25 Years of Proton Pump Inhibitors: A Comprehensive Review

Trends in Proton Pump Inhibitor Use in Sweden by Sex and Age: A Drug Utilisation Study

BACKGROUND

Proton pump inhibitors (PPIs) are among the most popular drugs worldwide. Yet, there are concerns on long-term safety and poor adherence to prescription guidelines. Off-label use in children and increasing maintenance use in older adults may be particularly worrisome.

OBJECTIVES

To assess differences in PPI use by age, sex calendar year and PPI type, and to explore potential underlying indications (ulcerogenic drugs, and indications) in Sweden.

METHODS

Proton pump inhibitor drug utilisation study based on the Swedish nationwide prescribed drug (2006-2023) and patient registries (2006-2022).

RESULTS

Proton pump inhibitors were used by 14.4% (women) and 10.5% (men) of adults; and 1.0-1.5% of children and adolescents (aged < 20 years). Proton pump inhibitor use was higher in women in all age-groups except small children (aged < 5 years). Proton pump inhibitor use has increased in all age groups, especially in young children (aged < 10 years) and the oldest groups (aged > 65 years). Proton pump inhibitor users aged > 85 years filled most prescriptions with an annual average of 9.5 (men), 11.6 (women) prescriptions. Most prescriptions were for omeprazole and esomeprazole: 63.7% and 23.5% in adults; 23.5% and 44.7% in children (2023). Prescriptions for other drugs for peptic ulcers/reflux became rare, with 99% of prescriptions in this category being PPIs by 2023. Gastro-intestinal diagnoses were predominantly recorded in men, became less prevalent and only explained part of PPI use, while ulcerogenic drugs were common (particularly in women), suggesting PPIs are regularly used for gastroprotection.

CONCLUSION

Proton pump inhibitor use has doubled in children and increased 50% in adults over the study period, in both sexes, while recorded gastrointestinal indications decreased. Alternative therapies were rarely prescribed in Sweden.

Effects of warning information at medication initiation on deprescribing intentions in older adults: A hypothetical vignette

OBJECTIVES

To explore to what degree providing patients warning information about the long-term risks of a medication would affect their subsequent desire to discontinue it.

METHODS

We conducted a vignette-based online experiment in which participants aged ≥ 65 years from the United States were asked to imagine starting and subsequently stopping omeprazole. Participants were randomized to one of four vignettes about starting omeprazole (potential long-term harms or no harm information; OTC vs. prescription). Participants reported interest in stopping omeprazole on a 6-point Likert scale. We calculated descriptive statistics and used logistic regression to compare participants with high (scores 4-6) versus low agreement (scores 1-3) with stopping.

RESULTS

Participants (n = 1245) had a median age of 70 years. After adjusting for demographic characteristics, older adults who received warning information when starting the medication were more likely to agree to stop omeprazole (OR 1.21, 95 % C.I. 1.02, 1.43). Willingness to stop omeprazole was higher among women (vs. men), among respondents with higher literacy, and among those who had never or previously used PPIs (vs current use).

CONCLUSION

Warning information about potential long-term risks when initiating a medication may increase the likelihood of subsequently stopping a medication when recommended by a PCP.

A multicenter retrospective study evaluating the effect of proton pump inhibitors on adjuvant tegafur-uracil/leucovorin efficacy for stage II-III colorectal cancer

We hypothesized that there is reduced efficacy of fluorinated pyrimidines, such as capecitabine, caused by low active folic acid levels induced by vitamin B12 deficiency, due to proton pump inhibitors (PPIs), and that this can be recovered by the administration of leucovorin (LV). Thus, we retrospectively analyzed the effects of PPIs on adjuvant tegafur-uracil (UFT) plus LV for stage II/III colorectal cancer (CRC). Patients newly diagnosed with stage II/III CRC who underwent curative surgery and received adjuvant UFT/LV therapy between January 2013 and June 2018 were included. The primary endpoint was the difference in relapse-free survival (RFS) between the PPI and non-PPI groups. Data from 396 eligible patients were evaluated, 84 of whom received PPIs. There were 93 relapse events and 57 deaths across the groups. RFS rates at 5 years were 73.8% (95% confidence interval [CI], 62.9-81.9%) and 77.1% (95% CI, 72.0-81.4%) in the PPI and non-PPI groups, respectively. Cox regression analysis showed no significant differences in RFS between the PPI and non-PPI groups (hazard ratio, 1.16; 95% CI, 0.72-1.87; P = 0.539). Our findings suggest that the concomitant use of PPIs does not significantly reduce the efficacy of adjuvant UFT/LV treatment for patients with stage II/III CRC.

Unlocking the potential of Radix Astragali and its active ingredients in gastric ulcer therapy

We studied the protective effects of Radix Astragali (RA) on gastric ulcer (GU). A literature search was conducted using databases from Web of Science, PubMed, Springer, ScienceDirect, Science Direct Chinese National Knowledge Infrastructure (CNKI), and Wanfang. The inclusion criteria for this study were limited to reports on the effects of RA, AS-IV, cycloastragenol, astragalus polysaccharide (APS), and astragalosides (AST) in the treatment of gastric ulcers. Any studies involving gastric lesions that were precancerous or cancerous were eliminated. The search period was from database inception through June 2024. The results suggested RA hold promiseas potential novel therapeutics for the therapy of GU.

Leveraging Omeprazole PBPK/PD Modeling to Inform Drug-Drug Interactions and Specific Recommendations for Pediatric Labeling

Background/Objectives: Omeprazole is widely used for managing gastrointestinal disorders like GERD, ulcers, and H. pylori infections. However, its use in pediatrics presents challenges due to drug interactions (DDIs), metabolic variability, and safety concerns. Omeprazole's pharmacokinetics (PK), primarily influenced by CYP2C19 metabolism, is affected by ontogenetic changes in enzyme expression, complicating dosing in children. Methods: This study aimed to develop and validate a physiologically based pharmacokinetic (PBPK) model for omeprazole and its metabolites to predict age-related variations in metabolism and response. Results: The PBPK model successfully predicted exposure to parent and metabolites in adults and pediatrics, incorporating competitive and mechanism-based inhibition of CYP2C19 and CYP3A4 by omeprazole and its metabolites. By accounting for age-dependent metabolic pathways, the model enabled priori predictions of omeprazole exposure in different age groups. Linking PK to the pharmacodynamics (PD) model, we described the impact of age-related physiological changes on intragastric pH, the primary outcome for proton pump inhibitors efficacy. Conclusions: The PBPK-PD model allowed for the virtual testing of dosing scenarios, providing an alternative to clinical studies in pediatrics where traditional DDI studies are challenging. This approach offers valuable insights for accurate dosing recommendations in pediatrics, accounting for age-dependent variability in metabolism, and underscores the potential of PBPK modeling in guiding pediatric drug development.

Optimization of the manufacturing process of a pediatric omeprazole enteric pellets suspension: Full Factorial Design

OBJECTIVE

The purpose of the present study was to apply the design of experiments (DoE) to develop an omeprazole enteric pellets suspension for use in the pediatric population.

METHODOLOGY

This experimental study employed a Full Factorial Design for drug development, encompassing three factors (Aerosil® R972, cetostearyl alcohol, and Span 80) at two levels (2% and 6% for factor A (Aerosil® R972) and 2% and 4% for factors B and C (cetostearyl alcohol and Span 80, respectively)).

RESULTS

Following the statistical optimization, the suspension F10 was formulated and subjected to a stability study for one month. The dissolution test results were suboptimal, achieving only an 22% release. Subsequently, eight additional suspensions were devised using hydrophilic oily vehicles (Labraphac Hydrophile WL 1219, Labrafil M2125 CS, and Labrafil M 1944 CS) and excipients (Gelucire 44/14 and Aerosil® 200) to enhance the dissolution profile. Suspension F17 showed over 75% within 30 min, displaying superior sedimentation time when compared to all other formulations, along with effortless resuspension.

CONCLUSION

The findings suggest that the optimal vehicle for the administration of omeprazole enteric pellets in suspension is the formulation comprising Labrafil M 1944 CS, Span 80, and Aerosil® 200. This study has paved the way for an oily suspension vehicle, opening new avenues of research for developing pediatric omeprazole formulations that fulfill gastro-resistance requirements.

Anti-inflammatory effects of Esomeprazole in septic lung injury by mediating endoplasmic reticulum stress

Acute lung injury characterized by overactive pulmonary inflammation is a common and serious complication of sepsis. Esomeprazole (ESO), a potent proton pump inhibitor (PPI), has been demonstrated as a promising anti-inflammatory agent in treating sepsis at high concentrations, the efficacy of which in sepsis-induced lung injury has not been explored. This research aimed to investigate the role of ESO in septic lung injury and the potential mechanism. The mice were pretreated by ESO prior to the construction of cecal ligation and puncture (CLP) sepsis model. MH-S lung macrophages were exposed to lipopolysaccharide (LPS) to induce inflammatory injury. The severity of lung damage was detected by H&E staining, measurement of lactic dehydrogenase (LDH) and lung wet/dry weight (W/D) ratio. The levels of inflammatory cytokines were detected by ELISA and Western blotting. The number of inflammatory cells was counted. Macrophage distribution was measured by immunohistochemical staining of macrophage markers. Western blotting also determined the expression of endoplasmic reticulum stress (ERS) and NLR family pyrin domain containing 3 (NLRP3) inflammasome-related proteins. CCK-8 method was used to detect cell viability. ESO concentration-dependently mitigated the pathological damage of lung tissues, reduced LDH activity, lung W/D ratio, decreased inflammatory cell counts and F4/80 expression in the lung tissues of sepsis mice. Besides, ESO suppressed inflammatory response, NLRP3 inflammasome activation and inactivated activating transcription factor 6 (ATF6)-CCAAT-enhancer-binding protein homologous protein (CHOP)-mediated ERS signaling both in vitro and in vivo. ATF6 overexpression partially reversed the impacts of ESO on NLRP3 inflammasome and the levels of inflammatory cytokines in LPS-induced MH-S cells. Anyway, ESO may inhibit ATF6/CHOP pathway to protect against inflammation in septic lung injury.

