Pill-induced esophageal strictures: clinical features and risk factors for development

Poly(lactic acid)-hyperbranched polyglycerol nanoparticles enhance bioadhesive treatment of esophageal disease and reduce systemic drug exposure

The effective treatment of esophageal disease represents a significant unmet clinical need, as existing treatments often lead to unnecessary systemic drug exposure and suboptimal concentrations at the disease site. Here, surface-modified bioadhesive poly(lactic acid)-hyperbranched polyglycerol nanoparticles (BNPs), with an average 100-200 nm diameter, were developed for local and sustained esophageal drug delivery. BNPs showed significantly higher adhesion and permeation into ex vivo human and rat esophageal tissue than non-adhesive nanoparticles (NNPs) and had longer residence times within the rat esophagus in vivo. Incubation with human esophagus (Het-1A) cells confirmed BNPs' biocompatibility at clinically relevant concentrations. In a rat model of achalasia, nifedipine-loaded BNPs significantly enhanced esophageal drug exposure, increased therapeutic efficacy, and reduced systemic drug exposure compared to NNPs and free drug. The safety of BNPs was demonstrated by an absence of intestinal, hepatic, and splenic toxicity following administration. This study is the first to demonstrate the efficacy of BNPs for esophageal drug delivery and highlight their potential for improving the lives of patients suffering with esophageal conditions.

Bioadhesive Dosage Forms for Esophageal Drug Delivery

The esophagus as a site for drug delivery has been much overlooked in comparison to the remainder of the gastrointestinal tract. The low permeability and transient nature of the esophagus means that it is unsuitable for delivery of drugs for systemic action. However, esophageal disorders including fungal infection, cancers, motility dysfunction, and damage due to gastric reflux may be treated using locally acting agents that offer benefits of reduced dosage and decreased side effects. Bioadhesive dosage forms that adhere to the esophageal mucosa and prolong contact have been investigated to improve the efficacy of locally acting agents. The rationale for local esophageal drug delivery and its limitations, the factors that determine adhesion to this organ, and the experimental models used in esophageal drug delivery research are reviewed.

Ulcère œsophagien secondaire à la prise de bacampicilline

INTRODUCTION

Many drugs may provoke oesophageal disorders. In France, doxycyclin, potassium chloride non-steroidal anti-inflammatories are the most frequent agents incriminated.

OBSERVATION

A 27 year-old man consulted for dysphagia and odynophagia due to oesophagitis following administration of bacampicillin.

COMMENTS

Several drugs can provoke oesophageal disorders including ulcerations. Predisposing circumstances exist. Ingestion of the drugs with a sufficient quantity of water (60 to 100 ml), whilst standing or sitting should be able to limit this type of event.

Drug-induced esophageal injuries and dysphagia

OBJECTIVE

To review and analyze medical literature documenting drug-induced esophageal injury and dysphagia and to formulate strategies to enhance pharmacists' prevention, detection, and treatment of these iatrogenic complications.

DATA SOURCES

A MEDLINE search (1966-April 2002) was conducted to identify primary and secondary literature using variable combinations of the following search terms: pill-induced, drug-induced, or iatrogenic with esophageal injury, esophageal damage, or dysphagia. Bibliographies were also reviewed to identify additional relevant references.

STUDY SELECTION AND DATA EXTRACTION

All case reports, reviews, and clinical studies relating to drug-induced esophageal injury or swallowing dysfunction were evaluated.

DATA SYNTHESIS

Drug-induced esophageal injury may be under-recognized. Several drugs have been associated with physical or chemically mediated injuries. Risk factors for injury have been identified and preventive and treatment strategies have been successful in limiting esophageal injury. Drug-induced dysphagia can have serious complications and is most often associated with typical neuroleptics such as haloperidol.

CONCLUSIONS

Pharmacists can play a pivotal role in proactively identifying situations where there is a higher likelihood of drug-induced esophageal injury or dysphagia. They can recommend preventive strategies to promote safe medication use, help identify iatrogenic complications when they occur, and assist in formulation of appropriate treatment strategies.

