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Wirth T, Lafforgue P, Pham T. NSAID: Current limits to prescription. Joint Bone Spine 2023; 91:105685. [PMID: 38159794 DOI: 10.1016/j.jbspin.2023.105685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/03/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed to alleviate pain and inflammation in conditions like arthritis, migraines, and post-operative recovery. Their mechanism involves inhibiting prostaglandins that contribute to inflammation. NSAIDs are categorized based on their structure, selectivity for COX-1 and COX-2 enzymes, and plasma half-life. They are effective in treating osteoarthritis, spondyloarthritis, and rheumatoid arthritis but might carry an elevated risk of adverse events. Despite their effectiveness, NSAIDs have limitations and risks that warrant cautious consideration. Extensive research has investigated their side effects, and this review aims to examine the current limitations of oral NSAID therapy, including safety profiles, specific scenarios where their use may not be appropriate, and gaps in knowledge. By critically evaluating these aspects, healthcare practitioners can make informed decisions about prescribing NSAIDs, optimizing patient outcomes while minimizing potential risks. This narrative review summarizes existing knowledge and underscores the importance of risk-benefit assessments in NSAID prescribing. Ultimately, the goal is to enhance the rational use of NSAIDs, maximizing benefits while mitigating adverse effects.
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Affiliation(s)
- Theo Wirth
- Service de rhumatologie, AP-HM, CHU Sainte-Marguerite, Aix-Marseille University, boulevard Sainte-Marguerite, 13009 Marseille, France; Autoimmune Arthritis Laboratory, Inserm UMRs1097, Aix-Marseille University, Marseille, France
| | - Pierre Lafforgue
- Service de rhumatologie, AP-HM, CHU Sainte-Marguerite, Aix-Marseille University, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - Thao Pham
- Service de rhumatologie, AP-HM, CHU Sainte-Marguerite, Aix-Marseille University, boulevard Sainte-Marguerite, 13009 Marseille, France.
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2
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Mihai IR, Burlui AM, Rezus II, Mihai C, Macovei LA, Cardoneanu A, Gavrilescu O, Dranga M, Rezus E. Inflammatory Bowel Disease as a Paradoxical Reaction to Anti-TNF-α Treatment-A Review. Life (Basel) 2023; 13:1779. [PMID: 37629636 PMCID: PMC10455403 DOI: 10.3390/life13081779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/06/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
TNF-α inhibitors (TNFis) have revolutionized the treatment of certain chronic immune-mediated diseases, being widely and successfully used in rheumatic inflammatory diseases, and have also proved their efficacy in the treatment of inflammatory bowel disease (IBD). However, among the side effects of these agents are the so-called paradoxical effects. They can be defined as the appearance or exacerbation of a pathological condition that usually responds to this class of drug while treating a patient for another condition. A wide range of paradoxical effects have been reported including dermatological, intestinal and ophthalmic conditions. The causal mechanism of occurrence may implicate an imbalance of cytokines, but is still not fully understood, and remains a matter of debate. These paradoxical reactions often show improvement on discontinuation of the medication or on switching to another TNFi, but in some cases it is a class effect that could lead to the withdrawal of all anti-TNF agents. Close monitoring of patients treated with TNFis is necessary in order to detect paradoxical reactions. In this study we focus on reviewing IBD occurrence as a paradoxical effect of TNFi therapy in patients with rheumatological diseases (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and juvenile idiopathic arthritis).
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Affiliation(s)
- Ioana Ruxandra Mihai
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.A.M.); (A.C.); (E.R.)
| | - Alexandra Maria Burlui
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.A.M.); (A.C.); (E.R.)
| | - Ioana Irina Rezus
- Department of Dermatovenerology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Cătălina Mihai
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (C.M.); (O.G.); (M.D.)
| | - Luana Andreea Macovei
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.A.M.); (A.C.); (E.R.)
| | - Anca Cardoneanu
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.A.M.); (A.C.); (E.R.)
| | - Otilia Gavrilescu
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (C.M.); (O.G.); (M.D.)
| | - Mihaela Dranga
- Department of Gastroenterology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (C.M.); (O.G.); (M.D.)
| | - Elena Rezus
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (L.A.M.); (A.C.); (E.R.)
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3
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Song KD. [Imaging Techniques and Differential Diagnosis for Inflammatory Bowel Disease]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:536-549. [PMID: 37325005 PMCID: PMC10265240 DOI: 10.3348/jksr.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/15/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The two main types of inflammatory bowel disease (IBD) are Crohn's disease and ulcerative colitis. Currently, when IBD is suspected, CT enterography is widely used as an initial imaging test because it can evaluate both the bowel wall and the outside of the bowel, helping to differentiate IBD from other diseases. When IBD is suspected, it is necessary to distinguish between Crohn's disease and ulcerative colitis. In most cases this is not difficult; however, in some cases, it is difficult and such cases are called IBD-unclassified. CT findings are often non-specific for ulcerative colitis, making it difficult to differentiate it from other diseases using imaging alone. In contrast, characteristic CT findings for Crohn's disease are often helpful in diagnosis, although diseases, such as tuberculous enteritis can mimic Crohn's disease. Recently, mutations in the gene encoding a prostaglandin transporter called SLCO2A1 have been discovered as the cause of the disease in some patients with multiple ulcers and strictures, similar to Crohn's disease. Therefore, genetic testing is being used to make a differential diagnosis.
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4
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Sohail R, Mathew M, Patel KK, Reddy SA, Haider Z, Naria M, Habib A, Abdin ZU, Razzaq Chaudhry W, Akbar A. Effects of Non-steroidal Anti-inflammatory Drugs (NSAIDs) and Gastroprotective NSAIDs on the Gastrointestinal Tract: A Narrative Review. Cureus 2023; 15:e37080. [PMID: 37153279 PMCID: PMC10156439 DOI: 10.7759/cureus.37080] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2023] [Indexed: 04/05/2023] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for their anti-inflammatory, antipyretic, and analgesic properties. However, their use is often associated with gastrointestinal tract (GIT) side effects due to the inhibition of both cyclooxygenase (COX)-1 and COX-2 enzymes, leading to a decrease in gastroprotective prostaglandins (PG). To minimize these adverse effects, various approaches have been explored, including selective COX-2 inhibitors, NO-NSAIDs (nitric oxide-releasing NSAIDs), and dual COX/LOX (lipoxygenase) NSAIDs. However, the effects of these gastroprotective NSAIDs on the GIT and their efficacy remains uncertain. This review aims to provide an overview of the current understanding of the effects of traditional NSAIDs and gastroprotective NSAIDs on GIT. We discuss the underlying mechanisms of GIT damage caused by NSAIDs, including mucosal injury, ulceration, and bleeding, and the potential of gastroprotective NSAIDs to mitigate these effects. We also summarize recent studies on the efficacy and safety of various gastroprotective NSAIDs and highlight the limitations and challenges of these approaches. The review concludes with recommendations for future research in this field.
