo group (20 of 101 patients, 19.8%; P = 0.01). Patients in the pantoprazole group required significantly fewer transfusions (1 +/- 2.5 vs 2 +/- 3.3; P = 0.003) and days of hospitalization (5.6 +/- 5.3 vs 7.7 +/- 7.3; P = 0.0003). Rescue therapies were needed more frequently in the placebo group (7.8% vs 19.8%; P = 0.01). Three (2.9%) patients in the pantoprazole group and eight (7.9%) in the placebo group required surgery to control their bleeding (P = 0.12). Two patients in the pantoprazole group and four in the placebo group died (P = 0.45). CONCLUSION In patients with bleeding peptic ulcers, the use of high dose pantoprazole infusion following successful endoscopic therapy is effective in reducing rebleeding, transfusion requirements and hospital stay.
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Affiliation(s)
- Showkat Ali Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India.
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20
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Abstract
Acid inhibition is safe and useful in several clinical settings. Proton pump inhibitors are more effective than H2-receptor antagonists in virtually all cases. Proton pump inhibitors should be used in: the eradication of Helicobacter pylori; the treatment of non-H. pylori-related peptic ulcer healing; for the prevention and treatment of non-steroidal anti-inflammatory drug-induced upper digestive lesions; for bleeding peptic lesions; and, especially, in the short-term and long-term control of gastro-oesophageal reflux disease. The timing, the dosing and the specific drugs should be adapted to the particular patient, clinical situation and local factors. For instance, in a patient with active bleeding from a duodenal ulcer, intravenous constant infusion should be the preferred treatment. When seeking oral 'potent' acid inhibition (refractory gastro-oesophageal reflux disease, and perhaps Barrett's oesophagus), available data suggest that the pharmacological and clinical profiles of esomeprazole are slightly better.
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Affiliation(s)
- Fernando Gomollón
- Facultad de Medicina, Gastroenterology Service, Clinical University Hospital, Zaragoza, Spain.
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21
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Abstract
Proton-pump inhibitors have been highly effective in managing acid-related gastrointestinal disorders, but challenges remain. This paper reviews the challenges in the management of patients with gastro-oesophageal symptoms who do not respond adequately to proton-pump inhibitor therapy; the treatment of patients with non-variceal upper gastrointestinal bleeding; the prevention of stress-related mucosal bleeding; the treatment and prevention of non-steroidal anti-inflammatory drug-related gastrointestinal injury; and the optimal combination of antisecretory and antibiotic therapy for the eradication of Helicobacter pylori infection, all of which represent unmet clinical needs. Antisecretory therapy with a rapid onset of action and sustained antisecretory effect may help to address some of the unmet needs discussed, especially in the management of gastro-oesophageal reflux disease, non-variceal upper gastrointestinal bleeding and non-steroidal anti-inflammatory drug-related gastrointestinal complications.
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Affiliation(s)
- R H Hunt
- Division of Gastroenterology, McMaster University Health Science Centre, Hamilton, ON, Canada.
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22
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Ferguson CB, Mitchell RM. Nonvariceal upper gastrointestinal bleeding: standard and new treatment. Gastroenterol Clin North Am 2005; 34:607-21. [PMID: 16303573 DOI: 10.1016/j.gtc.2005.08.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nonvariceal upper gastrointestinal bleeding remains a challenging problem with a significant morbidity and mortality. In recent years endoscopic techniques have evolved, resulting in improved primary hemostasis and a reduction in the risk of rebleeding. Combination endoscopic therapy followed by high-dose proton pump inhibitor shows improved outcomes. Innovative endoscopic therapies hold promise but are as yet unproved. An aging population with significant medical comorbidities has a major influence on the overall outcome from upper gastrointestinal bleeding.