Real-world-evidence, prospective-observational study to evaluate safety and effectiveness of rabeprazole dual-delayed-release capsules in patients with gastroesophageal reflux disease

BACKGROUND

Abnormal gastric acid reflux into the esophagus causes symptoms of gastroesophageal reflux disease (GERD) such as heartburn and regurgitation and also leads to mucosal damage. This damage can further lead to complications such as Barrett's esophagus and esophagitis. Conventional proton pump inhibitors (PPIs) often fail to reduce nocturnal acid production, leaving patients with unresolved symptoms that worsen at night and decreased satisfaction. Happi ER, a novel dual delayed-release (DDR) formulation of rabeprazole, aims to address these limitations by providing both immediate and prolonged acid suppression.

AIM

To evaluate the safety and effectiveness of rabeprazole DDR 20 mg capsule in patients with GERD.

METHODS

This study involved a multicenter, real-world, prospective, observational design over an eight-week period. A total of 1022 GERD patients were treated with rabeprazole DDR 20 mg capsules (Happi ER), as prescribed by their physicians. We included adult patients with confirmed GERD and persistent heartburn symptoms despite prior PPI use. Outcome measures included heartburn severity, frequency of night-time awakenings, use of rescue medications, and overall patient satisfaction.

RESULTS

Rabeprazole DDR 20 mg capsules (Happi ER) were shown to be highly effective in treating GERD symptoms. At the end of the study, the mean heartburn score improved significantly from 2.46 ± 0.67 at baseline to 0.16 ± 0.39 (P < 0.0001). The median number of night-time awakenings decreased to 0 (P < 0.0001). More than 93% of patients rated the therapy as "excellent" or "very good", reflecting high satisfaction. No significant adverse effects were reported, and the safety profile was comparable to that of traditional PPIs.

CONCLUSION

By providing both rapid and sustained acid suppression, Happi ER effectively treats GERD, particularly with respect to night-time symptoms. Its safety and efficacy profile make it a viable option for individuals with mild-to-moderate GERD, significantly improving the quality of life and symptom management.

Why think twice before prescribing proton pump inhibitors

Proton pump inhibitors (PPIs) represent a class of drugs most prominently known for their use in acid-related disorders. Omeprazole, a drug belonging to this class, is among the top 10 most prescribed drugs in the USA. PPIs have a direct effect on the gastric pH and therefore on the gastric mucosa. This review aims to present the most common adverse effects PPIs have on the gastric mucosa in particular.

CONCLUSION

PPIs affect the composition of gut and gastric microbiota and will eventually modulate the immune response.

WHAT IS KNOWN

• Proton-pump inhibitors are amonth the most frequent prescirbed drugs becasue of their well demonstrated efficacy in acid-related disorders. • Because of their mode of action and their metabolism, a large spectrum of adversee effects have been reported.

WHAT IS NEW

• Although the well-known success of PPIs in the wide spectrum of all acid-related conditions should not refrain health care professionals to use them when indicated, insufficient attention is given to the multiple adverse effects reported for this class of drugs. • Well designed prospective trials collecting adverse effects are required, since most studies reporting adverse effects are retrospective, are biassed and have methodological issues.

Effects of Tegoprazan, Potassium-Competitive Acid Blocker, on the Gastric Emptying and Postprandial Symptoms in Healthy Humans

BACKGROUND AND AIMS

Proton pump inhibitors are potent gastric acid inhibitors. However, they may worsen symptoms such as postprandial fullness and early satiation by reducing gastric emptying (GE). This study aims to evaluate the effects of tegoprazan, a new potassium-competitive acid blocker, on GE and dyspeptic symptoms.

METHODS

A randomized, double-blind, placebo-controlled design was adopted for this study. Participants underwent GE tests and responded to a questionnaire regarding gastrointestinal symptoms before and after administration of tegoprazan 50 mg. GE was assessed using scintigraphy over 4 h with a standardized solid meal.

RESULTS

Thirty participants were recruited (19 men, mean age 28.2 ± 7.3 years). After medication, no significant differences were observed in gastric half emptying time (T1/2) and gastric retention at 4 h (GE 4 h) between the tegoprazan and the control group (114.2 ± 48.9 min vs. 93.7 ± 34.7 min, P = 0.20; 10.1 ± 12.0% vs. 4.3 ± 5.4%, P = 0.11, respectively). Furthermore, there were no statistically significant differences detected in the changes within each group between two groups (T1/2, 9.9 ± 52.7 min vs. - 4.7 ± 30.5 min, P = 0.36; GE 4 h, 5.2 ± 13.9% vs. - 1.3 ± 6.5%, P = 0.12). The changes in dyspeptic symptom scores after tegoprazan administration did not significantly differ from those in the control group with no correlation between symptoms and GE parameters.

CONCLUSIONS

In healthy adults, the administration of tegoprazan did not show a significant impact on GE and dyspeptic symptoms, especially postprandial fullness or early satiation.

Site-specific activation of the proton pump inhibitor rabeprazole by tetrathiolate zinc centres

Proton pump inhibitors have become top-selling drugs worldwide. Serendipitously discovered as prodrugs that are activated by protonation in acidic environments, proton pump inhibitors inhibit stomach acid secretion by covalently modifying the gastric proton pump. Despite their widespread use, alternative activation mechanisms and potential target proteins in non-acidic environments remain poorly understood. Employing a chemoproteomic approach, we found that the proton pump inhibitor rabeprazole selectively forms covalent conjugates with zinc-binding proteins. Focusing on DENR, a protein with a C4 zinc cluster (that is, zinc coordinated by four cysteines), we show that rabeprazole is activated by the zinc ion and subsequently conjugated to zinc-coordinating cysteines. Our results suggest that drug binding, activation and conjugation take place rapidly within the zinc coordination sphere. Finally, we provide evidence that other proton pump inhibitors can be activated in the same way. We conclude that zinc acts as a Lewis acid, obviating the need for low pH, to promote the activation and conjugation of proton pump inhibitors in non-acidic environments.

Association between CYP2C19 polymorphism and proton pump inhibitors adverse drug reactions: a narrative review

Proton pump inhibitors (PPIs) are widely prescribed medications for the management of acid-related disorders, due to their effectiveness and favorable pharmacokinetics. However, the occurrence and severity of adverse drug reactions (ADRs) in patients using PPIs, particularly in relation to their association with CYP2C19 polymorphisms, are of great concern. This association has largely been investigated through observational studies, which have shown conflicting or weak findings. Therefore, this review aims to examine the current evidence regarding the long-term ADRs of PPIs and their link to CYP2C19 variants.

Management of Perforated Peptic Ulcer: A Review

Importance

Perforated peptic ulcer disease (PUD) affects 4 million people annually worldwide, with a lifetime prevalence of 5% to 10%. Of those affected, 5% will progress to the point of perforation. Despite advances in the understanding and treatment, perforated PUD continues to have a high rate of morbidity (50%) and mortality (30%). This review summarizes the current evidence on management of perforated PUD, including management of failed repairs.

Observations

Approaches for repair include primary closure and omental patch closure. Omental patch may be most useful in large perforations with friable tissue. Minimally invasive surgery is the preferred approach in perforated PUD, with improved outcomes compared with open techniques. Leak from the ulcer after repair is seen in approximately 12% to 17% of cases. Approaches to releak include expectant management, radiologic and/or endoscopic intervention, and repeat surgery. Morbidity and mortality after releak are especially high, and complete healing of the leak may take time.

Conclusions and Relevance

Despite advances in medical management and surgical techniques, perforated PUD continues to have a relatively high rate of morbidity and mortality. Minimally invasive surgery is the current preferred treatment approach.

Efficacy of cyclin-dependent kinase inhibitors with concurrent proton pump inhibitors in patients with breast cancer: a systematic review and meta-analysis

BACKGROUND

The impact of concurrent proton pump inhibitors (PPIs) use on the prognosis of patients with breast cancer undergoing cyclin-dependent kinase inhibitors (CDKIs) treatment is currently uncertain. Considerable divergence exists regarding the clinical studies. In this study, we aim to perform a comprehensive analysis to evaluate the influence of concomitant PPI use on the effectiveness and adverse effects of CDKIs in patients with breast cancer.

METHODS

This study encompassed all pertinent clinical studies published up to the present, following the PRISMA guidelines. The study used hazard ratio (HR) or odds ratio (OR) as a summary statistic and used fixed or random effects models for pooled estimation.