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Affiliation(s)
- Rohab Sohail
- Internal Medicine, Quaid-e-Azam Medical College, Bahawalpur, PAK
| | - Midhun Mathew
- Department of Internal Medicine, Pennsylvania Hospital, Philadelphia, USA
| | - Khushbu K Patel
- Internal Medicine, Index Medical College Hospital & Research Center, Indore, IND
| | - Srija A Reddy
- Internal Medicine, Malla Reddy Institute of Medical Sciences, Hyderabad, IND
| | - Zaroon Haider
- Internal Medicine, Combined Military Hospital (CMH) Lahore Medical College and Institute of Dentistry, Lahore, PAK
| | - Mansi Naria
- Internal Medicine, American University of Barbados, Bridgetown, BRB
| | - Ayesha Habib
- Internal Medicine, Punjab Medical College, Faisalabad, PAK
| | - Zain U Abdin
- Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | | | - Anum Akbar
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, USA
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5
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Differentiation of Isolated Small Bowel Crohn’s Disease from Other Small Bowel Ulcerative Diseases: Clinical Features and Double-Balloon Enteroscopy Characteristics. Gastroenterol Res Pract 2022; 2022:5374780. [PMID: 35677723 PMCID: PMC9170512 DOI: 10.1155/2022/5374780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/04/2022] [Indexed: 11/17/2022] Open
Abstract
Background. The diagnosis of isolated small bowel Crohn’s disease (ISBCD) has always been challenging. Aims. This study is aimed at comparing the clinical features and double-balloon enteroscopy (DBE) characteristics of ISBCD with those of other small bowel ulcerative diseases (OSBUD). Methods. Patients with coexisting colonic and/or ileal valve lesions (
) or whose final diagnosis was not determined (
) were excluded. One hundred thirty-nine patients with ISBCD and 62 patients with OSBUD found by DBE were retrospectively analyzed. Results. The age of ISBCD onset was lower than that of OSBUD (OR 0.957, 95% CI 0.938-0.977,
). Abdominal pain was more common in ISBCD (OR 4.986, 95% CI 2.539-9.792,
). Elevated fibrinogen levels (OR 1.431, 95% CI 1.022-2.003,
) and lower levels of D-dimer (OR 0.999, 95% CI 0.999-1.000,
) were also more supportive of the diagnosis of ISBCD. Nonsteroidal anti-inflammatory drugs (NSAIDs) used for more than two weeks decreased the probability of a diagnosis of ISBCD (OR 0.173, 95% CI 0.043-0.695,
). Abdominal computed tomography revealed a higher proportion of skip lesions in ISBCD than in OSBUD (OR 9.728, 95% CI 3.676-25.742,
). The ulcers of ISBCD were more distributed in the ileum (111 (79.9%) vs. 29 (46.8%),
), and their main morphology differed in different intestinal segments. Longitudinal ulcers (OR 14.293, 95% CI 4.920-41.518,
) and large ulcer (OR 0.128, 95% CI 0.044-0.374,
) contributed to the differentiation of ISBCD from OSBUD. We constructed a diagnostic model, ISBCD index (
, 95% CI: 0.830-0.925), using multifactorial binary logistic regression to help distinguish between these two groups of diseases. Conclusion. Clinical features, laboratory tests, abdominal computed tomography, DBE characteristics, and pathology help to distinguish ISBCD from OSBUD.
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6
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Klang E, Kopylov U, Mortensen B, Damholt A, Soffer S, Barash Y, Konen E, Grinman A, Yehuda RM, Buckley M, Shanahan F, Eliakim R, Ben-Horin S. A Convolutional Neural Network Deep Learning Model Trained on CD Ulcers Images Accurately Identifies NSAID Ulcers. Front Med (Lausanne) 2021; 8:656493. [PMID: 34513857 PMCID: PMC8429810 DOI: 10.3389/fmed.2021.656493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 08/10/2021] [Indexed: 12/16/2022] Open
Abstract
Background and Study Aims: Deep learning (DL) for video capsule endoscopy (VCE) is an emerging research field. It has shown high accuracy for the detection of Crohn's disease (CD) ulcers. Non-steroidal anti-inflammatory drugs (NSAIDS) are commonly used medications. In the small bowel, NSAIDs may cause a variety of gastrointestinal adverse events including NSAID-induced ulcers. These ulcers are the most important differential diagnosis for small bowel ulcers in patients evaluated for suspected CD. We evaluated a DL network that was trained using CD VCE ulcer images and evaluated its performance for NSAID ulcers. Patients and Methods: The network was trained using CD ulcers and normal mucosa from a large image bank created from VCE of diagnosed CD patients. NSAIDs-induced enteropathy images were extracted from the prospective Bifidobacterium breve (BIf95) trial dataset. All images were acquired from studies performed using PillCam SBIII. The area under the receiver operating curve (AUC) was used as a metric. We compared the network's AUC for detecting NSAID ulcers to that of detecting CD ulcers. Results: Overall, the CD training dataset included 17,640 CE images. The NSAIDs testing dataset included 1,605 CE images. The DL network exhibited an AUC of 0.97 (95% CI 0.97-0.98) for identifying images with NSAID mucosal ulcers. The diagnostic accuracy was similar to that obtained for CD related ulcers (AUC 0.94-0.99). Conclusions: A network trained on VCE CD ulcers similarly identified NSAID findings. As deep learning is transforming gastrointestinal endoscopy, this result should be taken into consideration in the future design and analysis of VCE deep learning applications.
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Affiliation(s)
- Eyal Klang
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.,Deep Vision Lab, Sheba Medical Center, Tel Hashomer, Israel
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | | | - Anders Damholt
- Chr. Hansen A/S, Human Health Innovation, Hoersholm, Denmark
| | - Shelly Soffer
- Deep Vision Lab, Sheba Medical Center, Tel Hashomer, Israel
| | - Yiftach Barash
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.,Deep Vision Lab, Sheba Medical Center, Tel Hashomer, Israel
| | - Eli Konen
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Ana Grinman
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Reuma Margalit Yehuda
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Martin Buckley
- APC Microbiome Ireland, Cork, Ireland.,Centre for Gastroenterology, Mercy University Hospital, Cork, Ireland
| | | | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Affiliated to Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
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Osman K, Kendi AT, Maselli D. Isolated angioedema of the bowel caused by aspirin. Clin J Gastroenterol 2021; 14:1096-1102. [PMID: 33999375 PMCID: PMC8127855 DOI: 10.1007/s12328-021-01430-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/29/2021] [Indexed: 12/12/2022]
Abstract
Angioedema is a self-limited, localized tissue swelling, resulting from fluid extravasation into interstitial spaces. It may occur in isolation or be accompanied by urticaria and/or anaphylaxis. The phenomenon has been linked to multiple medications, including non-steroidal anti-inflammatory drugs (NSAIDs) and angiotensin-converting enzyme inhibitors (ACEIs). NSAID-induced angioedema is observed in < 0.3% of patients taking NSAIDs. While isolated visceral angioedema has been reported from ACEIs, it has not been documented from NSAID use, particularly aspirin usage. Here, we report a case of isolated visceral angioedema attributed to aspirin use.
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Affiliation(s)
- Karim Osman
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55902, USA.
