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Lee SR, Ahn HJ, Choi EK, Park SH, Han KD, Oh S, Lip GYH. Reduction of Upper Gastrointestinal Bleeding Risk With Proton Pump Inhibitor Therapy in Asian Patients With Atrial Fibrillation Receiving Direct Oral Anticoagulant: A Nationwide Population-based Cohort Study. Clin Gastroenterol Hepatol 2024; 22:981-993.e11. [PMID: 38184099 DOI: 10.1016/j.cgh.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND & AIMS In patients with atrial fibrillation (AF) receiving direct oral anticoagulant (DOAC), upper gastrointestinal bleeding (UGIB) is a serious complication. There are limited data on the benefit of preventive proton pump inhibitor (PPI) use to reduce the risk of UGIB in DOAC users. METHODS We included patients with AF receiving DOAC from 2015 to 2020 based on the Korean Health Insurance Review and Assessment database. The propensity score (PS) weighting method was used to compare patients with PPI use and those without PPI use. The primary outcome was hospitalization for UGIB. Weighted hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were evaluated using the Cox proportional hazards regression model. RESULTS A total of 165,624 patients were included (mean age: 72.2 ± 10.8 years; mean CHA2DS2-VASc score: 4.3 ± 1.8; mean HAS-BLED score: 3.3 ± 1.2). Among them, 99,868 and 65,756 were in the non-PPI group and PPI group, respectively. During a median follow-up of 1.5 years, the PPI group was associated with lower risks of hospitalization for UGIB and UGIB requiring red blood cell transfusion than non-PPI group (weighted HR, 0.825; 95% CI, 0.761-0.894 and 0.798; 95% CI, 0.717-0.887, respectively, both P < .001). The benefits of PPI on the risk of hospitalization for UGIB were greater in those with older age (≥75 years), higher HAS-BLED score (≥3), prior GIB history, and concomitant use of antiplatelet agent (all P-for-interaction < .1). Low-dose PPI was consistently associated with a lower risk of significant UGIB by 43.6-49.3% (P < .001). CONCLUSIONS In this large Asian cohort of patients with AF on DOAC, PPI co-therapy is beneficial for reducing the risk of hospitalization for UGIB, particularly in high-risk patients.
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Affiliation(s)
- So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Sang-Hyun Park
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung-Do Han
- Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y H Lip
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Fischbach W, Bornschein J, Hoffmann JC, Koletzko S, Link A, Macke L, Malfertheiner P, Schütte K, Selgrad DM, Suerbaum S, Schulz C. Update S2k-Guideline Helicobacter pylori and gastroduodenal ulcer disease of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:261-321. [PMID: 38364851 DOI: 10.1055/a-2181-2225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
| | - Jan Bornschein
- Translational Gastroenterology Unit John, John Radcliffe Hospital Oxford University Hospitals, Oxford, United Kingdom
| | - Jörg C Hoffmann
- Medizinische Klinik I, St. Marien- und St. Annastiftskrankenhaus, Ludwigshafen, Deutschland
| | - Sibylle Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum Munich, Munich, Deutschland
- Department of Paediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Alexander Link
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Lukas Macke
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Peter Malfertheiner
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
| | - Kerstin Schütte
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Niels-Stensen-Kliniken Marienhospital Osnabrück, Osnabrück, Deutschland
| | - Dieter-Michael Selgrad
- Medizinische Klinik Gastroenterologie und Onkologie, Klinikum Fürstenfeldbruck, Fürstenfeldbruck, Deutschland
- Klinik für Innere Medizin 1, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Sebastian Suerbaum
- Universität Munich, Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Munich, Deutschland
- Nationales Referenzzentrum Helicobacter pylori, Pettenkoferstr. 9a, 80336 Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Christian Schulz
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
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3
