Incidence of gastropathy in destructive arthropathies

Lack of Pharmacokinetic Interaction between Esomeprazole and the Nonsteroidal Anti-Inflammatory Drugs Naproxen and Rofecoxib in Healthy Subjects

BACKGROUND

We investigated the potential interactions between esomeprazole and a non-selective nonsteroidal anti-inflammatory drug (NSAID; naproxen) or a cyclo-oxygenase (COX)-2-selective NSAID (rofecoxib) in healthy subjects.

METHODS

Two studies of identical randomised, open, three-way crossover design were conducted. Subjects (n = 32 for both studies) were to receive 1 week's treatment with esomeprazole 40mg once daily (studies A and B), naproxen 250mg twice daily (study A), rofecoxib 12.5mg once daily (study B), and esomeprazole in combination with naproxen (study A) or rofecoxib (study B). Study periods were separated by a 2-week washout period.

RESULTS

On day 7 of dosing, the ratios (and 95% CIs) for the area under the plasma concentration-time curve during the dosing interval (AUC(tau)) and observed maximum plasma concentration (C(max)) of esomeprazole and NSAID combination/NSAID alone were 0.98 (0.94, 1.01) and 1.00 (0.97, 1.04), respectively, for study A, and 1.15 (1.06, 1.24) and 1.14 (1.02, 1.28), respectively, for study B. The ratios (and 95% CIs) for AUC(tau) and C(max) of esomeprazole and NSAID combination/esomeprazole alone were 0.96 (0.89, 1.03) and 0.92 (0.85, 1.00), respectively, for study A, and 1.05 (0.96, 1.15) and 1.05 (0.94, 1.18), respectively, for study B. All treatments were well tolerated during the study period.

CONCLUSION

Naproxen and rofecoxib do not interact with esomeprazole, and esomeprazole does not affect the pharmacokinetics of naproxen or rofecoxib. These findings indicate that esomeprazole can be used in combination with NSAIDs without the risk of a pharmacokinetic interaction.

Sucralfate therapy in NSAID bleeding gastropathy

BACKGROUND AND AIMS

A randomized, double-blind, placebo-controlled, multicenter study was conducted to assess the efficacy of 2 g sucralfate suspension in treating gastric mucosal lesions caused by long-term treatment with nonsteroidal anti-inflammatory drugs (NSAIDs).

METHODS

Only patients given NSAIDs continuously for at least 2 months with positive fecal occult blood (FOB) and endoscopically confirmed mild to moderate mucosal lesions (Lanza scale, grades 2-4) were included. After 1-week run-in phase, patients were stratified into 2 groups according to gastropathy-related symptoms during the preceding 7 days (symptomatic vs. asymptomatic) and randomized to 2 g (10 mL) of sucralfate suspension or placebo twice a day over a 6-week period. NSAIDs were given according to each patient's dosage schedule and always after meals.

RESULTS

Twenty-five patients received sucralfate and 25 received placebo. At the end of the study, 68% (17/25) of patients given sucralfate had no lesions (Lanza grade 0) on endoscopy compared with 35% (8/23) in controls (P = 0.042). The Lanza grades in patients given sucralfate were significantly improved compared with the placebo patients (P = 0.022).

CONCLUSIONS

In this target population selected according to positive FOB test and endoscopic evidence of mucosal injury, chronic administration of sucralfate significantly decreased NSAID-induced gastric erosions.

Gastro-duodenal protection in an era of cyclo-oxygenase-2-selective nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective and necessary for the relief of pain and inflammation in patients with arthritis. NSAIDs are however also associated with an increased risk for ulceration in the stomach and in the duodenum, and many NSAID users experience bothersome dyspeptic symptoms during continued NSAID therapy. PPIs like omeprazole, have been shown to heal and to prevent ulcers and dyspeptic symptoms during continued NSAID therapy, and during continued NSAID therapy the prostaglandin analogue, misoprostol, has been shown to reduce the risk for ulcer complications. The COX-2 selective NSAID, rofecoxib, is in comparison with naproxen, a non-selective NSAID, associated with fewer clinically important upper gastrointestinal events. The incidence of myocardial infarctions seems, however, to be lower with naproxen than with rofecoxib, and this is expected to lead to low-dose aspirin use in rofecoxib users at risk for cardiovascular events. Co-administration of the COX-2 selective NSAID, celecoxib, and low-dose aspirin, is associated with the same risk for upper gastrointestinal ulcer complications alone and combined with symptomatic ulcers, as the non-selective NSAIDs, ibuprofen and diclofenac. A proton pump inhibitor (PPI) should be used for healing of NSAID-associated ulcers, and a PPI or misoprostol should be considered for prevention of ulceration in non-selective NSAID users at risk for ulceration. The experience with COX-2 selective NSAIDs is still limited, and it remains to be studied whether subpopulations of COX-2 selective NSAID users will benefit from gastro-duodenal protection.