- Department of Internal Medicine, Beth Israel Lahey Clinic, Burlington, MA, 01803, USA.
| | - Ayse Tuba Kendi
- Department of Radiology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55902, USA
| | - Daniel Maselli
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55902, USA
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8
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Abstract
Small bowel evaluation is warranted in all newly diagnosed cases of Crohn’s disease (CD) as small bowel is involved in two-thirds of CD patients at diagnosis and the involvement can be discontinuous. Endoscopic evaluation of the small bowel in suspected or established CD can be done by video capsule endoscopy (VCE), device assisted enteroscopy (DAE) (which includes single and double balloon enteroscopy, novel motorized spiral enteroscopy (NMSE) and balloon guided endoscopy (BGE)) and intra-operative enteroscopy (IOE). In suspected CD with a negative ileo-colonoscopy, VCE is the preferred initial diagnostic modality in the absence of obstructive symptoms or known stenosis. VCE should be preceded by cross-sectional imaging or patency capsule testing if obstruction is suspected given with high retention risk. In established cases, small bowel cross-sectional imaging (magnetic resonance or computed tomography enterography) is preferred over VCE as it can assess transmural and extra-luminal involvement. VCE is indicated subsequently if necessary to assess disease extent, unexplained symptoms (e.g., anemia, malnutrition) or mucosal healing. Pan-enteric capsule endoscopy (PCE) and the use of artificial intelligence are the recent developments with VCE. DAE with small bowel biopsy can provide definitive evidence of CD including the extent and severity. A final diagnosis of CD is based on the constellation of clinical, radiologic, histologic and endoscopic features. Newer technologies like NMSE and BGE can help with deeper and faster small bowel evaluation. DAE has also allowed endoscopic treatment of small bowel strictures, small bowel bleeding and retrieval of retained capsule or foreign bodies. Endoscopic balloon dilation (EBD), endoscopic electro-incision, strictureplasty and stenting have shown promising results in CD related small bowel strictures. In conclusion, endoscopic evaluation of the small bowel is rapidly evolving field that has a major role in diagnosis and management of small bowel CD and can alter treatment outcomes in properly selected patients.
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9
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McCain JD, Pasha SF, Leighton JA. Role of Capsule Endoscopy in Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2021; 31:345-361. [PMID: 33743930 DOI: 10.1016/j.giec.2020.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In Crohn disease (CD), the use of capsule endoscopy (CE) for suspected versus established disease is very different. Most patients with CD are diagnosed with ileocolonoscopy. In patients with a negative ileocolonoscopy, CE is the next best test in suspected CD. In patients with established CD, the potential benefits of CE are rating severity of disease, establishing extent and distribution, and following mucosal healing in a treat to target strategy. In those with proximal small bowel disease, CE can help in diagnosis and prognostication. In ulcerative colitis, CE has a limited role, but that may change with evolving technology.
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Affiliation(s)
- Josiah D McCain
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Shabana F Pasha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Jonathan A Leighton
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
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10
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Paton DJW, Kumarasinghe MP. NSAID-associated submucosal fibrous nodules of the small intestine revisited. Pathology 2020; 52:717-719. [PMID: 32771210 DOI: 10.1016/j.pathol.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/18/2020] [Accepted: 05/25/2020] [Indexed: 11/23/2022]
Affiliation(s)
- David J W Paton
- Western Diagnostic Pathology, Perth, WA, Australia; Curtin Medical School, Curtin University, Perth, WA, Australia.
| | - M Priyanthi Kumarasinghe
- PathWest Laboratory Medicine, QE2 Medical Centre, Perth, WA, Australia; School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia
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11
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Abstract
Chronic pain management during the coronavirus disease 2019 (COVID-19) pandemic is a challenging process, especially with growing evidence that COVID-19 infection is associated with myalgias, referred pain, and widespread hyperalgesia. In light of the limited data available for COVID-19-related impact on chronic pain patients, this review explores the changes in the healthcare delivery system due to social distancing and safety precautions to provide the appropriate management of chronic pain patients during the COVID-19 pandemic. Understanding both the general problems facing chronic pain patients as well as specific problems in the COVID-19 era including deconditioning, increased mental health concerns, financial burdens, and potential for medication-induced immune-suppression is vital in the appropriate management of patients. Telemedicine, the practice of caring for patients remotely when the provider and patient are not physically present with each other, is becoming increasingly used and recognized as a valuable tool to both health care providers and patients. This paper concentrates on the proper utilization of the available resources to help patients with the most severe conditions as well as the most vulnerable group. COVID-19 may be associated with a profound effect on both the health care system and patients with chronic pain. As a result, delaying, or stopping, treatment for chronic pain patients will have negative consequences, and strong pain evaluations must be administered to triage patients appropriately. Recent recommendations for the safe use of non-opioid analgesics, opioid analgesics, and interventional pain management procedures are vital to know and understand specifically during the pandemic era. Further researches are needed to identify the advance planning and rapid responses to reduce the impact of the pandemic.
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12
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Lim DH, Jung K, Lee SB, Park IK, Cha HJ, Park JH, Kim BG, Jung SW, In Du Jeong, Kim JH, Kim SE, Moon W, In Park M, Park SJ. Non-steroidal anti-inflammatory drug-induced enteropathy as a major risk factor for small bowel bleeding: a retrospective study. BMC Gastroenterol 2020; 20:178. [PMID: 32513198 PMCID: PMC7282042 DOI: 10.1186/s12876-020-01329-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/01/2020] [Indexed: 12/21/2022] Open
Abstract
Background Small bowel (SB) bleeding accounts for 5% of all gastrointestinal (GI) bleeding cases and 80% of obscure GI bleeding cases. Although angioectasia is the common etiology of SB bleeding, nonsteroidal anti-inflammatory drug (NSAID)-induced SB lesions are also reported as a major cause in studies from Eastern countries. Herein, we assessed the frequency of occurrence of NSAID-induced SB lesions in Korean patients with obscure GI bleeding. Methods We retrospectively analyzed medical records of all consecutive patients aged ≥18 years who underwent capsule endoscopy from March 2018 to February 2019 at Ulsan University Hospital and Kosin University Gospel Hospital. Results Of the 83 subjects (all Korean; mean age ± standard deviation: 59 ± 18 years; age range: 18–84 years; men: n = 52; women: n = 31), 55 (66.2%) had stool with clear blood and 28 (33.8%) had normal stool with iron deficiency anemia. The detection rate of SB bleeding and lesions using capsule endoscopy was 72.3% (60 of 83 patients). A significantly higher frequency (40 of 51) of ulcerative/erosive lesions than other causes was observed in patients with inactive bleeding but visible SB lesions. As a result, NSAID-induced enteropathy accounted for 30.1% of 83 patients with obscure GI bleeding (25 of the all 60 SB bleeding cases). Conclusions Contrary to what is reported for patients in Western countries, this study in Korean patients showed an improved diagnostic yield of capsule endoscopy for obscure GI bleeding and that NSAID-induced enteropathy was the most common etiology of SB bleeding. Aggressive small intestine examination is required for patients with unexplained GI bleeding.
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Affiliation(s)
- Doo-Ho Lim
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Seung Bum Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea.