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Drusch S, Neumann A, Michelon H, Pépin M, Zureik M, Herr M. Do Proton Pump Inhibitors Reduce Upper Gastrointestinal Bleeding in Older Patients with Atrial Fibrillation Treated with Oral Anticoagulants? A Nationwide Cohort Study in France. Drugs Aging 2024; 41:65-76. [PMID: 38114724 PMCID: PMC10769917 DOI: 10.1007/s40266-023-01085-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are largely used in older adults and data are needed in off-label indications, such as the prevention of upper gastrointestinal bleeding (UGIB) in patients receiving oral anticoagulants (OACs). This study aimed to assess whether PPIs reduce the risk of UGIB in patients initiating oral anticoagulation. METHODS We conducted a longitudinal study based on the French national health database. The study population included 109,693 patients aged 75-110 years with a diagnosis of atrial fibrillation who initiated OACs [vitamin K antagonist (VKA) or direct OAC (DOAC)] between 2012 and 2016. We used multivariable Cox models weighted by inverse of probability of treatment to estimate the adjusted hazard ratio (aHR) of UGIB between PPI users and nonusers over a 6- and 12-month follow-up. RESULTS PPI users represented 23% of the study population (28% among VKA initiators and 17% among DOAC initiators). The mean age (83 ± 5.3 years) and proportion of women (near 60%) were similar between groups. The risk of UGIB in the first 6 months after initiation of OAC decreased by 20% in PPI users compared with PPI nonusers [aHR6 months = 0.80, 95% confidence interval (CI) 0.65-0.98], but was not significantly modified when the follow-up was extended to 12 months (aHR12 months = 0.90, 95% CI 0.76-1.07), with a stronger effect among patients treated with vitamin K antagonists (aHR6 months = 0.73, 95% CI 0.58-0.93; aHR12 months = 0.81, 95% CI 0.67-0.99). CONCLUSIONS This study suggests that PPIs were associated with reduced risk of gastrointestinal bleeding after initiation of oral anticoagulation in older patients with atrial fibrillation, particularly within 6 months after initiation of an antivitamin K antagonist.
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Affiliation(s)
- Solene Drusch
- EPI-PHARE, Epidemiology of Health Products (French National Agency for Medicines and Health Products Safety, and French National Health Insurance), Saint-Denis, France.
- Anti-Infective Evasion and Pharmacoepidemiology, University of Paris-Saclay, UVSQ, Inserm, Montigny-le-Bretonneux, France.
| | - Anke Neumann
- EPI-PHARE, Epidemiology of Health Products (French National Agency for Medicines and Health Products Safety, and French National Health Insurance), Saint-Denis, France
| | - Hugues Michelon
- Pharmacy Department, Sainte-Périne Hospital, GHU AP-HP, University of Paris-Saclay, Paris, France
| | - Marion Pépin
- Geriatrics Department, Ambroise Paré Hospital, GHU AP-HP, University of Paris-Saclay, Boulogne-Billancourt, France
- Clinical Epidemiology, University of Paris-Saclay, UVSQ, Inserm, Villejuif, France
| | - Mahmoud Zureik
- EPI-PHARE, Epidemiology of Health Products (French National Agency for Medicines and Health Products Safety, and French National Health Insurance), Saint-Denis, France
- Anti-Infective Evasion and Pharmacoepidemiology, University of Paris-Saclay, UVSQ, Inserm, Montigny-le-Bretonneux, France
| | - Marie Herr
- Anti-Infective Evasion and Pharmacoepidemiology, University of Paris-Saclay, UVSQ, Inserm, Montigny-le-Bretonneux, France
- Epidemiology and Public Health department, Raymond Poincaré Hospital, GHU AP-HP, University of Paris-Saclay, Garches, France
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Dutta AK, Jain A, Jearth V, Mahajan R, Panigrahi MK, Sharma V, Goenka MK, Kochhar R, Makharia G, Reddy DN, Kirubakaran R, Ahuja V, Berry N, Bhat N, Dutta U, Ghoshal UC, Jain A, Jalihal U, Jayanthi V, Kumar A, Nijhawan S, Poddar U, Ramesh GN, Singh SP, Zargar S, Bhatia S. Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship. Indian J Gastroenterol 2023; 42:601-628. [PMID: 37698821 DOI: 10.1007/s12664-023-01428-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/10/2023] [Indexed: 09/13/2023]
Abstract
Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.