RESULTS

This study incorporated 10 research articles involving 2993 participants. Among patients with breast cancer undergoing treatment with CDKIs, the simultaneous administration of PPIs was associated with a notable reduction in overall survival (HR = 2.00; 95% CI, 1.35-2.96). Nevertheless, no substantial correlation was observed between the simultaneous utilization of PPIs and the progression-free survival (PFS) of patients (HR = 1.30; 95% CI, 0.98-1.74). PFS did not change significantly when considering different drugs, treatment lines, or regions alone. Furthermore, the simultaneous administration of PPIs was found to result in a notable decrease in the incidence of grades 3/4 risk factors (OR = 0.63, 95% CI, 0.46-0.85).

CONCLUSION

The concurrent administration of PPIs did not result in significant alterations in the risk of disease advancement among patients with breast cancer undergoing CDKIs treatment. The utilization of PPIs led to a decrease in the adverse effects linked to the administration of CDKIs.

Efficacy of Potassium-Competitive Acid Blockers Versus Proton Pump Inhibitors for Gastric Ulcers: Bayesian and Frequentist Network Meta-Analysis With Cross-Inference Through a Quality management System

Purpose

Proton pump inhibitors (PPIs) have been the mainstay treatment for gastric ulcer (GU) for over 30 years. However, since the discovery of a new class of acid suppressants, potassium-competitive acid blockers (P-CABs), the desire for a therapeutic agent has continued and the clinical trials on P-CABs have been conducted. In this regard, we aimed to assess whether P-CABs are noninferior to PPIs in patients with GU in terms of efficacy.

Methods

We performed a systematic review and network meta-analysis (NMA) based on randomized controlled trials (RCTs). Additionally, we used a new methodology of inference concept with the purpose of grouping between P-CABs and PPIs. Moreover, our quality management system was integrated throughout the research to ensure data accuracy.

Findings

We initially screened 438 studies and extracted 10 homogeneous GU RCTs with 6315 participants. The odds ratios (ORs) for the 4-week cure rate in Bayesian + frequentist NMA, tegoprazan 100 mg (OR = 4.14, 95% credible interval [CI] 0.56-26.3) and pantoprazole 40 mg (OR = 4.12, 95% CI 1.90-8.88) were the largest, respectively. The ORs for the 8-week cure rate in Bayesian + frequentist NMA, lansoprazole 30 mg (OR = 8.77, 95% credible interval [CI] 0.95-78.9) and lansoprazole 30 mg (OR = 7.91, 95% CI 2.60-24.03) was the largest, respectively.

Conclusions

The results of the NMA reveal that the cure rates of P-CABs in cases of GU were not inferior to those of PPIs. As the inference by grouping PPIs and P-CABs, the results showed similar trends in terms of effectiveness between the two therapeutic classes.

Over- and Underuse of Proton Pump Inhibitors in Nursing Homes: A Multisite Longitudinal Cohort Study

OBJECTIVES

Proton pump inhibitors (PPIs) are used to manage excess stomach acid production and provide gastroprotection from bleeding risk-increasing drugs (BRIDs). We aimed to determine the prevalence of potentially inappropriate PPI use in nursing homes and associated factors.

DESIGN

Longitudinal cohort study using 8 years of electronic data.

SETTING AND PARTICIPANTS

The study included 6439 permanent residents aged ≥65 years from 34 homes managed by 2 aged care providers in New South Wales.

METHOD

Continuous PPI use (>12 weeks) in the absence of long-term BRID (>30 days) use was deemed inappropriate overuse whereas long-term BRID use without concomitant PPI for gastroprotection was classified as inappropriate underuse. Binary logistic regression was used to determine factors associated with PPI overuse.

RESULTS

Fifty-four percent of residents (n = 3478) received a PPI, with a median duration of 46 weeks, whereas 58.5% (n = 3770) were long-term BRID users. Four of 5 PPI users (83.6%, n = 2906) used PPIs for >12 weeks, and after accounting for BRID use, the prevalence of inappropriate PPI overuse was 27.1% (n = 944). PPI overuse was 4 times more likely in residents in provider A compared with residents in provider B [odds ratio (OR) 4.08, 95% CI 2.73-6.09]. The prevalence of PPI underuse was 38.5% (n = 1452).

CONCLUSIONS AND IMPLICATIONS

One in 4 PPI users exceeded the clinically recommended duration, whereas 2 in 5 long-term BRID users did not receive a PPI for gastroprotection. There is a pressing need for tailored interventions, such as medication reviews and deprescribing initiatives, to improve PPI prescribing.

The use of concomitant medications on nephrotoxicity associated with teicoplanin: A retrospective observational study

BACKGROUND

Teicoplanin (TEIC) is a nephrotoxic agent. However, little is known about the effects of concomitant medications on nephrotoxicity. In this study, we investigated the effects of concomitant drugs on nephrotoxicity.

METHODS

A retrospective observational case-control study was conducted on patients (≥18 years) who started TEIC at the Tokyo Dental College, Ichikawa General Hospital, between January 2013 and April 2023. The primary outcome was nephrotoxicity, defined as an increase in serum creatinine levels of ≥50 % or ≥0.5 mg/dL from baseline. Logistic regression analysis was used to determine the risk factors for nephrotoxicity associated with TEIC. In addition, we investigated the relationship between nephrotoxicity and predicted free TEIC concentrations.

RESULTS

Of 305 patients, 43 (14.1 %) developed nephrotoxicity. The multivariate logistic regression analysis identified that serum albumin (odds ratio [OR] = 0.50, 95 % confidence interval [CI] 0.27-0.89, p = 0.02), concomitant use of loop diuretics (OR = 2.22, 95 % CI 1.10-4.59, p = 0.03), antivirals (OR = 3.24, 95 % CI 1.32-7.62, p < 0.01), and vasopressors (OR = 2.57, 95 % CI 1.10-5.78, p = 0.03) were the associated risk factors for nephrotoxicity in patients administered with TEIC. In 216 patients, predicted TEIC concentrations were 3.6 [interquartile range (IQR), 2.6-4.9] μg/mL in the nephrotoxicity group versus 3.6 [IQR, 2.5-4.7] μg/mL in the non-nephrotoxicity group, with no significant difference (p = 0.69).

CONCLUSION

Our results indicate the importance of modifying the concomitant use of loop diuretics, antivirals, and vasopressors.

Ru-Ph Nanozyme-Based Hydrogels for Tumor Chemodynamic Therapy by Enhancing Enzyme Catalytic Efficiency Through Multiple Pathways

The discovery of nanozymes has opened new possibilities for tumor therapy. However, their reliance on the tumor microenvironment and limited catalytic efficiency hinder broader applications. In this study, ruthenium-phenanthroline nanoparticles (Ru-Phs) are synthesized by combining ruthenium with phenanthroline and subsequently coloaded with the proton pump inhibitor (PPI) pantoprazole into sodium alginate (ALG) to form a Ru-Phs-PPI-ALG hydrogel for in situ tumor therapy. This hydrogel demonstrates excellent chemodynamic properties, forming a gel within tumor tissues and gradually releasing Ru-Phs, which generates highly toxic reactive oxygen species (ROS) via peroxidase-like (POD-like) activity. The inclusion of PPI reduced the intracellular pH of tumor cells, accelerating the Fenton reaction and ROS accumulation. Additionally, the high photothermal conversion efficiency of Ru-Phs-PPI-ALG enables heat generation under near-infrared (NIR) irradiation, which not only disrupts tumor cell structures but also further enhances the POD-like catalytic activity of Ru-Phs. The hydrogel effectively killed 4T1 cells in vitro, and transcriptomic analysis confirms its potent chemodynamic efficacy. In vivo experiments demonstrate significant tumor ablation and excellent biocompatibility. This multipathway strategy to increase enzyme activity and improve chemodynamic effects provides a promising approach for advancing nanozyme applications in tumor therapy.

Proton Pump Inhibitor Use and Incident Cardiovascular Disease in Older Postmenopausal Women

BACKGROUND

Epidemiological studies have been inconsistent regarding an association between proton pump inhibitor (PPI) use and risk of primary cardiovascular disease (CVD) events.

METHODS

We studied 85,189 postmenopausal women (mean age 63 years at baseline) without known CVD at enrollment into the Women's Health Initiative Observational Study (1993-1998). PPI use was determined from medication inventories at baseline and Year-3. CVD events were physician adjudicated and defined as a composite of coronary heart disease, stroke, and CVD mortality. Follow up was from baseline to September 2010. Multivariable Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for incident CVD according to baseline PPI use (no/yes), use duration (non-user, < 1 year, 1-3 years, > 3 years), and time-varying based on updated Year-3 information. Propensity score adjustment was used to control for residual confounding.

RESULTS

At baseline, 1747 (2.1%) women reported using PPIs. During a mean follow-up of 11 years, 5778 (6.8%) cases of primary CVD were identified. PPI users had significantly higher risk of CVD compared with non-users in the fully adjusted model (HR: 1.21, 95% CI: 1.02-1.43), and after propensity score adjustment (HR: 1.27, 95% CI: 1.21-1.32). Longer PPI use duration was associated with incrementally higher CVD risk (HRs: < 1 year: 1.11, 1-3 years: 1.27, > 3 years: 1.33; p for trend = 0.02).

CONCLUSIONS

PPI use was associated with higher risk of incident primary CVD in older postmenopausal women. These findings underscore the importance of guideline-directed PPI use to avoid unwanted adverse events.