| | - In Kyu Park
- Department of General Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Hee Jeong Cha
- Department of Pathology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Jae Ho Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Byung Gyu Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Seok Won Jung
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - In Du Jeong
- Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, South Korea
| | - Jae Hyun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
| | - Seun Ja Park
- Department of Internal Medicine, Kosin University College of Medicine, Kosin University Gospel Hospital, Busan, South Korea
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Bielsa-Fernández M, Tamayo-de la Cuesta J, Lizárraga-López J, Remes-Troche J, Carmona-Sánchez R, Aldana-Ledesma J, Avendaño-Reyes J, Ballesteros-Amozorrutia M, De Ariño M, de Giau-Triulzi L, Flores-Rendón R, Huerta-Guerrero H, González-González J, Hernández-Guerrero A, Murcio-Pérez E, Jáquez-Quintana J, Meixueiro-Daza A, Nogueira-de Rojas J, Rodríguez-Hernández H, Santoyo-Valenzuela R, Solorzano-Olmos S, Uscanga-Domínguez L, Zamarripa-Dorsey F. Consenso mexicano sobre diagnóstico, prevención y tratamiento de la gastropatía y enteropatía por antiinflamatorios no esteroideos. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 85:190-206. [DOI: 10.1016/j.rgmx.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/27/2019] [Accepted: 11/27/2019] [Indexed: 02/07/2023]
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Bielsa-Fernández M, Tamayo-de la Cuesta J, Lizárraga-López J, Remes-Troche J, Carmona-Sánchez R, Aldana-Ledesma J, Avendaño-Reyes J, Ballesteros-Amozorrutia M, De Ariño M, de Giau-Triulzi L, Flores-Rendón R, Huerta-Guerrero H, González-González J, Hernández-Guerrero A, Murcio-Pérez E, Jáquez-Quintana J, Meixueiro-Daza A, Nogueira-de Rojas J, Rodríguez-Hernández H, Santoyo-Valenzuela R, Solorzano-Olmos S, Uscanga-Domínguez L, Zamarripa-Dorsey F. The Mexican consensus on the diagnosis, treatment, and prevention of NSAID-induced gastropathy and enteropathy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020. [DOI: 10.1016/j.rgmxen.2019.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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COMPARING OF FAECAL CALPROTECTIN LEVELS IN PATIENTS WITH OSTEOARTHRITIS TAKING NSAID TREATMENT AND PATIENTS WITHOUT NSAIDS THERAPY. EUREKA: HEALTH SCIENCES 2020. [DOI: 10.21303/2504-5679.2020.001193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Faecal calprotectin (FC) level can be increased in several conditions, which are characterised by neutrophilic inflammation. Some medications, particularly NSAIDs, can elevate its level as well. NSAIDs are taken by patients in many chronic conditions, including osteoarthritis (OA).
On the other hand, there is growing evidence that osteoarthritis is not only a degenerative disease, but it has a significant inflammatory component. The role of systemic inflammation is well-known in inflammatory joint diseases, but there is some evidence that it can play an essential role in the OA as well. It can suggest that in the OA, the inflammatory changes could be found in the different organs and systems.
The aim of this study was to investigate the FC level in patients with osteoarthritis depending on the NSAIDs intake and to compare it to the FC levels in healthy adults.
Materials and methods. In this small observational study, we evaluated the FC levels in patients suffering from OA (36 persons), divided them into two groups depending on their NSAIDs intake, and compared it to FC levels in healthy participants (12 persons). We compared the FC levels depending on the selectivity of the NSAIDs taken by our participants, as well.
Results. The median calprotectin level in our patients was 72.57 (IQR 20.55-221.57) mg/kg, 95 %CI 26,18-109.01. OA patients had higher levels than the healthy group (p<0.001). OA patients who took NSAIDs had the highest FC levels – 221.57 (IQR 91.56-448.61) – higher, than those who did not take it – 72.57 (IQR 35.26-164.79) (p=0.03) and than healthy participants, who has normal FC levels (p<0.001); the FC levels of patients who did not take NSAIDs also exceeds healthy subject’s levels (p<0.001). The FC levels in the collective group have a sufficient positive correlation with the duration of NSAIDs intake, VAS score and strong correlation with Lequesne index values. We found that both NSAIDs groups have a significantly greater prevalence of elevated or high FC levels than the control group (p<0.001) and that NSAIDs patients significantly more often have high FC levels than those who do not take NSAIDs (p=0.035). When comparing FC levels in patients depending on the type of NSAIDs they take, we found that those who take non-selective NSAIDs has significantly higher FC levels than those who do not take NSAIDs – 264.1 (IQR 89.72-464.67) to 25.65 (IQR 19.5-75.33) (p=0.0003). The FC levels of who take selective NSAIDs – 98.53 (91.56-105.5) – did not differ significantly to non-selective NSAIDs taker’s group values and non-selective NSAIDs taker’s values (p>0.05).
Conclusions. Patients who suffer from OA have higher FC levels than healthy individuals, and patients with OA who take NSAIDs regularly have higher FC levels than those who do not. The intake of non-selective NSAIDs is associated with higher FC levels, than the intake of high-selective NSAIDs. FC levels of those who take high-selective NSAIDs do not differ statistically from those who do not intake NSAIDs. Further research is needed in this area.
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Jolobe OMP. Also beware of coexisting small bowel enteropathy or coexisiting colorectal sources of chronic blood loss. J Intern Med 2019; 286:111. [PMID: 30575173 DOI: 10.1111/joim.12864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Parfenov AI, Akopova AO, Shcherbakov PL, Mikcheeva OM. Role of video capsulе endoscopy in the diagnostic algorithm of small bowel Crohn's disease. TERAPEVT ARKH 2019; 91:37-42. [DOI: 10.26442/00403660.2019.04.000079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Aim. To evaluate the possibilities of video capsule endoscopy (VCE) for diagnosing small bowel Crohn's disease (SBCD). Materials and methods. The study included 25 patients (12 men, 13 women) diagnosed with Crohn's disease. The mean age of the patients was 31.84±10.5 years. The VCE was performed using the GivenImaging system (Yokneam, Israel), OMOM (China). After the end of each test, the data was analyzed at a rate of 8 to 10 frames per second using Rapid® Reader (version 7.0). Results and discussion. The examination of patients in accordance with the diagnostic algorithm showed that for 11 patients (44%) the clinical assumption of SBCD was confirmed only with the help of VCE (1st group). Consequently, the use of VCE in these patients was crucial in the diagnosis of SBCD, since standard methods of analisys were insufficient to establish this diagnosis. For 14 patients (2nd group), the diagnosis of SBCD was established with the help of colonoscopy and/or diagnostic imaging modalities. The use of VCE allowed to confirm the diagnosis, to clarify the localization and extent of inflammation of the small intestine. Conclusion. VCE can be recommended for the diagnosis of SBCD during the period of early inflammatory manifestations in the small intestine mucosa.
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Üsküdar Cansu D, Üsküdar Teke H, Temel T, Ertürk A, Kahraman O, Korkmaz C. Do Anti-TNF Agents Increase the Risk of Inflammatory Bowel Disease Evolution in Patients with Ankylosing Spondylitis? Real Life Data. J Natl Med Assoc 2018; 111:262-269. [PMID: 30389147 DOI: 10.1016/j.jnma.2018.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 10/05/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether there is any association with anti-tumor necrosis factor (TNF) agent administration and development of new-onset inflammatory bowel disease (IBD) in ankylosing spondylitis (AS) patients. METHODS Records of the patients who met 1984 modified New York criteria for AS between 1998 and 2016 at Rheumatology Department were evaluated retrospectively and data about the patients, IBD properties and medication were obtained. RESULTS Among 420 patients, 310 were male, the average age was 42.9 ± 1.3 years, average disease duration was 16.7 ± 10.4 years. Anti-TNF agents were in use by 154 patients, 52 patients were receiving etanercept (ETN), infliximab (INF), adalimumab (ADA), and golimumab (GO) treatments were ongoing in 50, 41, and 11 patients, respectively. New-onset IBD developed in 10 patients; 3 from the group treated with non-anti-TNF drugs (1.1%) and 7 from the group treated with anti-TNF agents (4.5%) (p = 0.042). No significant difference was detected between three anti-TNF agent forms in relation with the risk of IBD onset. In AS patients, existence of familial AS (OR 4.69 (95%CI 1.28-17.19, p = 0.020) and anti-TNF agent treatment (OR 4.17 (95%CI 1.06-16.38, p = 0.041) were independent risk factors for new-onset IBD development. CONCLUSION Despite the increased risk of new-onset IBD development during the course of AS, paradoxical response to anti-TNF drugs must also be considered as a source that triggers onset of IBD.