Oral medication-induced esophageal injury in elderly patients

SUMMARY

ABSTRACT Although oral medication induced esophageal injury (OMIEI), is a well-known and preventable condition, many cases are still missed, particularly in the elderly patients. OBJECTIVE To determine the frequency and outcome of oral medication-induced esophageal injury in elderly patients. METHODS Records of 390 patients aged over 65 years, with diagnoses of dysphagia, odynophagia, and noncardiac chest pain, over the period of 11 years, were selected for a retrospective review. Patients who had barium studies only, in whom endoscopy was not done or was unsuccessful, and those with incomplete data were excluded, leaving 250 patients for further review. RESULTS Diagnosis of OMIEI was made in 27% (68 of 250) patients. Fifty-one of 68 (75%) patients with OMIEI responded to conservative management, including H2 blockers, proton pump inhibitors, antacids, or sucralfate. The remaining 17 patients (25%) developed esophageal strictures requiring dilation. CONCLUSIONS A high index of clinical suspicion and low threshold for empiric treatment and diagnostic measures (endoscopy, barium swallow study), may be helpful, if indicated, for early diagnosis and prompt therapy of OMIEI.

Medication-induced oesophageal disorders

Medication-induced oesophageal distress and injury have become increasingly common conditions. First, smooth muscle relaxants may worsen or produce symptoms of pre-existing gastro-oesophageal reflux disease; notable examples include certain calcium antagonists (nifedipine), nitrates, sildenafil, nicotine, theophylline, and substances with antimuscarinic potential. Second, drugs with local toxicity may produce de novo damage including inflammation, strictures, ulcers, and bleeding. Notorious examples are alendronate, certain antibiotics including tetracyclines and clindamycin, all NSAIDs/aspirin, quinidine, potassium chloride, and ferrous sulfate. Cyclooxygenase-2 inhibitors may be devoid of such toxicity, but may damage the mucosa by interfering with regenerative cell proliferation. The galenic formulation can modulate the risk of oesophageal injury. For this reason, medicines containing the same potentially toxic ingredient may be less exchangeable than commonly thought. Diagnostic gold standard is endoscopy. The best treatment is removal of the offending drug and supportive care. Prevention requires a re-appraisal of the drug's indication and adherence to guidelines of optimal drug intake including ingestion in an upright position and swallowing with enough fluid. The clinical relevance of drug-induced oesophageal injury and the feasibility of therapeutic alternatives are individually addressed.

Foreign bodies

Foreign bodies are uncommon, but they are important and interesting. Foreign bodies may be ingested, inserted into a body cavity, or deposited into the body by a traumatic or iatrogenic injury. Most ingested foreign bodies pass through the gastrointestinal tract without a problem. Most foreign bodies inserted into a body cavity cause only minor mucosal injury. However, ingested or inserted foreign bodies may cause bowel obstruction or perforation; lead to severe hemorrhage, abscess formation, or septicemia; or undergo distant embolization. Motor vehicle accidents and bullet wounds are common causes of traumatic foreign bodies. Metallic objects, except aluminum, are opaque, and most animal bones and all glass foreign bodies are opaque on radiographs. Most plastic and wooden foreign bodies (cactus thorns, splinters) and most fish bones are not opaque on radiographs. All patients should be thoroughly screened for foreign bodies before undergoing a magnetic resonance imaging study.

Gastrointestinal safety of an extended-release, nondeformable, oral dosage form (OROS: a retrospective study

BACKGROUND

The OROS osmotic (OSM) dosage form optimises extended-release oral administration by controlling the rate of drug release for a predetermined time, providing constant, patterned, or pulsed delivery profiles. OSM products include prescription medications for urology, CNS, and cardiovascular indications, as well as over-the-counter nasal/sinus congestion medications.

METHODS

This retrospective study examines US gastrointestinal (GI) safety data for the OROS dosage form following nearly two decades of use. Although GI injury and obstruction are known effects of oral medications, some reports have suggested that extended-release products pose a greater risk of GI injury and obstruction than other oral dosage forms. Products incorporating OROS technology are being prescribed to an expanding range of patients; a review of the GI safety data for this dosage form thus seemed timely and appropriate. US safety information was obtained from three sources: English language literature published from 1982 until June 1, 2000 from five major biomedical databases;postmarketing safety reports from January 1, 1983 until June 1, 2000 available through the Freedom of Information Act; andcommercial safety information obtained directly from ALZA Corporation's in-house safety database for those OSM products for which ALZA has reporting responsibility. US distribution data from IMS National Prescription Audit trade mark Plus data were used to estimate cumulative product distribution totals. These totals were combined with numbers of unique GI events to determine the estimated frequency of events.