The efficacy and safety of Vonoprazan and Tegoprazan in Helicobacter pylori eradication: a comprehensive systematic review and meta-analysis of randomized controlled trials

Background

Potassium-competitive acid blocker (P-CAB)-based therapies are emerging as promising alternatives for eradicating Helicobacter pylori infection. However, the comparative efficacy of P-CAB-based therapy versus proton-pump inhibitor (PPI)-based therapy in treating H. pylori infection remains uncertain.

Objectives

This meta-analysis evaluated the efficacy and safety of P-CAB-based therapies, including Vonoprazan (VPZ) and Tegoprazan (TPZ), compared to PPI-based therapies for H. pylori infection. Subgroup analysis assessed the influence of drug history, experimental drug, treatment duration, combination therapies, and geographic regions on treatment outcomes.

Design

Meta-analysis.

Data sources and methods

Comprehensive searches were conducted in major databases, including PubMed, Embase, the Cochrane Library, and Web of Science, up to January 1, 2024. The primary outcome was the eradication rate, analyzed by intention-to-treat (ITT). Secondary outcomes included adverse events. Heterogeneity among studies was assessed using the χ2 test and the I 2 test. I 2 > 50% or p < 0.05 indicated significant heterogeneity.

Results

The analysis totally included 28 randomized controlled trials (RCTs) comprising 37 studies and 8818 patients diagnosed with H. pylori infection. Of these, 14 RCTs, including 20 studies and 4286 patients, compared P-CAB-based therapy with 14-day bismuth-based quadruple therapy (BQT). P-CAB-based therapy exhibited superior eradication rates compared to both 14-day BQT and PPI-based therapy (ITT analysis: 87.0% vs 79.8%, risk ratio (RR) = 1.08, 95% CI: 1.04-1.12, p < 0.0001; and 85.6% vs 77.8%, RR = 1.09, 95% CI: 1.05-1.12, p < 0.00001, respectively). This enhanced efficacy was particularly pronounced in patients with clarithromycin-resistant infections (73.7% vs 41.5%, RR = 1.53, 95% CI: 1.07-2.20, p = 0.02). Subgroup analysis demonstrated higher eradication rates with P-CAB-based therapy in treatment-naïve participants, VPZ recipients, and those receiving 7- or 14-day regimens (dual, triple, or quadruple therapy). However, no significant differences were observed in treatment-experienced subgroups, TPZ recipients, or those on 10-day regimens. In addition, P-CAB-based therapy showed a lower incidence of adverse events than PPI-based treatments (RR = 0.73, 95% CI: 0.63-0.86, p < 0.0001).

Conclusion

P-CAB-based therapies are more effective than traditional PPI-based treatments for eradicating H. pylori infection, with a reduced incidence of adverse events.

PROSPERO registration

CRD42024503665.

Effects of proton pump inhibitor (PPI) use on migraine - a critical review

BACKGROUND

Proton pump inhibitor (PPI) drugs are widely used and are among the most significant achievements of modern pharmacology. Their primary purpose is treating and preventing gastric acid-related disorders. Migraine and PPI intake are prevalent, and many people are affected by both. In the last few years, a potential link between PPI intake and the development of headaches-especially migraine-has come to increased attention. In this review, we critically examine the scientific data concerning the co-occurrence of these two entities.

FINDINGS

There seems to be a possible link between the use of PPIs and the occurrence of headache, especially migraine, suggesting a pathophysiological connection on several levels. Moreover, PPI use is only partially without side effects, even if these may not occur immediately. Whether the relation is causative or merely co-existential is currently not yet clear. The influence of genetics, environment, gut microbiome, medication intake and evolution of headache is multidirectional.

CONCLUSION

A relation between the prevalence of migraine and the use of PPIs on a population and personal level seems likely. Although PPIs have many advantages, they should be prescribed with caution, especially in patients who suffer from headaches and migraine. In this narrative review, we aim to critically evaluate existing data and offer a potential approach to accurately identify any connections and interactions, leading to a better understanding of how these conditions may influence each other.

Acid-Neutralizing Omeprazole Formulation for Rapid Release and Absorption

Background/Objectives: Omeprazole undergoes degradation in acidic conditions, which makes it unstable in low pHs found in the gastric environment. The vast majority of already marketed omeprazole formulations use enteric polymer coatings to protect the drug from exposure to acidic pH in the stomach, allowing for drug release in the small intestine where the pH is higher. This study aimed to explore the technical aspects of using stomach acid neutralizers as an alternative to polymeric coatings for omeprazole. Methods: After evaluating various neutralizers, magnesium oxide and sodium bicarbonate were chosen to be incorporated into capsules containing omeprazole, which then underwent in vitro dissolution testing to assess their ability to maintain optimal pH levels and ensure appropriate dissolution kinetics. Hygroscopicity and chemical stability of the selected formulation were tested to prove pharmaceutical quality of the product. An in vivo pharmacokinetic study was conducted to demonstrate the efficacy of the omeprazole-sodium bicarbonate formulation in providing faster absorption in humans. Results: Sodium bicarbonate was selected as the most suitable antacid for ensuring omeprazole stabilization. Its quantity was optimized to effectively neutralize stomach acid, facilitating the rapid release and absorption of omeprazole. In vitro studies demonstrated the ability of the formulation to neutralize gastric acid within five minutes. In vivo studies indicated that maximum concentrations of omeprazole were achieved within half an hour. The product met the requirements of pharmaceutical quality. Conclusions: An easily manufacturable, fast-absorbing oral formulation was developed as an alternative to enteric-coated omeprazole.

Biophysical interactions between self-sufficient cytochrome P450 from Tepidiphilus thermophilus and ilaprazole

Proton pump inhibitors (PPIs), metabolized by cytochrome P450 (P450) enzymes, are widely used to inhibit gastric acid secretion. This study investigated CYP116B46, a self-sufficient monooxygenase with a reductase domain, to elucidate its interaction with ilaprazole, a PPI. Binding assays and docking simulations indicate that CYP116B46 serves as a suitable model for studying PPI metabolism.

A Randomized, Comparative Trial of a Potassium-Competitive Acid Blocker (X842) and Lansoprazole for the Treatment of Patients With Erosive Esophagitis

INTRODUCTION

X842 is a new type of gastric acid-suppressing agent with a rapid onset of action and a long duration of effect. We aim to investigate the efficacy and safety of different doses of X842 vs lansoprazole in the treatment of patients with erosive esophagitis (EE).

METHODS

This phase 2 study included 90 patients with EE (Los Angeles grades A-D) who were randomized (1:1:1) to receive oral low-dose X842 (50 mg/d, n = 31), high-dose X842 (100 mg/d, n = 31), or lansoprazole (30 mg/d, n = 30) for 4 weeks. The main efficacy end point was the EE healing rate, which was the proportion of patients who achieved endoscopic healing after 4 weeks of treatment.

RESULTS

For intention-to-treat analysis, the EE healing rates at 4 weeks were 93.6% (29/31), 79.3% (23/29), and 80.0% (24/30) for the X842 50 mg, the X842 100 mg, and the lansoprazole 30 mg groups. For per-protocol analysis, the EE healing rates at 4 weeks were 93.6% (29/31), 80.8% (21/26), and 82.1% (23/28) in the 3 groups, respectively. The EE healing rate did not significantly differ among the 3 groups in either the intention-to-treat ( P = 0.2351) or per-protocol ( P = 0.3320) analysis. The incidence of drug-related treatment-emergent adverse events did not differ among groups. No severe drug-related treatment-emergent adverse events occurred in the X842 group.

DISCUSSION

Our findings confirmed that X842 had efficacy and a favorable safety profile similar to those of lansoprazole. Therefore, X842, a novel potassium-competitive acid blocker, is expected to become a promising therapeutic agent for EE.

DepRescribing inapprOpriate Proton Pump InhibiTors (DROPIT): study protocol of a cluster-randomised controlled trial in Swiss primary care

OBJECTIVES

Proton pump inhibitors (PPIs) are widely prescribed medications and commonly used for the treatment of gastric acid-related disorders. Nevertheless, PPIs are often overused leading to potential adverse effects and unnecessary healthcare costs. Deprescribing strategies have emerged to safely reduce or substitute inappropriate PPIs and optimise patient care in an evidence-based manner. This protocol describes a study to evaluate the effectiveness of a PPI deprescribing intervention in comparison to usual care in the Swiss primary care setting.

DESIGN

An open-label, cluster randomised controlled trial.

SETTING

Swiss primary care settings.

PARTICIPANTS

Included participants will be adults with inappropriate PPI treatment and will be recruited by general practitioners (GPs). Participants treated by the same GP constitute a cluster. Clusters are randomised 1:1 to either the intervention group or the control group.

INTERVENTIONS

The intervention components consist of deprescribing tools including educational material, decision aids for both participants and GPs, and additional trainings for GPs only. Patients in the control group will receive usual care. Data will be collected at baseline, 3-, 6-, 9- and 12-month follow-up time through online surveys or a phone call for both GPs and participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

The first co-primary endpoint is the effectiveness of the deprescribing intervention measured by the change of prescribed PPI dose. The second co-primary endpoint is safety, which is measured with the Reflux Disease Questionnaire assessing change in gastrointestinal symptoms. There are several secondary endpoints, such as the total number of prescribed medications, occurrences of changes in prescription patterns, PPI discontinuation and cost-effectiveness.

CONCLUSIONS

The findings from this study will provide evidence on the effectiveness and safety of a PPI deprescribing intervention for patients and GPs. Successful implementation of our PPI deprescribing strategy has the potential to improve patient outcomes and lower costs.