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Affiliation(s)
- Döndü Üsküdar Cansu
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey.
| | - Hava Üsküdar Teke
- Division of Hematology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Tuncer Temel
- Division of Gastroenterology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Adem Ertürk
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Osman Kahraman
- Department of Internal Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Cengiz Korkmaz
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
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20
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Shin SJ, Noh CK, Lim SG, Lee KM, Lee KJ. Non-steroidal anti-inflammatory drug-induced enteropathy. Intest Res 2017; 15:446-455. [PMID: 29142512 PMCID: PMC5683975 DOI: 10.5217/ir.2017.15.4.446] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/05/2017] [Accepted: 05/07/2017] [Indexed: 12/18/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are well known to be associated with serious upper gastrointestinal complications, such as peptic ulcer, bleeding, perforation, and obstruction. Recently, attention has been mainly focused on the small bowel injuries caused by NSAIDs, and new endoscopic techniques such as capsule endoscopy and double balloon endoscopy can help in detecting such injuries. This article reviewed the epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of small bowel injuries caused by NSAIDs. Small bowel injures by NSAIDs might occur with a similar frequency and extent as those observed in the upper gastrointestinal tract. The pathogenesis of NSAID-induced enteropathy is complex and not clearly understood. The various lesions observed in the small bowel, including petechiae, reddened folds, loss of villi, erosions, and ulcers can be detected by capsule endoscopy. A drug that could prevent or treat NSAID-induced enteropathy has not yet been developed. Therefore, further investigations should be performed to elucidate the pathogenesis of such enteropathy and develop suitable preventive and treatment strategies.
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Affiliation(s)
- Sung Jae Shin
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Choong-Kyun Noh
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Sun Gyo Lim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Kee Myung Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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Curcumin, a component of turmeric, efficiently prevents diclofenac sodium-induced gastroenteropathic damage in rats: A step towards translational medicine. Food Chem Toxicol 2017; 108:43-52. [DOI: 10.1016/j.fct.2017.07.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 07/13/2017] [Accepted: 07/17/2017] [Indexed: 12/20/2022]
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De Bortoli N, Ripellino C, Cataldo N, Marchi S. Unspecified intestinal malabsorption in patients treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers: a retrospective analysis in primary care settings. Expert Opin Drug Saf 2017; 16:1221-1225. [PMID: 28871813 DOI: 10.1080/14740338.2017.1376647] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To investigate the possible relationship between the use of Angiotensin II Receptor Blockers (ARBs) or Angiotensin-Converting-Enzyme Inhibitors (ACE-i) and unspecified intestinal malabsorption (IM) within the Italian and German real-life context. RESEARCH DESIGN AND METHODS a retrospective cohort of patients with a new unspecified IM diagnosis during the period 1 January 2010-31 December 2013 was extracted from Italian IMS Health Longitudinal Patient Database and German IMS Disease Analyzer. Only patients with at least one prescription of ARB or ACE-i medication during the 6 months preceding the IM diagnosis were included and then followed up for 12 months to assess treatment exposure. RESULTS After stratification by year and molecule, the proportion of patients experiencing an unspecified IM diagnosis on total patients receiving ARBs or ACE-i ranged from 0% to 0.14%, showing no relevant differences between molecules and no time trends. CONCLUSIONS this study indicates that ACE-i or ARBs were rarely associated to an unspecified IM diagnosis. No relevant difference between each specific ACE-i and ARB was highlighted.
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Affiliation(s)
- Nicola De Bortoli
- a Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery , University of Pisa , Pisa , Italy
| | - Claudio Ripellino
- b Department of Real World Evidence , HEOR Consultant Freelance , Milan , Italy
| | - Nazarena Cataldo
- c Department of Real World Evidence , QuintilesIMS , Milan , Italy
| | - Santino Marchi
- a Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery , University of Pisa , Pisa , Italy
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Weiss GA, Hennet T. Mechanisms and consequences of intestinal dysbiosis. Cell Mol Life Sci 2017; 74:2959-2977. [PMID: 28352996 PMCID: PMC11107543 DOI: 10.1007/s00018-017-2509-x] [Citation(s) in RCA: 320] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/08/2017] [Accepted: 03/15/2017] [Indexed: 02/07/2023]
Abstract
The composition of the gut microbiota is in constant flow under the influence of factors such as the diet, ingested drugs, the intestinal mucosa, the immune system, and the microbiota itself. Natural variations in the gut microbiota can deteriorate to a state of dysbiosis when stress conditions rapidly decrease microbial diversity and promote the expansion of specific bacterial taxa. The mechanisms underlying intestinal dysbiosis often remain unclear given that combinations of natural variations and stress factors mediate cascades of destabilizing events. Oxidative stress, bacteriophages induction and the secretion of bacterial toxins can trigger rapid shifts among intestinal microbial groups thereby yielding dysbiosis. A multitude of diseases including inflammatory bowel diseases but also metabolic disorders such as obesity and diabetes type II are associated with intestinal dysbiosis. The characterization of the changes leading to intestinal dysbiosis and the identification of the microbial taxa contributing to pathological effects are essential prerequisites to better understand the impact of the microbiota on health and disease.
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Affiliation(s)
- G Adrienne Weiss
- Institute of Physiology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland
| | - Thierry Hennet
- Institute of Physiology, University of Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland.
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Shim KN, Jeon SR, Jang HJ, Kim J, Lim YJ, Kim KO, Song HJ, Lee HS, Park JJ, Kim JH, Chun J, Park SJ, Yang DH, Min YW, Keum B, Lee BI. Quality Indicators for Small Bowel Capsule Endoscopy. Clin Endosc 2017; 50:148-160. [PMID: 28391667 PMCID: PMC5398361 DOI: 10.5946/ce.2017.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 03/14/2017] [Accepted: 03/16/2017] [Indexed: 02/06/2023] Open
Abstract
Capsule endoscopy (CE) enables evaluation of the entire mucosal surface of the small bowel (SB), which is one of the most important steps for evaluating obscure gastrointestinal bleeding. Although the diagnostic yield of SB CE depends on many clinical factors, there are no reports on quality indicators. Thus, the Korean Gut Image Study Group (KGISG) publishes an article titled, “Quality Indicators for Small Bowel Capsule Endoscopy” under approval from the Korean Society of Gastrointestinal Endoscopy (KSGE). Herein, we initially identified process quality indicators, while the structural and outcome indicators are reserved until sufficient clinical data are accumulated. We believe that outcomes of SB CE can be improved by trying to meet our proposed quality indicators.