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Affiliation(s)
- Amit Kumar Dutta
- Department of Gastroenterology, Christian Medical College and Hospital, Vellore, 632 004, India.
| | | | - Vaneet Jearth
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ramit Mahajan
- Dayanand Medical College and Hospital, Ludhiana, 141 001, India
| | | | - Vishal Sharma
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | | | | | - Govind Makharia
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | | | - Richard Kirubakaran
- Center of Biostatistics and Evidence Based Medicine, Vellore, 632 004, India
| | - Vineet Ahuja
- All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Neha Berry
- BLK Institute of Digestive and Liver Disease, New Delhi, 201 012, India
| | - Naresh Bhat
- Aster CMI Hospital, Bengaluru, 560 092, India
| | - Usha Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Uday Chand Ghoshal
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ajay Jain
- Choithram Hospital and Research Center, Indore, 452 014, India
| | | | - V Jayanthi
- Sri Ramachandra Medical College, Chennai, 600 116, India
| | - Ajay Kumar
- Institute of Digestive and Liver Diseases, BLK - Max Superspeciality Hospital, New Delhi, 201 012, India
| | | | - Ujjal Poddar
- Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, 226 014, India
| | | | - Shivram P Singh
- Kalinga Gastroenterology Foundation, Cuttack, 753 001, India
| | - Showkat Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, 190 011, India
| | - Shobna Bhatia
- Sir H N Reliance Foundation Hospital, Mumbai, 400 004, India
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Aktualisierte S2k-Leitlinie Helicobacter
pylori und gastroduodenale Ulkuskrankheit der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – Juli 2022 – AWMF-Registernummer: 021–001. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:544-606. [PMID: 37146633 DOI: 10.1055/a-1975-0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
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Burgos-Gonzalez AD, Huerta C, Peñalver MJ, Sordo L, Pulido J, Soriano LC. Effect of tramadol and DOACs with special attention to dabigatran on concomitant use, on the risk of mayor bleeding using BIFAP database in Spain. Pharmacoepidemiol Drug Saf 2023; 32:397-406. [PMID: 36180248 DOI: 10.1002/pds.5525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/05/2022] [Accepted: 07/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Tramadol, a weak opioid, inhibits the reuptake of serotonin, a key feature on vascular homeostasis. A suspected interaction exists between dabigatran and tramadol, which might trigger an excess on risk of bleeding however, there is a gap in knowledge on this topic. PURPOSE To estimate the effects of tramadol, dabigatran and concomitant use on the risk of hospitalized major bleeds (Gastrointestinal bleeding and intra-extracranial bleeds). METHODS Among a validated established cohort of new users of oral anticoagulants for non-valvular atrial fibrillation (NVAF) aged 18 years or older, we identified all hospitalized bleed episodes (GIB and extra/intracranial bleeds) within 2008-2015. A nested case-control analysis was conducted using conditional logistic regression. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated for dabigatran, tramadol, and concomitant use. Several sensitivity analyses were carried out. RESULTS aORs (95%CIs) for current use of only dabigatran, only tramadol and concomitant users were 1.73 (1.37-2.18) and 1.38 (1.13-1.67) and 2.04 (0.74-5.67) compared with non-users of both drugs (>365 days). aORs for current continuers and non-continuer users of dabigatran were 1.36 (1.00-1.86) and 2.19 (1.61-2.98), respectively. For the latter, non-continuer users with a short duration of dabigatran cumulated the highest risk (3.36 [1.88-5.99]). There also was an increased risk with concomitant use of tramadol and rivaroxaban (2.24 [1.19-4.21]), or antagonist of vitamin K (1.30 [1.00-1.69]). CONCLUSION There was a trend towards and increased risk of excess bleeds when using concomitantly with dabigatran. The effect decreases with a narrower definition of current use.