TRIAL REGISTRATION NUMBER

NCT06129474.

Neurological Manifestations Associated With Hypomagnesemia Due to Proton-Pump Inhibitors: A Case Series

We discuss a case series that explores the presentation and diagnostic challenges of three elderly male patients with hypomagnesemia. This series highlights the association between hypomagnesemia and hypocalcemia, both of which contribute to neurological symptoms. Proton-pump inhibitors, when taken for a long duration, are known to cause hypomagnesemia. This series also emphasizes the reversible neurological syndromes in patients with hypomagnesemia due to prolonged pantoprazole intake.

Characterization of intestine-specific TRPM6 knockout C57BL/6 J mice: effects of short-term omeprazole treatment

The transient receptor potential melastatin type 6 (TRPM6) is a divalent cation channel pivotal for gatekeeping Mg2+ balance. Disturbance in Mg2+ balance has been associated with the chronic use of proton pump inhibitors (PPIs) such as omeprazole. In this study, we investigated if TRPM6 plays a role in mediating the effects of short-term (4 days) omeprazole treatment on intestinal Mg2+ malabsorption using intestine-specific TRPM6 knockout (Vill1-TRPM6-/-) mice. To do this, forty-eight adult male C57BL/6 J mice (50% TRPM6fl/fl and 50% Vill1-TRPM6-/-) were characterized, and the distal colon of these mice was subjected to RNA sequencing. Moreover, these mice were exposed to 20 mg/kg bodyweight omeprazole or placebo for 4 days. Vill1-TRPM6-/- mice had a significantly lower 25Mg2+ absorption compared to control TRPM6fl/fl mice, accompanied by lower Mg2+ serum levels, and urinary Mg2+ excretion. Furthermore, renal Slc41a3, Trpm6, and Trpm7 gene expressions were higher in these animals, indicating a compensatory mechanism via the kidney. RNA sequencing of the distal colon revealed a downregulation of the Mn2+ transporter Slc30a10. However, no changes in Mn2+ serum, urine, and feces levels were observed. Moreover, 4 days omeprazole treatment did not affect Mg2+ homeostasis as no changes in serum 25Mg2+ and total Mg2+ were seen. In conclusion, we demonstrate here for the first time that Vill1-TRPM6-/- mice have a lower Mg2+ absorption in the intestines. Moreover, short-term omeprazole treatment does not alter Mg2+ absorption in both Vill1-TRPM6-/- and TRPM6fl/fl mice. This suggests that TRPM6-mediated Mg2+ absorption in the intestines is not affected by short-term PPI administration.

Natural language processing assisted detection of inappropriate proton pump inhibitor use in adult hospitalised patients

OBJECTIVES

To establish a clinical application monitoring system for proton pump inhibitors (PPI-MS) and to enhance the detection and intervention of inappropriate PPI use in adult hospitalised patients.

METHODS

Natural language processing technology was applied to indication recognition of therapeutic PPI applications and the assessment of admission record recognition for preventive PPI applications. Symptom judgement was based on the tense-negation model and regular expressions. Evidence-based rules for clinical PPI application were embedded for the construction of PPI-MS. A total of 9421 patient records using PPI from July 2022 to July 2023 were analysed to validate the performance of the system and to identify common issues related to inappropriate clinical PPI use.

RESULTS

Out of 9421 hospitalised patients detected using PPI, 4736 (50.27%) were used for prophylaxis and the rest for therapeutic use. Among the prophylactic medications, 2274 patients (48.02%) were identified as receiving inappropriate prophylactic PPI. The main reasons were inappropriate prophylaxis without indication. Additionally, 258 cases of inappropriate therapeutic PPI use were identified, mainly involving the use of esomeprazole for peptic ulcers and Zollinger-Ellison syndrome. The efficiency of the PPI rational medication monitoring system, when coupled with human involvement, was 32 times that of manual monitoring. Among cases of inappropriate prophylactic PPI use, 45.29% were due to lack of indications, 28.34% involved inappropriate administration routes, 15.74% were related to inappropriate dosing frequencies and 10.62% were attributed to inappropriate drug selection. There were 933 cases related to the use of antiplatelet and anticoagulant drugs and 708 cases related to the use of non-steroidal anti-inflammatory drugs. The overall accuracy of the PPI-MS system was 88.69%, with a recall rate of 99.33%, and the F1 score was 93.71%.

CONCLUSIONS

Establishing a PPI medication monitoring system through natural language processing technology, while ensuring accuracy and recall rates, improves evaluation efficiency and homogeneity. This provides a new solution for timely detection of issues relating to clinical PPI usage.

A pharmacovigilance study of the association between proton pump inhibitors and tumor adverse events based on the FDA adverse event reporting system database

Background

Proton pump inhibitors (PPIs) are effective treatments for acid-related disorders but may pose tumor risks with long-term use. Current research on PPI-associated tumor adverse events (TAEs) is limited and inconclusive. This study aims to comprehensively analyze the relationship between PPIs and TAEs.

Methods

We analyzed PPI adverse reaction reports from the FDA Adverse Event Reporting System (FAERS) database spanning from 2004 to 2024, focusing on five commonly used PPIs: esomeprazole, pantoprazole, lansoprazole, omeprazole, and rabeprazole. We conducted a disproportionality analysis utilizing the Reporting Odds Ratio (ROR) to identify potential TAEs associated with PPIs. We conducted univariate logistic regression analysis to explore the influencing factors.

Results

A total of 3,133 TAEs were identified, representing 2.36% of all PPI-related adverse events (AEs). The most common TAEs were gastric cancer (19.05%) and malignant neoplasm (7.23%). Disproportionality analysis revealed ten significant TAEs associated with PPIs, including gastric adenocarcinoma and renal cell carcinoma. The median age of those reporting TAEs was 59 (interquartile range [IQR]: 51-70), and 29.70% of them resulted in a fatality. TAEs associated with PPIs were less likely to occur in elderly patients (65-75: OR = 0.91 [0.87-0.95], p < 0.001; >75: OR = 0.93 [0.89-0.98], p < 0.01).

Conclusion

TAEs constitute a small but significant fraction of PPI-related AEs. This study highlights the need for cautious long-term use of PPIs and further research to understand the underlying mechanisms and risk factors. Clinicians should be aware of the potential tumor risks associated with prolonged PPI treatment.

Association Between Clinical Use of Lansoprazole and the Risk of Coronary Heart Disease: A Nationwide Pharmacoepidemiological Cohort Study

PURPOSE

Proton pump inhibitors (PPIs) are widely prescribed for gastrointestinal disorders. Lansoprazole, a PPI, has been recognized for its potential effects of improving insulin resistance, reduction of oxidative stress, and improvement in atherosclerosis through peroxisome proliferator-activated receptor gamma (PPARγ) induction. This study aims to investigate whether lansoprazole poses a distinct risk of coronary heart disease (CHD) compared to other PPIs.

METHODS

A retrospective cohort study utilized data from the National Health Insurance Research Database in Taiwan spanning from 2000 to 2013. The exposed cohort included 1666 patients with lansoprazole use, while the comparison cohort comprised 6664 patients using other PPIs. The primary outcome was incident CHD. Cox regression models were employed to assess the association between lansoprazole use and CHD risk, presenting hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Patients prescribed lansoprazole demonstrated a significantly reduced risk of CHD compared to those undergoing other PPI treatments in individuals without a history of CHD. Lansoprazole users exhibited a 25% lower risk of developing CHD compared to other PPI users (adjusted HR 0.75; 95% CI 0.65-0.87). Intriguingly, this inverse association between lansoprazole use and CHD risk was consistent across genders and various age groups.

CONCLUSION

This study suggests that lansoprazole is associated with a decreased risk of CHD in comparison to other PPIs in patients without a history of CHD. Further research is warranted to elucidate the clinical implications of these findings.

Potassium-Competitive Acid Blockers and Proton Pump Inhibitors: The Dynamic Duo of Acid Blockers

The management of acid-based disorders was transformed in the 1980s with the advent of proton pump inhibitors (PPIs), which target the hydrogen-potassium adenosine triphosphatase (proton pump) of the parietal cell. Potassium-competitive acid blockers (P-CABs), a newer class of medications, act at the same proton pump through a novel mechanism resulting in profound and sustained acid suppression. Although trials in Asian populations over the past decades have highlighted the potential benefit of P-CABs, clinical trials in Western populations have been initiated more recently. These trials evaluated vonoprazan in patients with Helicobacter pylori infection, erosive esophagitis, and heartburn with nonerosive reflux disease and have demonstrated promising results, culminating in US Food and Drug Administration approval for these indications. Adverse event profiles between PPIs and P-CABs appear comparable thus far, although additional long-term data on P-CABs are needed. While navigating the evolving landscape of acid suppression, it is crucial to identify which patients and diseases are poised to derive the most benefit from this emerging therapeutic option. This article seeks to highlight important pharmacologic properties of PPIs and P-CABs, understand the current literature with a focus on clinical trials in Western populations, and explore potential scenarios for integrating P-CABs into therapeutic regimens.

Proton pump inhibitors and gastrointestinal symptoms among patients with COVID-19 infection

INTRODUCTION

The administration of proton pump inhibitors (PPIs) is anticipated to elevate an individual's susceptibility to enteric infections as a result of altering the gut flora. The influence of PPIs on the clinical manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is still uncertain. This study aims to investigate the impact of PPI usage on the clinical manifestation of COVID-19, namely its gastrointestinal symptoms.