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Affiliation(s)
- Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seong Ran Jeon
- Department of Internal Medicine,Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyun Joo Jang
- Department of Internal Medicine, Hallym University College of Medicine, Hwaseong, Korea
| | - Jinsu Kim
- Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yun Jeong Lim
- Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Hyun Joo Song
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Hyun Seok Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hyun Kim
- Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Jaeyoung Chun
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bora Keum
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Bo-In Lee
- Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea
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Cheung KS, Leung WK. Gastrointestinal bleeding in patients on novel oral anticoagulants: Risk, prevention and management. World J Gastroenterol 2017; 23:1954-1963. [PMID: 28373761 PMCID: PMC5360636 DOI: 10.3748/wjg.v23.i11.1954] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 01/18/2017] [Accepted: 03/02/2017] [Indexed: 02/06/2023] Open
Abstract
Novel oral anticoagulants (NOACs), which include direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban), are gaining popularity in the prevention of embolic stroke in non-valvular atrial fibrillation as well as in the prevention and treatment of venous thromboembolism. However, similar to traditional anticoagulants, NOACs have the side effects of bleeding, including gastrointestinal bleeding (GIB). Results from both randomized clinical trials and observations studies suggest that high-dose dabigatran (150 mg b.i.d), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GIB compared with warfarin. Other risk factors of NOAC-related GIB include concomitant use of ulcerogenic agents, older age, renal impairment, Helicobacter pylori infection and a past history of GIB. Prevention of NOAC-related GIB includes proper patient selection, using a lower dose of certain NOACs and in patients with renal impairment, correction of modifiable risk factors, and prescription of gastroprotective agents. Overt GIB can be managed by withholding NOACs followed by delayed endoscopic treatment. In severe bleeding, additional measures include administration of activated charcoal, use of specific reversal agents such as idarucizumab for dabigatran and andexanent alfa for factor Xa inhibitors, and urgent endoscopic management.
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Abstract
The most common small bowel inflammatory disorders include Crohn disease, nonsteroidal antiinflammatory drug (NSAID) enteropathy, and celiac disease. Capsule endoscopy, computed tomography enterography, and magnetic resonance enterography have a complementary role in the diagnosis of Crohn disease and evaluation of patients with established Crohn disease. The higher risk of capsule retention with known Crohn disease and NSAID enteropathy can be minimized by cross-sectional imaging or the patency capsule. The main role of deep enteroscopy is tissue diagnosis, endoscopic management of small bowel lesions and strictures, and retrieval of retained capsules.
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Affiliation(s)
- Jonathan A Leighton
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
| | - Shabana F Pasha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
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Arulanandan A, Dulai PS, Singh S, Sandborn WJ, Kalmaz D. Systematic review: Safety of balloon assisted enteroscopy in Crohn's disease. World J Gastroenterol 2016; 22:8999-9011. [PMID: 27833391 PMCID: PMC5083805 DOI: 10.3748/wjg.v22.i40.8999] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/01/2016] [Accepted: 08/01/2016] [Indexed: 02/07/2023] Open
Abstract
AIM To determine the overall and comparative risk of procedure related perforation of balloon assisted enteroscopy (BAE) in Crohn's disease (CD). METHODS Systematic review (PROSPERO #CRD42015016381) of studies reporting on CD patients undergoing BAE. Seventy-three studies reporting on 1812 patients undergoing 2340 BAEs were included. Primary outcome of interest was the overall and comparative risk of procedure related perforation of diagnostic BAE in CD. Secondary outcomes of interest were risk of procedure related perforation of diagnostic double balloon enteroscopy (DBE), risk of procedure related perforation of therapeutic BAE, efficacy of stricture dilation, and clinical utility of endoscopically assessing small bowel disease activity. RESULTS Per procedure perforation rate of diagnostic BAE in CD was 0.15% (95%CI: 0.05-0.45), which was similar to diagnostic BAE for all indications (0.11%; IRR = 1.41, 95%CI: 0.28-4.50). Per procedure perforation rate of diagnostic DBE in CD was 0.12% (95%CI: 0.03-0.44), which was similar to diagnostic DBE for all indications (0.22%; IRR = 0.54, 95%CI: 0.06-0.24). Per procedure perforation rate of therapeutic BAE in CD was 1.74% (95%CI: 0.85-3.55). Eighty-six percent of therapeutic perforations were secondary to stricture dilation. Dilation was attempted in 207 patients and 30% required surgery during median follow-up of 18 months. When diagnostic BAE assessed small bowel disease activity, changes in medical therapy resulted in endoscopic improvement in 77% of patients. CONCLUSION Diagnostic BAE in CD has a similar rate of perforation as diagnostic BAE for all indications and can be safely performed in assessment of mucosal healing.
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Singh DP, Borse SP, Nivsarkar M. Clinical importance of nonsteroidal anti-inflammatory drug enteropathy: the relevance of tumor necrosis factor as a promising target. Transl Res 2016; 175:76-91. [PMID: 27083387 DOI: 10.1016/j.trsl.2016.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 12/13/2022]
Abstract
The pathogenesis of nonsteroidal anti-inflammatory drug (NSAID) enteropathy is still unclear, and consequently, there is no approved therapeutic strategy for ameliorating such damage. On the other hand, molecular treatment strategies targeting tumor necrosis factor (TNF) exerts beneficial effects on NSAID-induced intestinal lesions in rodents and rheumatoid arthritis patients. Thus, TNF appears to be a potential therapeutic target for both the prevention and treatment of NSAID enteropathy. However, the causative relationship between TNF and NSAID enteropathy is largely unknown. Currently approved anti-TNF agents are highly expensive and exhibit numerous side effects. Hence, in this review, the pivotal role of TNF in NSAID enteropathy has been summarized and plant-derived polyphenols have been suggested as useful alternative anti-TNF agents because of their ability to suppress TNF activated inflammatory pathways both in vitro and in vivo.
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Affiliation(s)
- Devendra Pratap Singh
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India; Registered Ph.D Scholar (External) at Institute of Pharmacy, NIRMA University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, India
| | - Swapnil P Borse
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India; Registered Ph.D Scholar (External) at Institute of Pharmacy, NIRMA University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, India
| | - Manish Nivsarkar
- Department of Pharmacology and Toxicology, B. V. Patel Pharmaceutical Education and Research Development (PERD) Centre, Thaltej, Ahmedabad, Gujarat, India.
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29
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Shim KN, Song EM, Jeen YT, Kim JO, Jeon SR, Chang DK, Song HJ, Lim YJ, Kim JS, Ye BD, Park CH, Jeon SW, Cheon JH, Lee KJ, Kim JH, Jang BI, Moon JS, Chun HJ, Choi MG. Long-Term Outcomes of NSAID-Induced Small Intestinal Injury Assessed by Capsule Endoscopy in Korea: A Nationwide Multicenter Retrospective Study. Gut Liver 2016; 9:727-33. [PMID: 25473079 PMCID: PMC4625701 DOI: 10.5009/gnl14134] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS We evaluated the long-term outcome and clinical course of patients of nonsteroidal anti-inflammatory drug (NSAID)-induced small intestinal injury by performing capsule endoscopy (CE). METHODS A multicenter retrospective study was conducted using data collected from the CE nationwide database registry, which has been established since 2002. RESULTS A total of 140 patients (87 males; mean age, 60.6±14.8 years) from the CE nationwide database registry (n=2,885) were diagnosed with NSAID-induced small intestinal injury and enrolled in our study. Forty-nine patients (35.0%) presented with a history of aspirin use and an additional 49 (35.0%) were taking NSAIDs without aspirin. The most prominent findings after performing CE were multiple ulcerations (n=82, 58.6%) and erosions or aphthae (n=32, 22.9%). During the follow-up period (mean, 15.9±19.0 months; range, 0 to 106 months), NSAID-induced small intestinal injury only recurred in six patients (4.3%). Older age and hypertension were positive predictive factors for recurrence. CONCLUSIONS These results suggest that the recurrence of NSAID-induced small bowel injury was not frequent in the presence of conservative treatment. Therefore, the initial diagnosis using CE and the medication history are important.