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Affiliation(s)
- Airam de Burgos-Gonzalez
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
- BIFAP, Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Consuelo Huerta
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - María José Peñalver
- Centro de Farmacovigilancia de la Región de Murcia, Consejería de Salud de la Región de Murcia, Murcia, Spain
| | - Luis Sordo
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
- CIBER Epidemiology and Public Health (CIBERESP)
| | - José Pulido
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
- CIBER Epidemiology and Public Health (CIBERESP)
| | - Lucía Cea Soriano
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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7
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Ahn HJ, Lee SR, Choi EK, Rhee TM, Kwon S, Oh S, Lip GYH. Protective effect of proton pump inhibitor against gastrointestinal bleeding in patients receiving oral anticoagulants: A systematic review and meta-analysis. Br J Clin Pharmacol 2022; 88:4676-4687. [PMID: 35921204 DOI: 10.1111/bcp.15478] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/22/2022] [Accepted: 07/27/2022] [Indexed: 11/28/2022] Open
Abstract
AIM The evidence of a protective effect of proton pump inhibitor (PPI) in oral anticoagulant (OAC) treated patients against gastrointestinal bleeding (GIB) is still lacking. We conducted a meta-analysis to estimate the risk of GIB in patients with OAC and PPI co-therapy. METHODS A systematic search of PubMed, EMBASE, Cochrane, and Scopus databases was performed for studies reporting GIB risk in OAC and PPI co-therapy. Primary outcomes were total GIB and major GIB events. Pooled estimates of GIB risk were calculated by a random-effect meta-analysis and reported as odds ratios (OR) and 95% confidence interval (CI). RESULTS A total of 10 studies and 1,970,931 patients were included. OAC and PPI co-therapy were associated with a lower odds of total and major GIB; OR (95% CI) was 0.67 (0.62-0.74) for total and 0.68 (0.63-0.75) for major GIB, respectively. No differences in the GIB of PPI co-therapy were observed between Asians and non-Asians (p-for-difference, total GIB=0.70, major GIB=0.75, respectively). For all kinds of OAC except for edoxaban, PPI cotreatment was related to a lower odds of GIB by 24-44%. The protective effect of PPI on total GIB was more significant in concurrent antiplatelets or non-steroidal anti-inflammatory drug users and those with high bleeding risks: patients with previous GIB history, HAS-BLED ≥3, or underlying gastrointestinal diseases. CONCLUSION In patients who receive OAC, PPI co-therapy is associated with a lower total and major GIB irrespective of ethnic group and OAC type, except for edoxaban. PPI co-therapy can be considered particularly in high GIB risk patients.
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Affiliation(s)
- Hyo-Jeong Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae-Min Rhee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y H Lip
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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8
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Ben Ghezala I, Luu M, Bardou M. An update on drug-drug interactions associated with proton pump inhibitors. Expert Opin Drug Metab Toxicol 2022; 18:337-346. [PMID: 35787720 DOI: 10.1080/17425255.2022.2098107] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) block the gastric H/K-ATPase, therefore inhibiting acid gastric secretion, leading to an increased pH (>4). They account for an extremely high number of prescriptions worldwide. Numerous drug-drug interactions have been described with PPIs, but all the described interactions do not have clinical significance. AREAS COVERED This review will discuss the latest updates on drug-drug interactions with PPIs, focusing on the last ten-year publications in the following areas: anti-infective agents, anticancer drugs, antiplatelet agents and anticoagulants, and antidiabetics. EXPERT OPINION Although pharmacokinetic interactions of PPIs have been described with many drugs, their clinical relevance remains controversial. However, given the extremely high number of people being treated with PPIs, clinicians should remain vigilant for interactions that may be clinically significant and require dose adjustment or therapeutic monitoring. Interestingly, not all PPIs have the same pharmacokinetic and pharmacodynamic profile, with some having a strong potential to inhibit CYP2C19, such as omeprazole, esomeprazole and lansoprazole, while others, pantoprazole, rabeprazole and dexlansoprazole, are weak CYP2C19 inhibitors. These may be preferred depending on co-prescribed treatments.In addition, new formulations have been developed to prevent some of the gastric pH-dependent drug interactions and should be evaluated in further large-scale prospective comparative studies.