METHODS

This is a cross-sectional cohort study involving COVID-19 patients. Patients were interviewed using a predesigned questionnaire that asked about their demographics, clinical manifestations of COVID-19 infection, and the extent and type of PPIs in use. PPI usage was confirmed by reviewing patients' electronic medical records. The primary outcome was to establish any association between the use of PPI and the symptoms and clinical presentation of COVID-19.

RESULTS

Out of a total of 254 participants, 69 (27.2%) were considered PPI users. Patients who were on PPI medications reported a significantly lower rate of myalgia (27.5% vs 51.9%; p = 0.0006) and heartburn (5.7% vs 15.6%; p = 0.03) but had a significantly higher rate of abdominal pain (27.5% vs 13.5%; p = 0.001) and diarrhoea (28.9% vs 14.5%, p = 0.02) when compared to those who were not using PPIs. Patients on PPIs were also shown to have significantly higher odds of developing diarrhoea (OR 2.0, 95% CI: 1.08 to 3.93, p = 0.02) and abdominal pain (OR 2.0, 95% CI: 1.22 to 3.93, p = 0.03), but a lower risk of developing myalgia (OR 0.5, 95% CI: 0.3 to 0.9, p = 0.02) when compared to non-PPI users.

CONCLUSION

This study shows that the use of PPIs could impact COVID-19 clinical presentation toward more gastrointestinal manifestations. Further studies investigating the link between other acid suppression medications and COVID-19 manifestations and severity should be carried out.

Protective effect of astaxanthin on indomethacin-induced gastric ulcerations in mice

Gastric ulcer disease remains one of the common medical burdens affecting millions worldwide due to its prevalent risk factors with the chronic usage of non-steroidal anti-inflammatory drugs at the top, reportedly through the stimulation of oxidative stress and triggering of inflammatory and apoptotic cascades in the gastric mucosa. Astaxanthin, a dietary keto-carotenoid derived from marine organisms is gaining a wide interest as a nutraceutical for its pronounced antioxidant properties. Here, we aim to examine the potential modulatory role of astaxanthin on indomethacin-induced gastric ulceration in experimental mice. Twenty-four Swiss albino mice were randomly distributed into four groups: a control group, an indomethacin group, and two groups pre-treated with either omeprazole or astaxanthin. The gastric tissues were assessed using gross morphology, ulcer scoring, gastric juice acidity, as well as reduced glutathione (GSH) and malondialdehyde (MDA) levels. Histopathological examination and immunostaining for nuclear factor-kappa B (NF-κB) and caspase-3 levels were also employed. Indomethacin group tended to show a higher number of mucosal ulcerations relative to control and pre-treated groups. The indomethacin group also showed significantly lower GSH levels and higher MDA levels relative to control. Immunostaining of gastric tissue sections showed a higher reactivity to NF-κB and caspase-3 in indomethacin group. Astaxanthin pre-treatment significantly elevated gastric juice pH, normalized GSH levels, and lowered the indomethacin-induced elevations in MDA, NF-κB, and caspase-3 levels. These results indicate that astaxanthin exhibits a comparable protective effect to omeprazole, against indomethacin-induced gastric ulceration. This anti-ulcerogenic effect could be mediated through its antioxidant, anti-inflammatory, and anti-apoptotic modulatory activities.

Pharmacological Evaluation of the Traditional Brazilian Medicinal Plant Monteverdia ilicifolia in Gastroesophageal Reflux Disease: Preliminary Results of a Randomized Double-Blind Controlled Clinical Trial

BACKGROUND/OBJECTIVES

The present work aimed to compare the effects of the standardized dry extract from the leaves of Monteverdia ilicifolia, popularly known as "espinheira-santa", with omeprazole in the management of dyspepsia related to gastroesophageal reflux disease (GERD).

METHODS

A double-blind, randomized, non-inferiority and double-dummy clinical trial was conducted. In total, 86 patients with GERD symptoms were randomized into three groups: Omeprazol (20 mg), M. ilicifolia (400 mg), or M. ilicifolia (860 mg). Capsules were provided by SUSTENTEC®, Pato Bragato, Brazil. It was requested that the participants take three capsules before breakfast and dinner for 4 weeks. Clinical outcomes were obtained at the beginning and end of the study, with GERD symptoms (QS-GERD), the impact of heartburn symptoms on quality of life (HBQOL), and medical records.

RESULTS

Overall, 75.6% of the participants showed adherence without any differences among the experimental groups. All groups had significant reductions in both QS-GERD and HBQOL scores. Omeprazole and 400 and 860 mg of M. ilicifolia decreased the QS-GERD total scores at the endpoint compared to the baseline (Chi-square = 129.808; p < 0.0001), as well as individual item scores, such as heartburn intensity (Chi-square = 93.568, p < 0.0001) and heartburn after meals (Chi-square = 126.426, p < 0.0001). There were no differences among the experimental groups after the intervention.

CONCLUSIONS

Our results suggest that capsules with a standardized dry extract from the leaves of M. ilicifolia at a dosage of 400 or 860 mg are non-inferior to omeprazole, a proton pump inhibitor.

Effects of Medication Period and Gastrin Levels on Endoscopic Gastric Mucosal Changes in Long-Term Proton Pump Inhibitor Users

Background/Objectives: Proton pump inhibitor (PPI) use has increased worldwide, including in continuous and longer-term users. Recent reports highlight PPI-related endoscopic gastric mucosal changes, including fundic gland polyps, hyperplastic polyps, multiple white and flat elevated lesions, cracked and cobblestone-like mucosa (CCLM), and black spots. PPI use elevates gastrin levels because of acid inhibition, and hypergastrinemia might be relevant to these findings. In this cross-sectional study, we retrospectively examined gastric mucosal changes in long-term PPI users, focusing on medication period and gastrin levels. Methods: We enrolled 57 patients who received a PPI (>1 year) at two clinics between January 2021 and March 2022. Participants were classified according to medication period: 1 < 5, 5-10, and ≥10 years. Gastrin levels were categorized as low, middle, and high (<250, 250-500, and ≥500 pg/mL, respectively). Odds ratios (OR) were estimated to assess the risk of endoscopic findings. Results: Of the 57 patients, 6 (10.5%), 25 (43.9%), and 26 (45.6%) were PPI users of 1 < 5, 5-10, and ≥10 years, respectively. There were no significant differences in the incidence of endoscopic findings among the medication periods. Low, middle, and high gastrin groups included 21 (36.8%), 21 (36.8%), and 15 (26.3%) patients, respectively. CCLM incidence was significantly elevated in higher gastrin level groups: middle (OR, 6.60; 95% confidence interval [CI], 1.46-29.75; p = 0.014) and high (OR, 9.00; 95% CI, 1.79-45.23; p = 0.0008) (p-trend = 0.0171). No significant differences were observed for other findings. Conclusions: No elevated risk of PPI-related gastric epithelial changes in long-term PPI users was observed time-dependently. Notably, higher gastrin levels were positively associated with CCLM development, irrespective of the medication period.

Pharmacokinetics and Pharmacodynamics of a Fixed-Dose Combination of Esomeprazole and Magnesium Hydroxide Compared to the Enteric-Coated Esomeprazole

PURPOSE

A fixed-dose combination (FDC) of proton pump inhibitors (PPIs) and antacid salts enables rapid acid suppression through the neutralizing effect of the antacid salt and the rapid absorption of PPIs. This study aimed to compare the pharmacokinetics (PKs) and pharmacodynamics (PDs) of a recently formulated FDC of esomeprazole and magnesium hydroxide to the enteric-coated esomeprazole in healthy subjects.

METHODS

A randomized, open-label, multiple-dose, two-treatment, two-way crossover design was conducted in healthy subjects. Forty-nine subjects were randomized to one of the two treatment sequences and received either the test drug (esomeprazole/magnesium hydroxide 40/350 mg) or reference drug (enteric-coated esomeprazole 40 mg) for 7 days in the first period and the alternative in the second period with a 14-day washout period. Blood samples were collected for up to 24 hours for PK assessment, and 24-hour gastric pH monitoring was conducted for PD assessment both before and after a single administration, as well as at a steady state after seven consecutive days of administration. The PK and PD parameters were compared between the two drugs.

FINDINGS

After multiple administrations, the median value of time to reach maximum concentration was faster in the test drug than in the reference drug, with a difference of 1.68 hours. The overall systemic exposure of the test drug was similar to that of the reference drug, and the PK parameter fell within the equivalence criteria. The test drug demonstrated a shorter time to reach gastric pH ≥ 4 compared to the reference drug (P = 0.0463). A decrease from baseline in integrated gastric acidity over 24 hours, which represents the degree of inhibition of gastric acid secretion, was equivalent between the two drugs.

IMPLICATIONS

The fixed-dose combination of esomeprazole and magnesium hydroxide showed rapid absorption and quicker gastric acid suppression than enteric-coated esomeprazole with comparable PK and PD properties.

CLINICALTRIALS

gov identifier: NCT04324905 (https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04324905).

Deprescribing strategies for proton pump inhibitors

ABSTRACT

Proton pump inhibitors (PPIs) are widely used for a number of gastric-acid related diseases. Although these agents demonstrate enhanced efficacy and tolerability compared with other acid-suppressive therapies, long-term use is associated with a number of adverse reactions. This article summarizes appropriate indications for short- and long-term use of PPIs and describes deprescribing strategies that clinicians can use to reduce unnecessary PPI use in their patients.