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Affiliation(s)
- Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Eun Mi Song
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Yoon Tae Jeen
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jin-Oh Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seong Ran Jeon
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Dong Kyung Chang
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Joo Song
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Korea
| | - Yun Jeong Lim
- Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Jin Soo Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Korea
| | - Cheol Hee Park
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Seong Woo Jeon
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Ji Hyun Kim
- Department of Gastroenterology, Inje University College of Medicine, Busan, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jeong Seop Moon
- Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea
| | - Hoon Jae Chun
- Department of Internal Medicine, Korea University College of Medicine, Korea
| | - Myung-Gyu Choi
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Korea
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A novel model for NSAID induced gastroenteropathy in rats. J Pharmacol Toxicol Methods 2016; 78:66-75. [DOI: 10.1016/j.vascn.2015.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/30/2015] [Accepted: 11/30/2015] [Indexed: 12/24/2022]
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Li M, de Graaf IAM, Groothuis GMM. Precision-cut intestinal slices: alternative model for drug transport, metabolism, and toxicology research. Expert Opin Drug Metab Toxicol 2016; 12:175-90. [DOI: 10.1517/17425255.2016.1125882] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Ming Li
- Pharmacokinetics, Toxicology & Targeting, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Inge A. M. de Graaf
- Pharmacokinetics, Toxicology & Targeting, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Geny M. M. Groothuis
- Pharmacokinetics, Toxicology & Targeting, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
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32
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Gastrointestinal bleeding in patients receiving oral anticoagulation: Current treatment and pharmacological perspectives. Thromb Res 2015; 136:1074-81. [PMID: 26508464 DOI: 10.1016/j.thromres.2015.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 10/06/2015] [Accepted: 10/07/2015] [Indexed: 02/07/2023]
Abstract
Gastrointestinal bleeding (GIB) is a potentially fatal and avoidable medical condition that poses a burden on global health care costs. The rate of major GIB related to the use of some direct acting oral anticoagulant drugs (DOACs), is higher than that detected in warfarin users. Current strategies in the treatment of GIBs in patients receiving warfarin or DOACs (vitamin K, activated charcoal; hemodialysis; recombinant factor VIIa; [activated] prothrombin complex concentrates) including indications for the treatment of bleeding based on different degrees of severity of the episodes, is reported in this article. Potential preventive strategies to mitigate the risk of GIBs (e.g. upper endoscopy/biopsy, colon cancer screening; eradication of Helicobacter pylori prior to starting anticoagulation; use of proton-pump inhibitors, identification of risk factors for bleeding) are also reported as well as the fact that some of them have not been tested so far in patients receiving DOACs. Antidotes that experimentally reverse the anti-coagulant effect of dabigatran (Idarucizumab; BI 655075; Boehringer Ingelheim); of rivaroxaban, apixaban, or edoxaban (Andexanet alfa, r-Antidote, PRT064445; Portola Pharmaceuticals) or of all DOACs (Aripazine, PER-977, ciraparantag; Perosphere Inc.) are discussed. Likewise, population pharmacokinetics modeling related to the rate of major DOACs-related GIBs is presented. It is also emphasized that the occurrence of GIB reflects the presence of patients at the highest risk for adverse outcomes. Finally, the implications of the concept that patient characteristics and the severity of illness (i.e. comorbidities) exert a greater impact on the risk of GIB than the type of antithrombotic agent employed, are analyzed.
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Lim YJ, Lee OY, Jeen YT, Lim CY, Cheung DY, Cheon JH, Ye BD, Song HJ, Kim JS, Do JH, Lee KJ, Shim KN, Chang DK, Park CH, Jang BI, Moon JS, Chun HJ, Choi MG, Kim JO. Indications for Detection, Completion, and Retention Rates of Small Bowel Capsule Endoscopy Based on the 10-Year Data from the Korean Capsule Endoscopy Registry. Clin Endosc 2015; 48:399-404. [PMID: 26473123 PMCID: PMC4604278 DOI: 10.5946/ce.2015.48.5.399] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 09/15/2014] [Accepted: 09/23/2014] [Indexed: 12/21/2022] Open
Abstract
Background/Aims Capsule endoscopy (CE) is widely used. However, CE has limitations including incomplete examination, inadequate bowel preparation, and retention. The aim of this study was to estimate the indications for and detection, completion, and retention rates of small intestine CE based on the 10-year data from the Korean Capsule Endoscopy Registry. Methods Twenty-four hospitals participated in this study. Clinical information, such as reasons for CE, method and quality of bowel preparation, and incomplete examination and capsule retention rates, was collected and analyzed. Results A total of 2,914 CEs were registered. The most common reason for CE was obscure gastrointestinal bleeding (59%). Significant lesions were detected in 66% of cases. Positive CE diagnosis occurred in 63% of cases. The preparation method did not significantly affect the quality of bowel preparation for CE. The overall incomplete rate was 33%, and was high in the elderly and those with poor bowel preparation. Capsule retention was 3% and high in patients with small bowel tumors and Crohn's disease and in children under 10 years of age. Conclusions CE is a valuable technique; while the overall detection rate is high, incompletion and retention rates are also relatively high. CE should be carefully considered in the elderly and children less than 10 years of age, as well as in patients with small bowel tumors and Crohn's disease.
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Affiliation(s)
- Yun Jeong Lim
- Department of Internal Medicine, Dongguk University College of Medicine, Goyang, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yoon Tae Jeen
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Chi Yeon Lim
- Department of Medicine, Dongguk University College of Medicine, Gyeongju, Korea
| | - Dae Young Cheung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Joo Song
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Korea
| | - Jin Su Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hyuk Do
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kwang Jae Lee
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Dong Kyung Chang
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheol Hee Park
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jeong Seop Moon
- Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea
| | - Hoon Jai Chun
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Myung-Gyu Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Oh Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
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Chatterjee S, Dureja GP, Kadhe G, Mane A, Phansalkar AA, Sawant S, Kapatkar V. Cross-Sectional Study for Prevalence of Non-Steroidal Anti-Inflammatory Drug-Induced Gastrointestinal, Cardiac and Renal Complications in India: Interim Report. Gastroenterology Res 2015; 8:216-221. [PMID: 27785299 PMCID: PMC5040529 DOI: 10.14740/gr658w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are the most common therapeutic products used for the management of inflammation and pain. However, their use is associated with gastrointestinal (GI), cardiovascular and renal complications. Although prevalence data regarding NSAID-induced complications are available worldwide, but none of the study has assessed the prevalence of GI, cardiac and renal complications in India. This study aimed to assess the point prevalence of GI, cardiac and renal complications associated with the use of NSAIDs in India. The study also aimed to evaluate the association between the risk factors and GI, renal and cardiac complications in patients using NSAIDs. METHODS This prospective, cross-sectional, multi-centric study was conducted in eight medical colleges across India (North, East, West, South and Central India). Data related to GI complications including gastric, duodenal and gastroduodenal erosions/ulcers/gastritis, renal complications including acute and chronic renal failure or cardiac complications including acute coronary syndrome (ACS), acute myocardial infarction (AMI) and cardiac failure, were collected from patients. RESULTS The cut-off date for interim data analysis was July 7, 2014. A total of 2,140 patients out of 3,600 were enrolled from eight centers at the time of interim analysis. The NSAID-associated point prevalence of GI complications was 30.08%; cardiac complication was 42.77%; and renal complication was 27.88%. CONCLUSIONS Results of the present interim analysis show that the prevalence of GI, cardiac and renal complications among patients is high due to exaggerated usage; however, the final analysis would provide the overall prevalence of these complications.