Can NSAID/ASA-induced erosions of the gastric mucosa be identified at histology?

Studies in animals have shown that NSAID/ASA-induced erosions have an ischaemic pathogenesis. We therefore studied the question of whether such erosions in human gastric biopsy material can be identified on the basis of the ischaemic necrosis. Histological sections prepared from forceps biopsy material obtained from 122 patients with erosions (at least three biopsy specimens from the erosion and two from antrum and corpus each) were classified by a pathologist blinded to the endoscopic findings and the medication used by the patients. NSAID/ASA erosions were diagnosed when a homogeneous eosinophilic ischaemic necrosis blending into the adjoining lamina propria presented. Helicobacter pylori (Hp)-induced erosions were diagnosed when, in the presence of Hp gastritis, erosive defects were covered with a non-homogeneous fibrinoid necrosis containing granulocytes and cell debris. Finally, the histological classification was compared with data on medication usage. The histological diagnosis was Hp-induced erosions in 59 patients, NSAID/ASA-induced erosions with no Hp gastritis in 23, and NSAID/ASA-induced erosions with concomitant Hp gastritis in 40. A comparison of this histological classification with the data provided by the referring physicians on patient medication revealed that 70% of the patients with histological diagnosis of NSAID/ASA-induced erosions in the absence of Hp gastritis, and 65% of those diagnosed to have NSAID/ASA-induced erosions and concomitant Hp gastritis, had been taking such drugs. Among the erosions diagnosed as H. pylori-induced, 81% of the patients were reported not to take such medication. The sensitivity of the diagnosis of NSAID/ASA-induced erosions was 72.9%, and specificity 79.6%. The results of the present study show that a high percentage of the NSAID/ASA-induced erosions of the gastric mucosa can indeed be correctly diagnosed at histology.

Omeprazole compared with misoprostol for ulcers associated with nonsteroidal antiinflammatory drugs. Omeprazole versus Misoprostol for NSAID-induced Ulcer Management (OMNIUM) Study Group

BACKGROUND

Misoprostol is effective for ulcers associated with the use of nonsteroidal antiinflammatory drugs (NSAIDs) but is often poorly tolerated because of diarrhea and abdominal pain. We compared the efficacy of omeprazole and misoprostol in healing and preventing ulcers associated with NSAIDs.

METHODS

In a double-blind study, we randomly assigned 935 patients who required continuous NSAID therapy and who had ulcers or more than 10 erosions in the stomach or duodenum (or both) to receive 20 mg or 40 mg of omeprazole orally in the morning or 200 microg of misoprostol orally four times daily. Patients were treated for four weeks or, in the absence of healing, eight weeks. Treatment success was defined as the absence of ulcers and the presence of fewer than five erosions at each site and not more than mild dyspepsia. We then randomly reassigned 732 patients in whom treatment was successful to maintenance therapy with 20 mg of omeprazole daily, 200 microg of misoprostol twice daily, or placebo for six months.

RESULTS

At eight weeks, treatment was successful in 76 percent of the patients given 20 mg of omeprazole (233 of 308), 75 percent of those given 40 mg of omeprazole (237 of 315), and 71 percent of those given misoprostol (212 of 298). The rates of gastric-ulcer healing were significantly higher with 20 mg of omeprazole (but not 40 mg of omeprazole) than with misoprostol. Healing rates among patients with duodenal ulcers were higher with either dose of omeprazole than with misoprostol, whereas healing rates among patients with erosions alone were higher with misoprostol. More patients remained in remission during maintenance treatment with omeprazole (61 percent) than with misoprostol (48 percent, P=0.001) and with either drug than with placebo (27 percent, P<0.001). There were more adverse events during the healing phase in the misoprostol group than in the groups given 20 mg and 40 mg of omeprazole (59 percent, 48 percent, and 46 percent, respectively).

CONCLUSIONS

The overall rates of successful treatment of ulcers, erosions, and symptoms associated with NSAIDs were similar for the two doses of omeprazole and misoprostol. Maintenance therapy with omeprazole was associated with a lower rate of relapse than misoprostol. Omeprazole was better tolerated than misoprostol.

Which peptic ulcers bleed? Results of a case-control study. DUSUK Study Group

BACKGROUND

The incidence of ulcer bleeding has not decrease despite effective medical treatment of peptic ulcer disease. Numerous studies have been performed on risk factors for ulcer bleeding, but only a few studies have related the risk of developing ulcer bleeding to the risk of developing uncomplicated ulcer disease.

METHODS

This study was performed as a multicenter interdisciplinary case-control study and was based on diagnosis by endoscopy, prospective data collection, and multivariate analysis. To every study patient with ulcer bleeding (case) one patient with uncomplicated peptic ulcer proven at endoscopy (control) was assigned with regard to sex, ulcer localization, and age (+/-5 years). The controls were randomly taken from three sources: inpatients, outpatients, and patients treated by a private physician.