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Affiliation(s)
- Inès Ben Ghezala
- INSERM, CIC1432, Plurithematic Unit, 21079 Dijon, France.,Centre d'Investigations Cliniques, Dijon Bourgogne University Hospital, 21079 Dijon, France.,Ophthalmology Department, Dijon Bourgogne University Hospital, 21079 Dijon, France
| | - Maxime Luu
- INSERM, CIC1432, Plurithematic Unit, 21079 Dijon, France.,Centre d'Investigations Cliniques, Dijon Bourgogne University Hospital, 21079 Dijon, France
| | - Marc Bardou
- INSERM, CIC1432, Plurithematic Unit, 21079 Dijon, France.,Centre d'Investigations Cliniques, Dijon Bourgogne University Hospital, 21079 Dijon, France.,Gastroenterology Department, Dijon Bourgogne University Hospital, 21079 Dijon, France
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9
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Wang M, Paterson M, Thabane L, Siegal D, Mbuagbaw L, Targownik L, Holbrook A. Association of direct oral anticoagulant-proton pump inhibitor cotherapy with adverse outcomes: protocol for a population-based cohort study. BMJ Open 2022; 12:e057991. [PMID: 35697453 PMCID: PMC9196177 DOI: 10.1136/bmjopen-2021-057991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Proton pump inhibitors (PPIs) are widely used for primary and secondary prevention of upper gastrointestinal bleeding. However, there remains controversy about the overall net clinical benefit of PPIs (omeprazole, rabeprazole, pantoprazole, lansoprazole) when coprescribed with direct oral anticoagulants (DOACs; dabigatran, rivaroxaban, apixaban, edoxaban). Our objective is to explore the risk of clinically relevant events, including bleeding, thromboembolic events and death, in patients prescribed DOACs while taking PPIs versus no PPI. METHODS AND ANALYSIS The protocol describes a retrospective cohort study of all Ontario residents aged 66 years or older with atrial fibrillation and at least one pharmacy dispensation for a DOAC identified using linked administrative healthcare databases covering 2009-2020. Ontario drug benefit dispensation records will be used to ascertain PPI exposure during DOAC therapy. The primary outcome is a composite of clinically relevant bleeding, thrombotic events or all-cause death. A minimum of 520 patients in total with at least one of the components of the composite outcome are needed. Poisson regression with a generalised estimating equation model will be used to calculate the adjusted incidence rate difference, incidence rate ratios 95% CI, adjusting for propensity for PPI use using inverse probability of treatment weights. ETHICS AND DISSEMINATION This research is exempt from REB review under section 45 of Ontario's Personal Health Information Protection Act. We will report our findings in a peer-reviewed biomedical journal and present them at conferences. The study will provide useful evidence to optimise the coprescription of DOACs and PPIs in practice.
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Affiliation(s)
- Mei Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Pharmacology & Toxicology, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Michael Paterson
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- The Research Institute of St. Joseph's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Biostatistics Unit, Research Institute of St. Joseph's Hamilton, Hamilton, Ontario, Canada
| | - Deborah Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Research Institute of St. Joseph's Hamilton, Hamilton, Ontario, Canada
| | - Laura Targownik
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Clinical Pharmacology & Toxicology, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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10
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Dong Y, He S, Li X, Zhou Z. Prevention of nNon-Vitamin K Oral Anticoagulants-Related Gastrointestinal Bleeding With Acid Suppressants: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2022; 28:10760296211064897. [PMID: 35037779 PMCID: PMC8777378 DOI: 10.1177/10760296211064897] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Whether the use of acid suppressants can reduce non-vitamin K oral anticoagulants
(NOACs)-related gastrointestinal bleeding (GIB) remains unclear. To systemically
evaluate the effect of acid suppressants on the risk of GIB in patients treated
with NOACs. All related studies were searched in four databases (Cochrane,
Embase, PubMed, and Web of Science) from their establishment to August 10, 2021.
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
statement was used to identify studies and Stata 16.0 software was used for
meta-analysis, including sensitivity and subgroup analysis. Six retrospective
cohort studies were included in this study. The use of acid suppressants
significantly reduced the GIB risk in patients taking NOACs, with an overall
relative risk (RR) of 0.70 (95% confidence interval [CI]: 0.61-0.82;
P < 0.001; I2 = 56.3%). This trend of reduced risk for GIB in
NOACs was more significant in upper GIB (UGIB; RR: 0.45; 95%CI: 0.22-0.90;
P = 0.025; I2 = 71.1%). The reduction was stronger for dabigatran
than for rivaroxaban and apixaban. The least reduction in the risk of GIB with
acid suppressant co-therapy was rivaroxaban (dabigatran: RR: 0.53; 95% CI:
0.45-0.62; P = <0.001; I2 = 39.8%; apixaban: RR: 0.67; 95% CI:
0.54-0.84; P = <0.001; I2 = 0; rivaroxaban: RR: 0.73; 95% CI:
0.66-0.81; P = <0.001; I2 = 37.6%). The included studies revealed
the protective effect of acid suppressants against NOACs-related GIB, especially
in the upper gastrointestinal tract. The protective effect was even stronger in
patients using dabigatran than in those using Xa inhibitors (rivaroxaban and
apixaban).