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Affiliation(s)
- Charles B Ferguson
- Department of Gastroenterology, Belfast City Hospital, Belfast, Northern Ireland
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23
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Kaplan GG, Bates D, McDonald D, Panaccione R, Romagnuolo J. Inappropriate use of intravenous pantoprazole: extent of the problem and successful solutions. Clin Gastroenterol Hepatol 2005; 3:1207-14. [PMID: 16361046 DOI: 10.1016/s1542-3565(05)00757-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Indications for intravenous proton pump inhibitors (IV PPI) include upper gastrointestinal bleeding (UGIB) from peptic ulcer disease with high-risk stigmata and patients receiving nothing by mouth (NPO). The objectives were to assess the extent of errors in indications for IV PPI use and to determine whether multidisciplinary interventions could improve IV PPI use and costs. METHODS Part 1: Patients prescribed IV PPI during a period of 4 months were divided into 2 settings, UGIB or non-UGIB. The setting-specific appropriateness of the IV PPI indication and dosing regimen was determined. Part 2: Patients prescribed IV PPI before and after multidisciplinary interventions (educating physicians, a computerized dose template, pharmacists altering IV PPI orders in non-UGIB patients who were not NPO, and recommending a GI consult when a continuous infusion was ordered) were studied. Incidence of prescribing errors, IV PPI costs, and potential confounders were compared. RESULTS Part 1: Only 50% of UGIB (n = 145) patients received IV PPI for an appropriate indication. Both indication and dosing regimen were appropriate in 21%. In the non-UGIB group (n = 95), 33% were truly NPO; 51% had a correct dosing frequency. Part 2: The postintervention (n = 105) group (vs the preintervention group, n = 113) showed a significant absolute reduction in the degree of inappropriate indication in the UGIB (26%; 95% confidence interval [CI], 10%-42%; P < .0001) and in the non-UGIB (41%; 95% CI, 24%-58%; P < .0001) subgroups. However, a greater improvement in underspending than overspending meant that overall costs were unchanged. CONCLUSIONS IV PPI was frequently prescribed inappropriately and incorrectly; simple maneuvers resulted in reductions in errors.
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Affiliation(s)
- Gilaad G Kaplan
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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24
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Hunt RH, Armstrong D, James C, Chowdhury SK, Yuan Y, Fiorentini P, Taccoen A, Cohen P. Effect on intragastric pH of a PPI with a prolonged plasma half-life: comparison between tenatoprazole and esomeprazole on the duration of acid suppression in healthy male volunteers. Am J Gastroenterol 2005; 100:1949-56. [PMID: 16128938 DOI: 10.1111/j.1572-0241.2005.41956.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare the inhibitory effect of a novel proton pump inhibitor (PPI), tenatoprazole 40 mg once daily, with esomeprazole 40 mg once daily on intragastric acidity. METHODS A randomized, investigator-blind, two-way, crossover study was conducted in 30 healthy Helicobacter pylori negative male volunteers. Tenatoprazole 40 mg or esomeprazole 40 mg was administered once daily for 7 consecutive days with a 4-wk washout period between treatments. Ambulatory 24-h intragastric pH was recorded at baseline, after 7 days' treatment, and 3 and 5 days after treatment was stopped. RESULTS At presumed steady-state (day 7), median 24-h pH values were 5.02 and 4.79 for tenatoprazole and esomeprazole, respectively. There was a significant difference between tenatoprazole and esomeprazole during the nocturnal period when mean pH was 4.64 +/- 0.67 versus 3.61 +/- 0.90, respectively (p < 0.0001), as well as a significantly higher mean percentage of time with pH >4 on tenatoprazole (72.5 +/- 14.9 vs 62.2 +/- 13.6, p < 0.0001). The effect of tenatoprazole was still present 5 days after treatment withdrawal especially during the night-time. The mean area under the plasma concentration-time curve and elimination half-time was significantly higher in the tenatoprazole group as compared with the esomeprazole group. CONCLUSION Tenatoprazole 40 mg daily provides a prolonged duration of acid suppression and a shorter nocturnal acid breakthrough in healthy volunteers, even after stopping the drug. Thus, tenatoprazole may provide greater clinical efficacy for patients in whom a once daily PPI is ineffective. Further studies are indicated.
