Geographic differences in low-dose aspirin-associated gastroduodenal mucosal injury

Global burden and risk factors of gastritis and duodenitis: an observational trend study from 1990 to 2019

In recent years, there has been a global trend of aging, which has resulted in significant changes to the burden of gastritis and duodenitis (GD). Using the global burden of disease (GBD) database spanning 1990 to 2019, we evaluated the temporal trends of age-standardized incidence rates (ASIR), age-standardized death rates (ASDR), and age-standardized disability-adjusted life years (AS-DALYs) for GD using estimated annual percentage changes (EAPC). Additionally, we examined the burden of GD across various strata, including social demographic index (SDI), age, and sex. Finally, the risk factors linked to the incidence and mortality of GD, utilizing Pearson correlation analysis. In 2019, there were 31 million GD patients globally, a notable increase of 12 million from 1990, while the ASIR, ASDR, and AS-DALYs for GD all showed a decrease. Correlation analysis showed a significant negative relationship between ASIR and SDI. Factors like hand hygiene and vitamin A deficiency had significant positive correlations with ASIR and ASDR in 2019. Over the past thirty years, the burden of GD has increased alongside global population aging. Future efforts should focus on exploring prevention for GD, with special attention to the elderly population in low SDI regions.

Proton pump inhibitors and gastroprotection in patients treated with antithrombotic drugs: A cardiologic point of view

Aspirin, other antiplatelet agents, and anticoagulant drugs are used across a wide spectrum of cardiovascular and cerebrovascular diseases. A concomitant proton pump inhibitor (PPI) treatment is often prescribed in these patients, as gastrointestinal complications are relatively frequent. On the other hand, a potential increased risk of cardiovascular events has been suggested in patients treated with PPIs; in particular, it has been discussed whether these drugs may reduce the cardiovascular protection of clopidogrel, due to pharmacodynamic and pharmacokinetic interactions through hepatic metabolism. Previously, the concomitant use of clopidogrel and omeprazole or esomeprazole has been discouraged. In contrast, it remains less known whether PPI use may affect the clinical efficacy of ticagrelor and prasugrel, new P2Y12 receptor antagonists. Current guidelines recommend PPI use in combination with antiplatelet treatment in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids, or non-steroidal anti-inflammatory drugs, and Helicobacter pylori (H. pylori) infection. In patients taking oral anticoagulant with risk factors for gastrointestinal bleeding, PPIs could be recommended, even if their usefulness deserves further data. H. pylori infection should always be investigated and treated in patients with a history of peptic ulcer disease (with or without complication) treated with antithrombotic drugs. The present review summarizes the current knowledge regarding the widespread combined use of platelet inhibitors, anticoagulants, and PPIs, discussing consequent clinical implications.

Factors associated with gastro-duodenal ulcer in compensated type 2 diabetic patients: a Romanian single-center study

INTRODUCTION

Helicobacter pylori infection is accepted as the leading cause of chronic gastritis, ulcer disease and gastric cancer, with an important impact on health care burden, especially in countries with a high prevalence of infection. The aim of the study was to investigate the influence of H. pylori infection, medication, associated medical conditions or social habits on endoscopic ulcer occurrence in the compensated type 2 diabetic population.

MATERIAL AND METHODS

Two hundred and sixty type 2 diabetic patients investigated on endoscopy (57 patients with peptic ulcer and 203 controls) with a complete set of biopsies, demographic and medical data were enrolled.

RESULTS

On univariate regression analysis, H. pylori infection (42.1% vs. 35.5%, p = 0.359) or a history of peptic ulcer (61.4% vs. 61.6%, p = 0.981) was not a predictor for ulcer on endoscopy in the diabetic population, and heartburn was more frequent in diabetics without ulcer (21.2% vs. 8.8%, p = 0.033). Anemia was the best predictor for ulcer on endoscopy in both diabetics with (p < 0.001, OR = 4.77, 95% CI: 2.02-11.28) and without (p = 0.027, OR = 2.76, 95% CI: 1.10-6.91) chronic proton pump inhibitor (PPI) therapy. In diabetic patients on PPI more than 1 month anticoagulants - acenocoumarol or low-weight molecular heparin (p = 0.038, OR = 2.37, 95% CI: 1.04-5.40), low-dose aspirin 75-125 mg/day (p = 0.029, OR = 2.61, 95% CI: 1.08-6.28) and alcohol consumption (p = 0.015, OR = 2.70, 95% CI: 1.19-6.13) were predictors for ulcer on endoscopy.