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Affiliation(s)
- Yongqi Dong
- 585250The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Song He
- 585250The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xue Li
- 585250The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhihang Zhou
- 585250The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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11
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Glasgow-Blatchford Score Predicts Post-Discharge Gastrointestinal Bleeding in Hospitalized Patients with Heart Failure. J Clin Med 2020; 9:jcm9124083. [PMID: 33348860 PMCID: PMC7766138 DOI: 10.3390/jcm9124083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 12/20/2022] Open
Abstract
Background: The Glasgow-Blatchford Score (GBS) is one of the most widely used scoring systems for predicting clinical outcomes for gastrointestinal bleeding (GIB). However, the clinical significance of the GBS in predicting GIB in patients with heart failure (HF) remains unclear. Methods and Results: We conducted a prospective observational study in which we collected the clinical data of a total of 2236 patients (1130 men, median 70 years old) who were admitted to Fukushima Medical University Hospital for acute decompensated HF. During the post-discharge follow-up period of a median of 1235 days, seventy-eight (3.5%) patients experienced GIB. The GBS was calculated based on blood urea nitrogen, hemoglobin, systolic blood pressure, heart rate, and history of hepatic disease. The survival classification and regression tree analysis revealed that the accurate cut-off point of the GBS in predicting post-discharge GIB was six points. The patients were divided into two groups: the high GBS group (GBS > 6, n = 702, 31.4%) and the low GBS group (GBS ≤ 6, n = 1534, 68.6%). The Kaplan–Meier analysis showed that GIB rates were higher in the high GBS group than in the low GBS group. Multivariate Cox proportional hazards analysis adjusted for age, malignant tumor, and albumin indicated that a high GBS was an independent predictor of GIB (hazards ratio 2.258, 95% confidence interval 1.326–3.845, p = 0.003). Conclusions: A high GBS is an independent predictor and useful risk stratification score of post-discharge GIB in patients with HF.
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12
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Martin TA, Wan DW, Hajifathalian K, Tewani S, Shah SL, Mehta A, Kaplan A, Ghosh G, Choi AJ, Krisko TI, Fortune BE, Crawford CV, Sharaiha RZ. Gastrointestinal Bleeding in Patients With Coronavirus Disease 2019: A Matched Case-Control Study. Am J Gastroenterol 2020; 115:1609-1616. [PMID: 32796176 PMCID: PMC7446989 DOI: 10.14309/ajg.0000000000000805] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Although current literature has addressed gastrointestinal presentations including nausea, vomiting, diarrhea, abnormal liver chemistries, and hyperlipasemia as possible coronavirus disease 2019 (COVID-19) manifestations, the risk and type of gastrointestinal bleeding (GIB) in this population is not well characterized. METHODS This is a matched case-control (1:2) study with 41 cases of GIB (31 upper and 10 lower) in patients with COVID-19 and 82 matched controls of patients with COVID-19 without GIB. The primary objective was to characterize bleeding etiologies, and our secondary aim was to discuss outcomes and therapeutic approaches. RESULTS There was no difference in the presenting symptoms of the cases and controls, and no difference in severity of COVID-19 manifestations (P > 0.05) was observed. Ten (32%) patients with upper GIB underwent esophagogastroduodenoscopy and 5 (50%) patients with lower GIBs underwent flexible sigmoidoscopy or colonoscopy. The most common upper and lower GIB etiologies were gastric or duodenal ulcers (80%) and rectal ulcers related to rectal tubes (60%), respectively. Four of the esophagogastroduodenoscopies resulted in therapeutic interventions, and the 3 patients with rectal ulcers were referred to colorectal surgery for rectal packing. Successful hemostasis was achieved in all 7 cases that required interventions. Transfusion requirements between patients who underwent endoscopic therapy and those who were conservatively managed were not significantly different. Anticoagulation and rectal tube usage trended toward being a risk factor for GIB, although it did not reach statistical significance. DISCUSSION In COVID-19 patients with GIB, compared with matched controls of COVID-19 patients without GIB, there seemed to be no difference in initial presenting symptoms. Of those with upper and lower GIB, the most common etiology was peptic ulcer disease and rectal ulcers from rectal tubes, respectively. Conservative management seems to be a reasonable initial approach in managing these complex cases, but larger studies are needed to guide management.
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Affiliation(s)
- Tracey A. Martin
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - David W. Wan
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Kaveh Hajifathalian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Sunena Tewani
- Division of Hospital Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Shawn L. Shah
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Amit Mehta
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Alyson Kaplan
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Gaurav Ghosh
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Anthony J. Choi
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Tibor I. Krisko
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Brett E. Fortune
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Carl V. Crawford
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Reem Z. Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
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