RESULTS

Owing to strict inclusion and exclusion criteria, 209 matched pairs were available for evaluation out of 401 patients with peptic ulcer bleeding. In univariate analysis the duration of ulcer pain and the number of previous ulcer treatments proved to be protective factors for ulcer bleeding. The intake of non-steroidal anti-inflammatory drugs (NSAID) as a whole, acetylsalicylic acid (aspirin), and paracetamol gave an increased risk for ulcer bleeding. Multivariate analysis identified four risk factors for peptic ulcer bleeding: lung disease, NSAID intake, no pretreatment with H2 blockers, and acetylsalicylic acid intake.

CONCLUSIONS

The following patient groups represent a risk for peptic ulcer bleeding: multimorbid patients, receiving NSAID and/or aspirin, and patients with no previous ulcer history.

Prevention of peptic ulcer and dyspeptic symptoms with omeprazole in patients receiving continuous non-steroidal anti-inflammatory drug therapy. A Nordic multicentre study

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are known to cause gastroduodenal lesions and dyspeptic symptoms.

METHODS

Patients with a history of dyspepsia or uncomplicated peptic ulcer disease and with a need for continuous NSAID treatment were randomized to receive either 20 mg omeprazole once daily or placebo. Gastroduodenal ulcers, erosions, and dyspeptic symptoms were evaluated after 1 and 3 months.

RESULTS

During a 3-month study period 4.7% (4 of 85) of omeprazole-treated patients developed peptic ulcer, compared with 16.7% (15 of 90) of patients treated with placebo. This prophylactic effect of omeprazole was sustained independently of previous peptic ulcer history or Helicobacter pylori status. Development of dyspeptic symptoms requiring active treatment, either alone or in combination with ulcer(s) or erosions, occurred in 15.3% (15 of 85) of patients treated with omeprazole and 35.6% of those who received placebo.

CONCLUSIONS

Omeprazole, 20 mg once daily, provides effective prophylactic therapy in patients at risk of developing NSAID-associated peptic ulcers or dyspeptic symptoms.

Epidemiological and financial aspects of the use of non-steroidal anti-inflammatory analgesics

The availability of many new nonsteroidal anti-inflammatory drugs (NSAIDs) has increased the total consumption during the past 20 years. The cost of different NSAID brands varies considerably probably reflecting increased research and development costs rather than a true therapeutic benefit for the patient. The current therapeutic problem in the treatment of musculoskeletal conditions with NSAIDs is to make a balanced analysis between benefits, risks, and costs. Assessment of risks and benefits should focus on the large subgroup (about 40%) of elderly NSAID users over 60 years who clearly stand at increased risk of NSAID-induced gastrointestinal complications. In the treatment of osteoarthritis more trials are needed to compare NSAIDs with plain analgesics (e.g. paracetamol).

Medical history profile: orthopaedic physical therapy outpatients

The purpose of this study was to compile a medical history profile of an orthopaedic physical therapy outpatient population. Currently, there is no literature describing the medical history of this population. Seven-hundred and five patients, aged 18-84 years, completed a self-administrated questionnaire at the time of their physical therapy evaluation. Ten private practice clinics in the Minneapolis/St. Paul, MN area participated in the data collection. The patient information collected included: 1) current and past medical history; 2) family medical history; 3) caffeine and alcohol intake; 4) cigarette use; and 5) drug use including over-the-counter, prescriptive, and/or drugs of abuse. Medical history information collected during the initial examination could significantly impact the physical therapy evaluation process and interpretation of evaluation findings. In addition, aspects of the patient's medical history may affect the tolerance and outcome of seemingly appropriate treatment intervention. The data collected should assist the clinician in providing optimal patient care, private practices in developing in-service programs for their staff, and physical therapy schools in evaluating course content related to this topic.

Epidemiology and economics of NSAID-induced gastropathy

Nonsteroidal anti-inflammatory drug (NSAID) use and gastrointestinal (GI) injury and symptoms are associated in clinical practice, but the importance of this injury is debatable. Most rheumatologists and general practitioners view NSAIDs as extremely valuable and generally well-tolerated first-line agents in the treatment of arthritis and musculoskeletal disorders. Generally, gastroenterologists and surgeons, on the other hand, insist that NSAIDs are dangerous and potentially lethal irritants to the GI mucosa. More frequent NSAID-induced gastropathy may be related to general epidemiological trends in NSAID-using populations: longer life expectancy, multiple risk co-factors for peptic ulcer disease (ie, smoking, alcohol, diet, comedication), and the increased availability of endoscopic examinations. Based on endoscopic studies, the prevalence of NSAID-induced adverse GI events has been documented in published reports. The frequency of bleeding is related to dose and duration of NSAID therapy. Overall, the prevalence of ulcer complications is higher in patients who consume NSAIDs. Cost-benefit analyses indicate that preventing potential GI damage with agents such as misoprostol may reduce the expense of treating the GI side effects associated with NSAID therapy.