CONCLUSIONS

In diabetic patients, anemia is the most important predictor for ulcer on endoscopy, but not H. pylori or digestive symptoms, while low-dose aspirin or anticoagulant therapy and alcohol consumption are the most important predictors for ulcer in diabetics on chronic proton pump inhibitor therapy.

Efficacy of Teprenone for Prevention of NSAID-Induced Gastrointestinal Injury: A Systematic Review and Meta-Analysis

Background: The study aimed to conduct a systematic review and meta-analysis comparing the efficacy of teprenone with control or other drugs for reducing the incidence of gastrointestinal (GI) adverse events in patients receiving long-term non-steroidal anti-inflammatory drugs (NSAIDs). Methods: Databases of PubMed, Embase, BioMed Central, CENTRAL, and Google Scholar were searched up to November 10th, 2020 for randomized controlled trials (RCTs) comparing teprenone with control or other drugs. A random-effects model was used for the meta-analysis. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was used for assessing the certainty of evidence. Results: Seven RCTs were included. Six compared teprenone with control and one with famotidine. Meta-analysis indicated a statistically significant reduced risk of GI ulcers in patients receiving teprenone as compared to control after 12 weeks/3months (RR 0.37 95% CI 0.17, 0.18 I ² = 0% p = 0.01). Pooled data of three open-label studies indicated statistically significant reduction of GI symptoms in patients on teprenone as compared to control at 6 months and 12 months, but not at 3 months. Comparing teprenone with control, our analysis indicated non-significant but a tendency of better reduction in Modified Lanza Score (MLS) with teprenone. The RCT comparing teprenone to famotidine demonstrated better reduction of MLS with famotidine. The certainty of evidence-based on GRADE was deemed to be low. Conclusion: Low-quality evidence indicates a beneficial role of teprenone in preventing GI injuries in patients receiving long-term NSAIDs. Further high-quality RCTs comparing teprenone with placebo as well as other gastroprotective drugs are needed to strengthen current evidence.

Clinical use of low-dose aspirin for elders and sensitive subjects

The use of low-dose aspirin (LDA) has been a common preventive measure to reduce the risk of cardiovascular events. This is attributed to aspirin’s ability to inhibit platelet activation. On the other hand, the use of LDA in human subjects has been associated with the development of gastrointestinal injuries like ulcer and bleeding, especially for those sensitive subjects such as elder human subjects. This opinion review will summarize the recent clinical reports regarding the use of LDA and the development of gastrointestinal conditions in China. Based on these reports, it seems that the use of LDA is commonly associated with gastrointestinal injuries, and stopping its use leads to recovery in elderly subjects. Therefore, we would like to suggest that gastroduodenal health and conditions should be seriously taken into consideration when LDA is recommended to the elderly, or other alternative means to reduce the risk of cardiovascular events such as nutritional interventions should be suggested.

The contribution of clinical and pathological predisposing factors to severe gastro-duodenal lesions in patients with long-term low-dose aspirin and proton pump inhibitor therapy

BACKGROUND

Preventive strategies developed to avoid the complications of antiplatelet therapies recommend the evaluation of risk factors for gastrointestinal events and indicated gastroprotective strategies.

AIM

We aimed to assess the impact of predisposing factors - histological findings, concomitant drug consumption, comorbidities, symptoms, social habits, Helicobacter pylori infection - on severe gastro-duodenal lesions in patients with low-dose aspirin and concomitant protective therapy with proton pump inhibitors (PPI).

METHOD

We enrolled 237 patients with LDA and PPI therapy, referred for upper digestive endoscopy, divided into two groups according to the severity of their endoscopic lesions (172 patients with no or mild endoscopic lesions and 65 patients with severe endoscopic lesions).