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Affiliation(s)
- Richard H Hunt
- Division of Gastroenterology, McMaster University Medical Centre, Hamilton, Ontario, Canada
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25
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Skledar SJ, Culley CM. Collaboratively Designed Practice Guidelines Promote Appropriate Use of Intravenous Proton Pump Inhibitors. Hosp Pharm 2005. [DOI: 10.1177/001857870504000606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To determine the effectiveness of practice guidelines for proton pump inhibitor use at an academic medical center. Methods Patients initiated on intravenous (IV) pantoprazole therapy between July 2001 and May 2002 were evaluated prospectively for appropriateness of therapy. Pharmacists assessed clinical use, dosing strategy, administration route, and prescribing patterns. Results A total of 85 patients were evaluated. Only 25% of the patients were prescribed IV pantoprazole according to established institutional guidelines. The majority of therapy meeting guideline criteria were initiated on pantoprazole by the Gastroenterology service. Due to overuse of pantoprazole, prescribing guidelines were revised to specify indications with proven efficacy (erosive GERD, Zollinger-Ellison or other hypersecretory conditions, and upper gastrointestinal bleeding). Patients who received pantoprazole for stress ulcer prophylaxis, an unapproved indication, had therapy automatically switched to a histamine receptor antagonist. For patients who tolerated oral medications or enteral feedings, therapy was automatically converted to the oral dosage form. Conclusions Evaluation of institutional pantoprazole utilization revealed usage extending beyond indications with proven efficacy. Pharmacists and physicians collaboratively developed evidence-based practice guidelines; adherence to appropriate indications showed a 50% improvement.
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Affiliation(s)
- Susan J. Skledar
- Drug Use and Disease State Management Program, University of Pittsburgh Medical Center, University of Pittsburgh School of Pharmacy
| | - Colleen M. Culley
- Drug Use and Disease State Management Program, University of Pittsburgh Medical Center, University of Pittsburgh School of Pharmacy, Department of Pharmacy and Therapeutics, University of Pittsburgh Medical Center, 302 Scaife Hall, 200 Lothrop Street, Pittsburgh, PA 15213
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26
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Kamada T, Hata J, Kusunoki H, Kido S, Hamada H, Aoki R, Nishida T, Komoto K, Todo H, Sumioka M, Tanimoto T, Sanuki E, Sumii K, Ogoshi H, Hidaka T, Dongmei Q, Chayama K, Haruma K. Effect of famotidine on recurrent bleeding after successful endoscopic treatment of bleeding peptic ulcer. Aliment Pharmacol Ther 2005; 21 Suppl 2:73-8. [PMID: 15943851 DOI: 10.1111/j.1365-2036.2005.02478.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM We investigated the effect of acid suppression therapy on recurrent bleeding after successful endoscopic treatment of bleeding peptic ulcer. METHODS A total of 400 patients with bleeding peptic ulcer received either intravenous infusion of famotidine (40 mg/day) (n = 207, 163 males, 44 females, mean age 61.5 years) or drip infusion of omeprazole (40 mg/day; n = 193, 134 males, 59 females, mean age 59.8 years) after successful endoscopic treatment. The fasting duration, hospital stay, volume of transfused blood, incidence of rebleeding and mortality were compared between the two groups. RESULTS The incidence of rebleeding did not differ significantly between the famotidine group (9%) and the omeprazole group (8%). The mean hospital stay was significantly shorter in the omeprazole group (18.4 days) than in the famotidine group (21.5 days, P = 0.009). However, there was no statistically significant difference in fasting duration, volume of transfused blood or mortality. CONCLUSION Our findings indicate that intravenous infusion of famotidine after successful endoscopic treatment is equivalent to drip infusion of omeprazole for prevention of recurrent bleeding.
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Affiliation(s)
- T Kamada
- Division of Gastroenterology, Department of Internal Medicine, Kawasaki Medical School, Matsushima, Kurashiki, Japan.