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Affiliation(s)
| | - Gur Prasad Dureja
- Department of Pain Medicine, New Delhi Pain Management Center, New Delhi, India
| | - Ganesh Kadhe
- Medical Affairs, Wockhardt Limited, Mumbai, India
| | - Amey Mane
- Medical Affairs, Wockhardt Limited, Mumbai, India
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Basnet S, Adhikari A, Sachidananda VK, Thippeswamy BS, Veerapur VP. Protective effect of Blumea lacera DC aerial parts in indomethacin-induced enterocolitis in rats. Inflammopharmacology 2015; 23:355-63. [DOI: 10.1007/s10787-015-0243-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 07/06/2015] [Indexed: 01/27/2023]
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Di Minno A, Spadarella G, Prisco D, Scalera A, Ricciardi E, Di Minno G. Antithrombotic drugs, patient characteristics, and gastrointestinal bleeding: Clinical translation and areas of research. Blood Rev 2015; 29:335-43. [PMID: 25866382 DOI: 10.1016/j.blre.2015.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/04/2015] [Indexed: 02/07/2023]
Abstract
Gastrointestinal bleeding (GIB) is a potentially fatal and avoidable medical condition that poses a burden on global health care costs. Current understanding of the roles of platelet activation and thrombin generation/activity in vascular medicine has led to the development of effective antithrombotic treatments. However, in parallel with a sustained coronary and cerebral flow patency, the increasingly intensive treatment with warfarin; direct oral anticoagulant drugs [DOACs], and/or with aspirin ± clopidogrel (or ± prasugrel or ± ticagrelor), has increased the burden of GIBs related to the use of antithrombotic agents. Compelling evidence concerning this issue is accumulating to indicate that: 1) the risk of GIB related to the use of antithrombotic drugs dramatically differs in different clinical settings; and 2) the characteristics of patients (e.g., severity of illness, comorbidities) in whom it is used exert a greater impact on the risk of GIB than the type of antithrombotic agent employed. The latter concept argues for the occurrence of GIB as reflecting the presence of patients at the highest risk for adverse outcomes. The HAS-BLED score identifies subjects at risk of bleeding among those untreated and those treated with warfarin, DOACs and/or low-dose aspirin. Its use within the frame of a severity score (e.g., the CHA2DS2-VASc score in patients with atrial fibrillation) helps balance the benefits and the risks of an antithrombotic treatment and identify those patients in whom the absolute gain (vascular events prevented) outweighs the risk of GIB. Potential implications of the latter information in settings other than atrial fibrillation is thoroughly discussed.
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Affiliation(s)
- Alessandro Di Minno
- Department of Farmacia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Gaia Spadarella
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Domenico Prisco
- Department of Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Largo Brambilla 3, 50134 Firenze, Italy
| | - Antonella Scalera
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Elena Ricciardi
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giovanni Di Minno
- Department of Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy.
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Akashi M, Ando T, Hamashima T, Yoshita H, Nanjo S, Mihara H, Fujinami H, Kajiura S, Nishikawa J, Miura Y, Hosokawa A, Sugiyama T. Multiple Colon Ulcers with Typical Small Intestinal Lesions Induced by Non-Steroidal Anti-Inflammatory Drugs. Intern Med 2015; 54:1995-9. [PMID: 26278290 DOI: 10.2169/internalmedicine.54.3919] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The diagnosis of NSAID-induced colon ulcers is difficult when the distribution or endoscopic findings are not typical. An 83-year-old woman was transferred to our hospital for hemorrhagic diarrhea. Colonoscopy showed multiple ulcers in the entire colon, particularly longitudinal ulcers in the transverse colon. These were unusual for NSAID-induced colopathy, although she had been on meloxicam. However, capsule endoscopy revealed multiple scars and erosions, characteristic of NSAIDs users. The final diagnosis was NSAID-induced enteropathy, and all lesions were in remission after meloxicam discontinuation. We herein emphasize the value of an endoscopic assessment of the entire digestive tract in the diagnosis of NSAID-induced mucosal lesions.
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Affiliation(s)
- Momoko Akashi
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Toyama, Japan
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Recent Advances in NSAIDs-Induced Enteropathy Therapeutics: New Options, New Challenges. Gastroenterol Res Pract 2013; 2013:761060. [PMID: 24159330 PMCID: PMC3789478 DOI: 10.1155/2013/761060] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/02/2013] [Accepted: 08/13/2013] [Indexed: 12/17/2022] Open
Abstract
The injurious effects of NSAIDs on the small intestine were not fully appreciated until the widespread use of capsule endoscopy. It is estimated that over two-thirds of regular NSAID users develop injury in the small intestinal injuries and that these injuries are more common than gastroduodenal mucosal injuries. Recently, chronic low-dose aspirin consumption was found to be associated with injury to the lower gut and to be a significant contributing factor in small bowel ulceration, hemorrhage, and strictures. The ability of aspirin and NSAIDs to inhibit the activities of cyclooxygenase (COX) contributes to the cytotoxicity of these drugs in the gastrointestinal tract. However, many studies found that, in the small intestine, COX-independent mechanisms are the main contributors to NSAID cytotoxicity. Bile and Gram-negative bacteria are important factors in the pathogenesis of NSAID enteropathy. Here, we focus on a promising strategy to prevent NSAID-induced small intestine injury. Selective COX-2 inhibitors, prostaglandin derivatives, mucoprotective drugs, phosphatidylcholine-NSAIDs, and probiotics have potential protective effects on NSAID enteropathy.
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Desai J, Kolb JM, Weitz JI, Aisenberg J. Gastrointestinal bleeding with the new oral anticoagulants--defining the issues and the management strategies. Thromb Haemost 2013; 110:205-12. [PMID: 23702623 DOI: 10.1160/th13-02-0150] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 04/27/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Jay Desai
- Mount Sinai School of Medicine, 311 East 79th Street, New York, NY 10021, USA
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Niu X, de Graaf IAM, Groothuis GMM. Evaluation of the intestinal toxicity and transport of xenobiotics utilizing precision-cut slices. Xenobiotica 2012; 43:73-83. [PMID: 23106567 DOI: 10.3109/00498254.2012.729870] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
1.The precision-cut intestinal slice (PCIS) technology is a relatively new addition to the battery of in vitro assays for evaluation of xenobiotic toxicity, metabolism, and transport. 2.The intestine is an important target for drug-induced toxicity due to its high exposure after oral administration. Therefore, the prediction of drug-induced intestinal side effects remains a significant safety issue in pharmaceutical development. Although animal experiments have been proven useful, species differences and the requirement for reduction of animal use warrant the development of in vitro methods which can apply human tissue. 3.The enterocytes lining the villi express high activities of enzymes and transporters involved in drug disposition. They vary highly in activities: along the length of the intestine and along the villi, gradients of expression levels of the enzymes and proteins exist, which necessitates an in vitro model that can reflect the different regions of the intestine. 4.In this chapter, the application of PCIS in studies on transport and toxicity of xenobiotics is reviewed. PCIS can be prepared from each region of the intestine and from various species in a similar manner, and the results published so far indicate that they represent a promising model to evaluate intestinal toxicity and transport.
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Affiliation(s)
- Xiaoyu Niu
- Division of Pharmacokinetics, Toxicology and Targeting, Department of Pharmacy, Groningen Research Institute for Pharmacy, University of Groningen, Groningen, The Netherlands
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