RESULTS

In the univariate logistic regression model, the factors associated with severe gastro-duodenal lesions were gender (OR=1.87, 95% CI: 1.04-3.41), anticoagulants (OR=2.40, 95% CI: 1.26-4.53), gastric atrophy and/or intestinal metaplasia (OR=1.85, 95% CI: 1.04-3.32), congestive heart failure (OR=2.59, 95% CI: 1.16-6.62), anaemia (OR=3.01, 95% CI: 1.67-5.47) and smoking (OR=4.29, 95% CI: 1.57-12.32). In the final model, anticoagulants (p=0.041<0.05) and anaemia (p=0.019<0.05) were risk factors for severe lesions via multivariate regression analysis, while for active/inactive chronic gastritis and smoking a positive dependency with a tendency towards statistical significance (p<0.10) was noticed for severe gastric lesions.

CONCLUSIONS

In patients treated with low-dose aspirin and gastroprotective therapy with proton pump inhibitors we have enough evidence to consider co-treatment with anticoagulants and anaemia important predictors for severe endoscopic lesions, while other factors such as inflammation in gastric biopsies, congestive heart failure, co-treatment with clopidogrel and smoking tended to have a positive influence on risk for severe gastro-duodenal lesions.

Clinical Risk Factors for Gastroduodenal Ulcer in Romanian Low-Dose Aspirin Consumers

Background. Aspirin use for cardiovascular or cancer prevention is limited due to its gastrointestinal side effects. Objective. Our prospective, observational case-control study aims to identify the predictive factors for ulcers in low-dose aspirin consumers (75-325 mg/day). Methods. The study included patients who underwent an upper digestive endoscopy and took low-dose aspirin treatment. Results. We recruited 51 patients with ulcer (ulcer group) and 108 patients with no mucosal lesions (control group). In univariate analysis, factors significantly associated with ulcers were male gender (p = 0.001), anticoagulants (p = 0.029), nonsteroidal anti-inflammatory drugs (p = 0.013), heart failure (p = 0.007), liver (p = 0.011) or cerebrovascular disease (p = 0.004), diabetes mellitus (p = 0.043), ulcer history (p = 0.044), and alcohol consumption (p = 0.018), but not Helicobacter pylori infection (p = 0.2). According to our multivariate regression analysis results, history of peptic ulcer (OR 3.07, 95% CI 1.06-8.86), cotreatment with NSAIDs (OR 8, 95% CI 2.09-30.58) or anticoagulants (OR 4.85, 95% CI 1.33-17.68), male gender (OR 5.2, 95% CI 1.77-15.34), and stroke (OR 7.27, 95% CI 1.40-37.74) remained predictors for ulcer on endoscopy. Conclusions. Concomitant use of NSAIDs or anticoagulants, comorbidities (cerebrovascular disease), and male gender are the most important independent risk factors for ulcer on endoscopy in low-dose aspirin consumers, in a population with a high prevalence of H. pylori infection.

Different Pathophysiology of Gastritis in East and West? A Western Perspective

Background

Gastritis results from multifactorial gastric mucosal injury. Helicobacter pylori (Hp) is the main cause, and associated diseases have typical underlying patterns of gastritis. Gastric ulcer and gastric cancer (GC) develop from chronic atrophic corpus gastritis (CAG) which therefore represents the most important pattern. GC incidences in East Asia are substantially higher than elsewhere, and this should be also reflected by higher prevalences of CAG and characteristic differences in pathophysiology compared to the West.

Summary

The few available comparative studies of gastritis in Eastern and Western patients are summarized. The main pathogenic factors of gastritis are discussed together with their limitations to explain local differences in disease outcome. Emphasis was put to also include less well-established pathogenic host and environmental factors of possible impact.

Conclusions

CAG is more prevalent in East Asian areas with high GC incidences than the West. Geographic heterogeneity of associated diseases is due to differences in Hp prevalence and virulence as well as modulating host and environmental factors. The following may contribute to the higher burden of CAG in the East: ABD type of CagA with vacA s1 and babA2 alleles of Hp, host Lewis(b) expression in sej/sej nonsecretors, H. heilmannii, low parietal cell mass, high sodium and nitrate intake, preferences in vegetable and fruit consumption, cigarette smoking, air pollution, alcohol. Conversely, green tea, nonfermented soy products and rice may confer protective effects. Hp is on the decline, but also in a world cleared from this bacterium, differences in host genetics will continue to modify gastric disease outcome together with maintained customs as part of cultural diversity.