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27
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Avgerinos A, Sgouros S, Viazis N, Vlachogiannakos J, Papaxoinis K, Bergele C, Sklavos P, Raptis SA. Somatostatin inhibits gastric acid secretion more effectively than pantoprazole in patients with peptic ulcer bleeding: a prospective, randomized, placebo-controlled trial. Scand J Gastroenterol 2005; 40:515-22. [PMID: 16036503 DOI: 10.1080/00365520510015458] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Gastric acid inhibition is beneficial in the management of peptic ulcer bleeding (PUB). The aim of this double-blind study was to test whether somatostatin (SST) increases intragastric pH in PUB as compared with pantoprazole (PAN) and placebo (PLA). MATERIAL AND METHODS Eligible patients were randomized to receive SST (500 microg/h+250 microg bolus), or PAN (8 mg/h+80 mg bolus) or PLA (normal saline) i.v., for 24 h. All patients underwent gastric pH monitoring during the infusion of the trial drugs. RESULTS The three groups (SST, n=14; PAN, n=14; PLA, n=15) were comparable for age, gender, aetiology of PUB and laboratory data at admission. Mean (+/-SE) baseline pH levels in the fundus increased during the administration of the trial drugs (SST: 1.94+/-0.18 to 6.13+/-0.37, p<0.0001; PAN: 1.93+/-0.16 to 5.65+/-0.37, p<0.0001; PLA: 1.86+/-0.12 to 2.10+/-0.15, p=0.0917). During the first 12 h of infusion, the mean (+/-SE) percentage time spent above pH 4.0 and 5.4 was higher with SST versus PAN (84.4%+/-4.8 versus 55.1%+/-8.3, p=0.0049 and 74.2%+/-6.5 versus 47.1%+/-8.3, p=0.0163, respectively) and there was a trend favouring the SST group regarding the time spent above pH 6.0 and 6.8 (65.7%+/-6.4 versus 43.3%+/-8.2, p=0.0669 and 49.2%+/-7.7 versus 28.4+/-6.6, p=0.0738, respectively). CONCLUSIONS In PUB, both SST and PAN inhibit gastric acid secretion as compared with placebo. However, during the first 12 h of the infusion, SST was more effective than PAN in maintaining high intragastric pH. These results may provide a rationale for the administration of SST in PUB.
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Affiliation(s)
- Alec Avgerinos
- Second Department of Gastroenterology, Evangelismos Hospital, Athens, Greece
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28
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Bardou M, Toubouti Y, Benhaberou-Brun D, Rahme E, Barkun AN. Meta-analysis: proton-pump inhibition in high-risk patients with acute peptic ulcer bleeding. Aliment Pharmacol Ther 2005; 21:677-86. [PMID: 15771753 DOI: 10.1111/j.1365-2036.2005.02391.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Recent data suggest that profound acid suppression may improve outcomes of patients in peptic ulcer bleeding. AIM To better characterize the role of different pharmacological therapies in this population. METHODS MEDLINE was used to identify randomized trials (01/1990-04/2003) that assessed the efficacy of pharmacological treatments for patients with bleeding peptic ulcers exhibiting high-risk stigmata (Forrest Ia-IIb). Three groups of treatment were assessed: proton-pump inhibitors given as high-dose bolus followed by intravenous constant infusion (40-80 mg and at least 6 mg/h), high-dose oral proton-pump inhibitors (at least twice the standard dosage), non-high-dose proton-pump inhibitors (other proton-pump inhibitors dosing schedules). Mixed-effect models were used to determine rate differences between treatment and control groups. RESULTS Eighteen studies (1855 patients) were included. High-dose intravenous proton-pump inhibitors significantly reduced rebleeding (-14.6%), surgery (-5.4%) and mortality (-2.7%) compared with placebo, and rebleeding (-20.6%) compared with H(2)RA. Compared with placebo, high-dose oral proton-pump inhibitors significantly reduced only rebleeding (-11.8%), while non-high-dose proton-pump inhibitor treatment significantly improved all three outcomes. CONCLUSIONS High-dose intravenous proton-pump inhibitor significantly decreases ulcer rebleeding, surgery and mortality. Early data on high-dose oral proton-pump inhibitor suggest improved rebleeding. The non-high-dose proton-pump inhibitor regimens, including a broad range of dosing, also improved outcomes, suggesting that doses inferior to those in the high-dose intravenous proton-pump inhibitor may be effective.