Gastroesophageal reflux disease: indications for antireflux surgery, outcomes, and side effects

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a frequent digestive disorder that presents with a broad spectrum of symptoms. Global consensus on which patients should be selected for anti-reflux surgery is lacking.

AREAS COVERED

This evidence-based review will analyze current indications for anti-reflux surgery, outcomes of the operation, and potential side effects.

EXPERT COMMENTARY

Treatment of GERD has three main purposes: control symptoms, improve quality of life, and prevent potential serious complications such as bleeding, esophageal stenosis, Barrett's esophagus, and esophageal adenocarcinoma. Although medical therapy is effective in the majority of patients, some might require anti-reflux surgery in order to achieve these goals. Adequate patient selection for anti-reflux surgery is critical to obtain optimal outcomes. Most patients undergoing a fundoplication have adequate long-term symptomatic relief. However, potential side effects of anti-reflux surgery should also be discussed with patients to help manage expectations from the operation.

Improving treatment of people with gastro-esophageal reflux disease refractory to proton pump inhibitors

Proton pump inhibitors (PPIs) are the main treatment recommended and used for gastro-esophageal reflux disease (GERD). However, they fail to control symptoms in a substantial proportion of patients who have PPI-refractory GERD, which is defined as persistent symptoms attributable to objective findings of gastro-esophageal reflux. There remains a lack of dedicated guidelines to direct the management of these patients, some of whom could benefit greatly from surgical treatment. Too often patients remain long-term on ineffective treatment or stop treatment with lack of active review often resulting in their dissatisfaction going unnoticed. Also, concerns over efficacy and side effects of surgical procedures can be off-putting for both patients and physicians. It has been suggested that response to PPIs is predictive of surgical outcome. In this Perspective article we instead recommend that the key determinant should be whether symptoms are caused by GERD. We also discuss the traditional and newer surgical treatment options for people with PPI-refractory GERD.

The Effects of Omeprazole on the Neuron-like Spiking of the Electrical Potential of Proteinoid Microspheres

This study examines a new approach to hybrid neuromorphic devices by studying the impact of omeprazole-proteinoid complexes on Izhikevich neuron models. We investigate the influence of these metabolic structures on five specific patterns of neuronal firing: accommodation, chattering, triggered spiking, phasic spiking, and tonic spiking. By combining omeprazole, a proton pump inhibitor, with proteinoids, we create a unique substrate that interfaces with neuromorphic models. The Izhikevich neuron model is used because it is computationally efficient and can accurately simulate the various behaviours of cortical neurons. The results of our simulations show that omeprazole-proteinoid complexes have the ability to affect neuronal dynamics in different ways. This suggests that they could be used as adjustable components in bio-inspired computer systems. We noticed a notable alteration in the frequency of spikes, patterns of bursts, and rates of adaptation, especially in chattering and triggered spiking behaviours. The findings indicate that omeprazole-proteinoid complexes have the potential to serve as adaptable elements in neuromorphic systems, presenting novel opportunities for information processing and computation that have origins in neurobiological principles. This study makes a valuable contribution to the expanding field of biochemical neuromorphic devices and establishes a basis for the development of hybrid bio-synthetic computational systems.

Proton Pump Inhibitor Usage in Urban vs. Rural Intensive Care Units: A Narrative Review of Implications for Standardization of Care

Intensive care unit (ICU) patients frequently require and benefit from stress ulcer prophylaxis (SUP) using proton pump inhibitors (PPIs). Despite recognized benefits, PPIs are overutilized in patients who do not have high-risk factors predisposing them to clinically significant gastrointestinal bleeding (CSGIB), including mechanical ventilation and coagulopathy. This overuse increases the risk of adverse effects associated with PPIs. Several urban healthcare systems have created educational initiatives aimed at reducing PPI usage in patients who do not meet recommendations or who are outside the period for serious risk of CSGIB. However, there was no available literature exploring PPI use or educational trends in rural hospitals. This situation presents an opportunity to investigate the disparities in PPI use between rural and urban healthcare settings. This narrative review aimed to assess current data on PPI usage in both urban and rural critical care environments, and to appraise existing practices, ultimately identifying gaps in current literature and informing future guidelines. With these evaluations, this review intended to provide a comprehensive overview of current PPI prescribing practices in the ICU and improve patient care across diverse healthcare settings.

The trends of pediatric duodenal ulcer and predictors of recurrence

BACKGROUND

Duodenal ulcer (DU) causes various symptoms in children. The prevalence of Helicobacter pylori (Hp)-associated DU has been reducing in some regions, yet the updated trend in Taiwan is unknown. Risk factors of DU recurrence have not been comprehensively investigated in children.

METHODS

This retrospective study included children diagnosed with DU to evaluate the demographics, symptoms, diagnostics, treatment, and outcomes. Specific populations (infant, surgery required) were sorted for subgroup analysis. Predictors of DU recurrence was analyzed in patients who received endoscopic follow-ups.

RESULTS

A total of 488 children were included. Most patients were male (72.5%), school-aged (11.3 ± 4.8 years old), and with varied underlying diseases in one-fifth. The annual incidences were around 3-5%, with a declining trend of case numbers and the Hp-positive proportion. Hp infection, concurrent gastric ulcer, perforation, and mortality were noted in 32.7%, 16%, 1.6%, and 1% of patients. Patients with or without Hp infection showed different clinical features but similar outcomes. The characteristics of subpopulations were depicted respectively. Male sex, lower Hb level, and perforation were independent risk factors associated with recurrence.

CONCLUSION

Hp-positive DU seems to wane. Patients with male sex, lower Hb level, or perforation at diagnosis carried a higher risk of recurrence, which may warrant active surveillance and endoscopic follow-up.

The association between proton-pump inhibitor use and recurrence of hepatocellular carcinoma after hepatectomy

BACKGROUND AND AIM

The association between long-term proton-pump inhibitors (PPIs) use and malignancies had long been discussed, but it still lacks consensus. Our study investigated the association between PPI use and hepatocellular carcinoma (HCC) recurrence following curative surgery.

METHODS

We retrospectively enrolled 6037 patients with HCC who underwent hepatectomy. Patients were divided into four groups according to their PPI usage. (non-users: < 28 cumulative defined daily dose [cDDD]; short-term users: 28-89 cDDD; mid-term users: 90-179 cDDD, and long-term users: ≥ 180 cDDD, respectively). Recurrence-free survival (RFS) and overall survival (OS) were analyzed using Kaplan-Meier method and Cox proportional hazard models.

RESULTS

Among the 6037 HCC patients, 2043 (33.84%) were PPI users. PPI users demonstrated better median RFS (3.10 years, interquartile range [IQR] 1.49-5.01) compared with non-users (2.73 years, IQR 1.20-4.74; with an adjusted hazard ratio [aHR] of 0.57, 95% confidence interval [CI] 0.44-0.74, P < 0.001). When considering the cumulative dosage of PPI, only long-term PPI users had significant lower risk of HCC recurrence than non-PPI group (adj-HR: 0.50; 95% CI: 0.35-0.70; P < 0.001). Moreover, the impact of long-term PPIs use on improving RFS was significant in most of the subgroup analysis, except in patients with advanced tumor stages, with non-cirrhosis, or with a history of chronic kidney disease. However, there were no significant differences in median OS between PPI users and non-users (4.23 years, IQR 2.73-5.86 vs 4.04 years, IQR 2.51-5.82, P = 0.369).

CONCLUSION

Long-term PPI use (≥ 180 cDDD) may be associated with a better RFS in HCC patients after hepatectomy.

Comparative Efficacy of Dexlansoprazole, Pantoprazole, Esomeprazole, and Rabeprazole in Achieving Optimal 24-Hour Intragastric pH Control: A Randomized Crossover Study Using Ambulatory pH Monitoring

INTRODUCTION

Proton pump inhibitors (PPIs) regulate gastric acid reflux. Dexlansoprazole's efficacy in prolonging acid suppression compared to conventional PPIs and placebo requires evaluation.

METHODS

A prospective, randomized, placebo-controlled, five-way crossover pilot study was conducted on healthy volunteers comparing the potency of dexlansoprazole to conventional PPIs in which five patients were randomized into five treatment cohorts, including dexlansoprazole 60 mg, pantoprazole 40 mg, esomeprazole 40 mg, rabeprazole 20 mg, and placebo, assessing 24-hour intragastric pH using Z/pH Recorder (ZepHr®, Diversatek, Inc., Milwaukee, WI) and analyzing statistical differences via paired t-test.

RESULTS

Dexlansoprazole showed significantly longer durations with pH > 4.0 compared to placebo (P < 0.001) and all other PPIs (P < 0.05) over 24 hours. Although not significant in the first 0-12-hour period, dexlansoprazole maintained significantly higher pH levels in the last 12-24-hour period compared to pantoprazole (P = 0.001) and esomeprazole (P = 0.044) but not with rabeprazole (P = 0.075). Additionally, during the 24-hour pH monitoring measured at 30-minute intervals, dexlansoprazole (mean pH = 3.98 ± 0.11) consistently showed higher values than pantoprazole (mean pH = 3.48 ± 0.12), rabeprazole (mean pH = 3.66 ± 0.05), esomeprazole (mean pH = 3.66 ± 0.05), and placebo (mean pH = 2.52 ± 0.12), indicating its superior potency.