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Affiliation(s)
- M Bardou
- Division of Gastroenterology, the McGill University Health Centre, Montreal General Hospital Site, Montréal, Québec H3G 1A4, Canada.
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29
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Khuroo MS, Khuroo MS, Farahat KLC, Kagevi IE. Treatment with proton pump inhibitors in acute non-variceal upper gastrointestinal bleeding: a meta-analysis. J Gastroenterol Hepatol 2005; 20:11-25. [PMID: 15610441 DOI: 10.1111/j.1440-1746.2004.03441.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Medical therapy is an attractive adjuvant to endoscopic treatment in upper gastrointestinal (UGI) bleeding. This review aims to assess the treatment effects of proton pump inhibitor (PPI) therapy in acute non-variceal UGI bleeding. Outcome measures evaluated were further bleeding, surgery, all-cause deaths, ulcer deaths and non-ulcer deaths. We searched MEDLINE (1966-2002) and EMBASE (1974-2002) using the terms 'gastrointestinal hemorrhage', 'peptic ulcer hemorrhage', 'proton pump inhibitor', 'omeprazole', 'pantoprazole', 'lansoprazole', 'rabeprazole' and 'esomeprazole'. The search was extended to the Cochrane controlled trials registry database, published abstracts from five international gastroenterology conferences, manufacturers of PPI, known contacts and bibliographies from each full-length published report. We included trials published in English and non-English languages. Eligible studies were randomized controlled trials that compared the treatment effects of PPI therapy with placebo or H2 receptor antagonists in patients with acute non-variceal UGI bleeding. Of the 175 articles screened, 26 controlled trials including 4670 subjects (2317 in treatment arm and 2353 in control arm) were analyzed. The methodology, population, intervention, and outcomes of each selected trial were evaluated using duplicate independent review. Disagreements were resolved by consensus. PPI therapy significantly reduced rates of further bleeding (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.40-0.57) and surgery (OR, 0.61; 95% CI, 0.48-0.76). All-cause deaths were unaffected (OR, 1.02; 95% CI, 0.76-1.37). Ulcer deaths showed a significant reduction (OR, 0.58; 95% CI, 0.35-0.96), while non-ulcer deaths showed a significant increase (OR, 1.60; 95% CI, 1.06-2.41) in the PPI therapy group. Sensitivity analysis of 22 trials published in peer-reviewed journals, 10 trials with double-blind design and 19 trials with high quality score and 22 trials using omeprazole in the treatment group showed results similar to those seen in the analysis of all 26 trials, confirming the stability of the conclusions. Subgroup analysis revealed that summary outcome measures were not influenced by control group therapy (placebo vs H2 receptor antagonists) or the use of prior endoscopic treatment to achieve hemostasis (given vs not given). However, the summary treatment effects for further bleeding and need for surgery were significant in only those trials enrolling patients with peptic ulcers having high risk for rebleeding and not in those trials enrolling patients with all causes of UGI bleeding. The summary treatment effects for further bleeding and need for surgery were significant in trials using intravenous as well as oral PPI. However, summary OR for all-cause deaths and non-ulcer deaths in trials using intravenous PPI were higher in the treatment group and not in trials using oral PPI. This raised the possibility of intravenous PPI-therapy-associated non-ulcer deaths in high-risk patients. PPI therapy in acute non-variceal UGI bleeding reduced rates of further bleeding, surgery and deaths caused by ulcer complications. However, non-ulcer deaths were increased. The overall mortality was unaffected. PPI therapy is useful only in a selected group of patients with acute non-variceal UGI bleeding, namely those with peptic ulcers having endoscopic high-risk stigmata for rebleeding.
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Affiliation(s)
- Mohammed S Khuroo
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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30
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Andriulli A, Annese V, Caruso N, Pilotto A, Accadia L, Niro AG, Quitadamo M, Merla A, Fiorella S, Leandro G. Proton-pump inhibitors and outcome of endoscopic hemostasis in bleeding peptic ulcers: a series of meta-analyses. Am J Gastroenterol 2005; 100:207-19. [PMID: 15654802 DOI: 10.1111/j.1572-0241.2005.40636.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To perform meta-analyses of studies on outcome of bleeding ulcers of different proton-pump inhibitors (PPIs) regimens, after stratification of patients by endoscopic stigmata, and analysis of studies with and without endotherapy. METHODS A total of 35 randomized trials comparing PPIs to placebo and/or H2-receptor antagonists (H2RAs) in 4,843 patients with high-risk endoscopic stigmata were retrieved. Outcomes were rebleeding, surgery, and mortality. RESULTS Monotherapy with oral or bolus PPIs was superior to placebo and H2RAs in reducing rebleeding in both bleeders and nonbleeders at index endoscopy; the need for surgery was reduced only when compared to H2RAs. In nonbleeders, PPI monotherapy was as effective as a combination of endotherapy with H2RAs. A combination of endotherapy with PPIs was superior to monotherapy in reducing bleeding and surgery, and superior to endotherapy alone in minimizing rebleeding, but not surgery; the benefit was lost when confronted to endotherapy plus H2RAs, whether PPIs were given as infusion or bolus. By pooling data from studies comparing high doses of PPIs as continuous infusion versus regular doses as intermittent bolus, rebleeding, surgery, and mortality were not significantly different. CONCLUSIONS Combination of endotherapy with either PPIs or H2RAs is indicated for nonbleeding ulcers at endoscopy with the intent to reduce rebleeding and surgery. Its value may extend to bleeding lesions, but current data are scanty. The benefit appears to be independent from route and doses of PPIs, as oral, bolus, or infusional methods are all effective.
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Affiliation(s)
- A Andriulli
- Divisions of Gastroenterology and Geriatrics, Casa Sollievo della Sofferenza Hospital, IRCCS, San Giovanni Rotondo, Italy
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31
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Mana F, Van Laer W, Van Laere W, Bossuyt A, Urbain D. The early effect of proton pump inhibitor therapy on the accuracy of the 13C-urea breath test. Dig Liver Dis 2005; 37:28-32. [PMID: 15702856 DOI: 10.1016/j.dld.2004.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The intake of proton pump inhibitors may interfere with the reliability of the urea breath test. AIM Prospective study to assess the accuracy of the urea breath test during the first days of therapy with proton pump inhibitors. PATIENTS Thirty patients who needed to start proton pump inhibitors therapy and 53 volunteers. METHODS A 13C-urea breath test was performed respectively before starting proton pump inhibitors therapy and every morning before its intake up until 10 days. The test was considered positive for values of 13CO2 > or = 3.0% delta over baseline. The coefficient of reproducibility for 95% interval of confidence of the urea breath test was calculated in both groups. RESULTS Of the 30 patients receiving proton pump inhibitors, 47% were positive for Helicobacter pylori. Among these, 43% developed false negative breath tests in the first 10 days. False positive results occurred in 37.5% of H. pylori-negative subjects in the first 10 days. The coefficient of reproducibility of the urea breath test was significantly higher in the group treated with proton pump inhibitors (11.0 versus 1.8 for the control group, p < 0.0001). CONCLUSION The intake of proton pump inhibitors impairs the accuracy of the 13C-urea breath test. False negative and false positive 13C-urea breath tests are common, occur as soon as after 1 day and increase with prolonged duration of treatment. The coefficient of reproducibility of the test in patients receiving proton pump inhibitors is not acceptable for clinical purpose and the test should not be performed once the medication has been started.
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Affiliation(s)
- F Mana
- Department of Gastroenterology, Free University of Brussels, Academisch Ziekenhuis, Laarbeeklaan 101, B-1090 Brussels, Belgium.