CONCLUSION

Dexlansoprazole's dual-delayed release mechanism demonstrates superior acid suppression compared to traditional PPIs and placebo in this pilot study. Larger studies are needed to further evaluate its long-term efficacy and safety.

Intake of Proton Pump Inhibitors Is Associated with a Shorter Time to First Treatment in Early-Stage Chronic Lymphocytic Leukemia

INTRODUCTION

Proton pump inhibitors (PPIs) are one of the most widely used drugs worldwide [Gut Liver. 2017;11(1):27-37]. The use of PPI has become a common practice and is overprescribed for all patients with cancer including patients with hematological malignancies. In the current study, we aimed to explore retrospectively the effect of PPI, on time to first treatment (TTFT) in a large cohort of patients with chronic lymphocytic leukemia (CLL) who were under watch-and-wait approach.

METHODS

The cohort is based on anonymized data obtained from electronic medical records of Maccabi Healthcare Services (MHS) members, who is the second-largest healthcare organization in Israel, with 2.5 million insured patients, and received a diagnosis of CLL during this period.

RESULTS

Our cohort included 3,474 patients with CLL who are treatment-naïve, and the median follow-up was 1,745 days (602-3,700). A total of 1,061 patients (30.5%) received a PPI agent, for a minimum of 3 months during the watch-and-wait period. The intake of PPI was found to be associated with a shorter TTFT: among PPI users, the 10-year treatment-free ratio is 79.2%, while among non-PPI users it is 90.6%.

CONCLUSION

Routine use of PPI in CLL patients may negatively impact their clinical course. Biology of this primary observation requires further investigation.

Development of Gastroretentive Floating Combination Tablets Containing Amoxicillin Trihydrate 500 mg and Levofloxacin 125 mg for Eradicating Resistant Helicobacter pylori

Background/Objectives: The aim of this work was to prepare and characterize gastroretentive floating combination tablets (GRCTs) containing 500 mg of amoxicillin trihydrate (AMX) and 125 mg of levofloxacin (LVX) that provide sustained drug release and stability at gastric pH levels for the eradication of resistant Helicobacter pylori. Method: GRCTs were prepared with low-density excipients and hydrophilic swellable polymers, including hydroxypropyl methylcellulose (HPMC) of various viscosities, polyethylene oxide (PEO), and carboxymethylcellulose (CMC), by the direct compression method. The prepared GRCTs were investigated and optimized in terms of pH stability, tablet hardness, floating lag time and total floating time, drug release rate, gel strength. Results: AMX and LVX in GRCT were stable at the HP eradication target pH above 4.0. The effervescent GRCT composition (AMX/LVX/HPMC [4000 cP]/CMC/microcrystalline cellulose/citric acid/sodium bicarbonate/calcium silicate/silicon dioxide/magnesium stearate = 500/125/50/50/125/40/60/30/10/10, w/w) yielded acceptable hardness (>6 kp), reduced floating lag time (<5 s), a long floating duration (>12 h), and sustained release rates of AMX and LVX (>90% until 12 h). This optimized GRCT had a gel strength of 107.33 ± 10.69 g and pH > 4.0, which maintained the tablets' shape and AMX stability for 12 h. Conclusions: Collectively, the formulated effervescent GRCTs combining AMX and LVX represented a promising candidate dosage form for eradicating resistant H. pylori.

Analytical quality by design-based development of a capillary electrophoresis method for Omeprazole impurity profiling

Omeprazole (OME) is a proton pump inhibitor used to treat gastroesophageal reflux disease associated conditions. The current study presents an Analytical Quality by Design-based approach for the development of a CE method for OME impurity profiling. The scouting experiments suggested the selection of solvent modified Micellar ElectroKinetic Chromatography operative mode using a pseudostationary phase composed of sodium dodecyl sulfate (SDS) micelles and n-butanol as organic modifier in borate buffer. A symmetric three-level screening matrix 37//16 was used to evaluate the effect of Critical Method Parameters, including Background Electrolyte composition and instrumental settings, on Critical Method Attributes (critical resolution values, OME peak width and analysis time). The analytical procedure was optimized using Response Surface Methodology through a Central Composite Orthogonal Design. Risk of failure maps made it possible to define the Method Operable Design Region, within which the following optimized conditions were selected: 72 mM borate buffer pH 10.0, 96 mM SDS, 1.45 %v/v n-butanol, capillary temperature 21 °C, applied voltage 25 kV. The method was validated according to ICH guidelines and robustness was evaluated using a Plackett-Burman design. The developed procedure enables the simultaneous determination of OME and seven related impurities, and has been successfully applied to the analysis of pharmaceutical formulations.

Efficacy and safety of Vonoprazan-based treatment of Helicobacter pylori infection: a systematic review and network meta-analysis

OBJECTIVE

The aim of this study was to evaluate the effectiveness and safety of the nine most widely studied Vonoprazan (VPZ)-based treatment regimens along with traditional Proton pump inhibitor (PPI)-based treatment regimens in eradicating Helicobacter pylori (H. pylori) infection.

DESIGN

Through searching PubMed, Embase, Cochrane Library, Web of Science, we exclusively included randomized controlled trials (RCTs) to investigate the efficacy of VPZ-based and PPI-based therapies for H. pylori infection. The included studies were evaluated for methodological quality using the Cochrane bias risk assessment tool, and the data analysis software was used to analyze the data accordingly.

RESULTS

The RCTs were collected from the earliest available date up to August 2023. Twenty-one RCTs were included, with a total sample size of 5481. The results of the network meta-analysis showed that the eradication rate of the VPZ-based quadruple 14-day (VPZ-Q14) treatment regimen in Intention-to-treat (ITT) analysis was the highest (SUCRA: 0.874); The eradication rate of the VPZ-based quadruple 10-day (VPZ-Q10) treatment plan in Per-protocol (PP) analysis was the highest (SUCRA: 0.849). All regimens were well tolerated without significant differences. According to the probability ranking of safety, high-dose VPZ-based dual 14-day therapy (H-VPZ-D14) ranked first in SUCRA, reaching 0.952. This indicates that H-VPZ-D14 treatment is the safest with a relatively low incidence of adverse effect. Therefore, VPZ-based therapies not only have a higher eradication rate, but also possess satisfactory safety.

CONCLUSION

Compared with traditional PPI-based therapies, VPZ-based therapies have shown superior eradication effects. Based on the Ranking Plot of the Network, the VPZ-Q14 or VPZ-Q10 treatment regimen for H. pylori has a higher eradication rate and acceptable differences compared to other treatment regimens. In addition, for regions with high antibiotic resistance rates, we recommend a 14-day quadruple therapy with bismuth based on VPZ.

Turn over the new leaf of the treatment in peptic ulcer bleeding: a review of the literature

Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, which has a high mortality risk. The standard therapy for acute peptic ulcer bleeding combines medication administration and endoscopic therapies. Both pharmacologic and endoscopic therapies have developed continuously in the past few decades. Proton pump inhibitors (PPIs) already reached a high efficacy in ulcer healing and have been widely used in the past few decades. Endoscopic hemostasis, which includes local epinephrine injection, heater probe coagulation, use of hemostatic clips, and/or band ligation, is highly effective with an overall hemostatic success rate of 85%-90%. However, 10%-20% of patients could not be cured by the current standard combination treatment. Recurrent ulcer bleeding, despite an initial successful hemostasis, is also a big problem for longer hospitalization stays, higher mortality, and higher complication rates, especially for malignant ulcer bleeding. How to manage all types of peptic ulcer bleeding and how to prevent early recurrent peptic ulcer bleeding remain unresolved clinical problems. Recently, several novel medications and endoscopic methods have been developed. Potassium competitive acid blockers have shown a stronger and longer acid suppression than PPI. Hemostatic powder spray and hemostatic gel emulsion are novel hemostatic weapons with emerging evidence, which are potential missing pieces of the puzzle. This literature review will go through the development of endoscopic hemostasis to the prospects of novel endoscopic treatments.

Emerging trends and hotspots in peptic ulcer from 2008 to 2023: A bibliometric analysis

Peptic ulcer (PU) is a common digestive disorder in the gastroduodenal. Although bibliometrics has become very popular in the medical field, a bibliometric analysis of research related to PU has yet to be reported. Therefore, this research aims to analyze the trends and hotspots of PU in the last 15 years. Literature data related to PU retrieved from the Web of Science Core Collection database from 2008 to 2023 were visualized and analyzed using CiteSpace 6.1.6.msi, VOSviewer 1.6.19, and SCImago Graphica Beta 1.0.35. Six thousand four hundred ninety-one papers were collected based on inclusion and exclusion criteria. The country with the highest number of publications was China. The institution with the highest number of publications was Baylor College of Medicine. The most prolific author was Yamaoka Yoshio. Malfertheiner Peter had the highest number of citations. The journal with the most publications is World Journal of Gastroenterology. The most cited Journal is Gastroenterology. The most cited reference was published by Marshall B. J. et al in 1984. The article with the highest burst strength was published in 2012 by Malfertheiner Peter. The keyword with the highest burst strength was "oxidative stress." Our research provides a bibliometric analysis of PU research to reveal the trends and hotspots of PU for 2008 to 2023. Our findings will help researchers to quickly understand the current state of research and provide a reference for in-depth studies in this area to foster the development of PU research.