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Barkun AN, Herba K, Adam V, Kennedy W, Fallone CA, Bardou M. The cost-effectiveness of high-dose oral proton pump inhibition after endoscopy in the acute treatment of peptic ulcer bleeding. Aliment Pharmacol Ther 2004; 20:195-202. [PMID: 15233700 DOI: 10.1111/j.1365-2036.2004.02035.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND Recent data suggest a role for high-dose oral proton pump inhibition in ulcer bleeding. AIM To compare the cost-effectiveness of oral high-dose proton pump inhibition to both high-dose intravenous proton pump inhibition and placebo administration. METHODS The model adopted a 30-day time horizon, and focused on patients with ulcer haemorrhage initially treated endoscopically for high-risk stigmata. Re-bleeding rates were set a priori based on non-head-to-head data from the literature, and charges and lengths of stay from a national American database. Sensitivity analyses were carried across a broad range of clinically relevant assumptions. RESULTS Re-bleeding rates for patients receiving intravenous, oral, or placebo therapies were 5.9%, 11.8%, and 27%, respectively. The mean lengths of stay and costs for admitted patients with and without re-bleeding were 4.7 and 3 days; $11,802, and $7993, respectively. High-dose intravenous proton pump inhibition was more effective and less costly (dominant) than high-dose oral proton pump inhibition with incremental savings of $136.40 per patient treated. The oral high-dose strategy in turn dominated placebo administration. Results remained robust according to one- and two-way sensitivity analyses. CONCLUSION In patients undergoing endoscopic haemostasis, subsequent high-dose intravenous proton pump inhibition is more cost-effective than high-dose oral proton pump inhibition, which in turn dominates placebo. The results from this exploratory-type cost analysis require confirmation by head-to-head prospective trials performed in Western populations.
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Affiliation(s)
- A N Barkun
- Division of Gastroenterology, McGill University Health Centre, Montreal General Hospital Site, Quebec, Canada.
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Barkun A, Sabbah S, Enns R, Armstrong D, Gregor J, Fedorak RNN, Rahme E, Toubouti Y, Martel M, Chiba N, Fallone CA. The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): Endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting. Am J Gastroenterol 2004; 99:1238-46. [PMID: 15233660 DOI: 10.1111/j.1572-0241.2004.30272.x] [Citation(s) in RCA: 241] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES From the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), we determined clinical outcomes and explored the roles of endoscopic and pharmacologic therapies in a contemporary real-life setting. METHODS Analysis of randomly selected patients endoscoped for nonvariceal upper gastrointestinal bleeding at 18 community and tertiary care institutions between 1999 and 2002. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression models identified predictors of outcomes. RESULTS One thousand eight-hundred and sixty-nine patients were included (66 +/- 17 yr, 38% female, 2.5 +/- 1.6 comorbid conditions, hemoglobin, 96 +/- 27 g/L, 54% received a mean of 2.9 +/- 1.7 units of blood). Endoscopy was performed within 24 h in 76%, with ulcers (55%) most commonly noted. High-risk endoscopic stigmata and endoscopic therapy were reported in 37%. Rebleeding, surgery, and mortality rates were 14.1%, 6.5%, and 5.4%, respectively. Decreased rebleeding was significantly and independently associated with PPI use (85% of patients, mean daily dose 56 +/- 53 mg) in all patients regardless of endoscopic stigmata, (odds ratio (OR):0.53, 95% confidence interval, 95% CI:0.37-0.77) and endoscopic hemostasis in patients with high-risk stigmata (OR:0.39, 95% CI:0.25-0.61). PPI use (OR:0.18, 95% CI:0.04-0.80) and endoscopic therapy (OR:0.31, 95% CI:0.11-0.91) were also each independently associated with decreased mortality in patients with high-risk stigmata. CONCLUSIONS These results appear to confirm the protective role of endoscopic therapy in patients with high-risk stigmata, and suggest that acute use of PPIs may be associated with a reduction of rebleeding in all patients, and lower mortality in patients with high-risk stigmata. Independent prospective validation of these observational findings is now required.
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Affiliation(s)
- Alan Barkun
- Department of Medicine, Division of Gastroenterology, McGill University, Montreal, Canada
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Barkun AN, Herba K, Adam V, Kennedy W, Fallone CA, Bardou M. High-dose intravenous proton pump inhibition following endoscopic therapy in the acute management of patients with bleeding peptic ulcers in the USA and Canada: a cost-effectiveness analysis. Aliment Pharmacol Ther 2004; 19:591-600. [PMID: 14987328 DOI: 10.1046/j.1365-2036.2004.01808.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The efficacy of high-dose intravenous proton pump inhibition has recently been shown, yet its cost-effectiveness remains poorly studied. AIM To assess the cost-effectiveness of this approach separately for American and Canadian health care settings. METHODS A validated decision model included patients with bleeding ulcers after successful endoscopic haemostasis. Probabilities were determined from the literature, and charges and lengths of stay from national databases. A third-party payer perspective was adopted over a 30-day time horizon. RESULTS Re-bleeding rates were 5.9% for patients who received high-dose intravenous proton pump inhibition and 22.9% for those who did not. Hospitalization costs for patients with and without re-bleeding were 11,802 US dollars and 7993 US dollars, and 5220 Canadian dollars and 2696 Canadian dollars, respectively. High-dose intravenous proton pump inhibition was more effective and less costly than the alternative of not administering it. The cost-effectiveness ratios for high-dose and no high-dose intravenous proton pump inhibition were 9112 US dollars and 11,819 US dollars (3293 dollars and 4284 dollars for the Canadian case), respectively. Sensitivity and threshold analyses showed that the results were robust across a wide range of clinically relevant assumptions. CONCLUSION In the USA and Canada, administering high-dose intravenous proton pump inhibition for 3 days is both more effective and less costly than not doing so for patients with bleeding ulcers after successful endoscopic haemostasis.
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Affiliation(s)
- A N Barkun
- Division of Gastroenterology, McGill University, Montréal, Québec, Canada.
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Hirota K, Kushikata T. Preanaesthetic H2 antagonists for acid aspiration pneumonia prophylaxis. Is there evidence of tolerance? Br J Anaesth 2003; 90:576-9. [PMID: 12697583 DOI: 10.1093/bja/aeg065] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Enns RA, Gagnon YM, Rioux KP, Levy AR. Cost-effectiveness in Canada of intravenous proton pump inhibitors for all patients presenting with acute upper gastrointestinal bleeding. Aliment Pharmacol Ther 2003; 17:225-33. [PMID: 12534407 DOI: 10.1046/j.1365-2036.2003.01412.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The administration of proton pump inhibitors intravenously after endoscopic treatment of peptic ulcers significantly reduces the recurrence of bleeding. AIM To evaluate the incremental cost-effectiveness in Canada of intravenous proton pump inhibitor before endoscopic therapy to patients presenting with acute upper gastrointestinal bleeding, compared with endoscopic treatment alone. METHODS From a third-party payer perspective, we modelled the costs and effectiveness over 60 days of the two approaches using decision analysis. The probabilities of various outcomes, such as re-bleeding and the need for surgery, were taken from the published literature. We included the costs of intravenous proton pump inhibitor, therapeutic endoscopy, surgical procedures and hospitalizations, all expressed in 2001 Canadian dollars. RESULTS In a hypothetical cohort of 1000 patients, the intravenous proton pump inhibitor approach resulted in mean savings of 20,700 Canadian dollars with 37 re-bleeding episodes averted. The investigation of uncertainty resulted in a likelihood of intravenous proton pump inhibitor being cost-effective of at least 0.73. CONCLUSION It is common in Canada to administer intravenous proton pump inhibitors to patients with upper gastrointestinal bleeding even before endoscopic confirmation of bleeding peptic ulcers. Our results suggest that this approach has a high likelihood of being cost-effective.
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Affiliation(s)
- R A Enns
- Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
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