RESULTS

Nearly 13 billion OSM tablets are estimated to have been distributed in the US. The incidence of all clinically significant GI adverse events for OSM products (including intestinal, gastric, and oesophageal irritation, injury, and obstruction) reported in the US was approximately one case in >76 million tablets distributed. The majority (78%; estimated incidence: one case in 29 million tablets) of cases were reported in patients taking Procardia XL (nifedipine). Oesophageal and lower GI obstruction were reported primarily in patients with pre-existing abnormalities or disease of the GI tract. Among paediatric patients, one obstruction was reported in an estimated 37.7 million tablets distributed. Reports of GI irritation associated with OSM products were consistent with known effects of the same drug substances in other dosage forms.

CONCLUSION

A review of long-term safety experience with products using OSM controlled-release technology yields a low incidence of clinically significant GI events. Properly prescribed, extended-release products provide substantial therapeutic and convenience benefits without additional risk.

[Doxycycline-induced esophageal ulcer]

We present the case of a 25-year-old woman who presented an esophageal ulcer due to doxycycline. We show the endoscopic image of the lesion and analyse the incidence, pathogenic mechanisms, symptomatology, diagnosis, treatment, and prevention of doxycycline-induced esophageal lesions.

Drug-induced oesophageal disorders: pathogenesis, incidence, prevention and management

Drug-induced injury of the oesophagus is a common cause of oesophageal complaints. 'Pill-induced' oesophagitis is associated with the ingestion of certain drugs and accounts for many cases of erosive oesophagitis. To date, more than 70 drugs have been reported to induce oesophageal disorders. Antibacterials such as doxycycline, tetracycline and clindamycin are the offending agents in more than 50% of cases. Other commonly prescribed drugs that cause oesophageal injury include aspirin (acetylsalicylic acid), potassium chloride, ferrous sulfate, quinidine, alprenolol and various steroidal and nonsteroidal anti-inflammatory agents. However, many physicians and even more patients are not aware of this problem. Capsules or tablets are commonly delayed in their passage through the oesophagus. Highly caustic coatings, direct medication injury and poor oesophageal clearance of pills can lead to acute inflammation. Oesophageal damage occurs when the caustic contents of a drug remain in the oesophagus long enough to produce mucosal lesions. Taking medications at bedtime or without fluids is a common cause of oesophagitis. The possibility of drug-related damage should be suspected in all cases of oesophagitis, chest pain and dysphagia. History and gastrointestinal endoscopy will confirm the diagnosis. Treatment is supportive, although acid reduction is used frequently as an adjunct. This review reflects the current state of knowledge in this field.

Pill-induced esophagitis caused by oral rifampin

OBJECTIVE

To report a case of pill-induced esophagitis caused by oral rifampin.

DATA SOURCES

English-language references identified via a MEDLINE search from January 1966 to May 1998 and a bibliographic review of pertinent articles.

DATA SYNTHESIS

A large number of oral medications have been reported to cause pill-induced esophagitis. This case represents the second report attributed to rifampin. A 70-year-old white man receiving vancomycin, gentamicin, and oral rifampin for treatment of Staphylococcus epidermidis prosthetic valve endocarditis reported dysphagia immediately after swallowing a rifampin capsule on the fourth day of therapy. The following day, fiberoptic laryngoscopy and esophagoscopy demonstrated a red capsule partially embedded in the neopharynx. A day later, upper esophageal obstruction consistent with edema related to pill-induced esophagitis was identified by barium swallow. Following the procedure, the patient was placed on total parenteral nutrition and took nothing by mouth. Sixteen days after first reporting dysphagia, he was placed on a full liquid diet. Several factors may have increased the patient's risk for pill-induced esophagitis, including age, bedridden state, gastroesophageal reflux disease, simultaneous administration of several medications, and neopharyngeal stricture.

CONCLUSIONS

Oral rifampin may cause esophagitis. Healthcare providers should be alert to the possibility of pill-induced esophagitis in susceptible patients. Patients with predisposing factors for the development of pill-induced esophagitis should be educated about proper swallowing of oral medications.

Medical therapy of gastroesophageal reflux and management of esophageal strictures

The goals of modern medical therapy for gastroesophageal reflux disease are threefold: first, eliminate symptoms; second, heal injured esophageal mucosa; third, manage and/or prevent complications. Selection of a particular medical regimen depends on the severity of the disease, effectiveness of the therapy, cost, and convenience of the medical regimen. An accurate diagnosis needs to be made in patients suspected with esophageal strictures. If there is a treatable underlying disease, specific therapy is essential. The goal of dilation therapy should be established and set about to accomplish in a timely, but unhurried fashion. Fluoroscopy and wire-guided dilators should be used liberally, especially for difficult strictures.

Gastric secretion of acid and pepsin in patients with esophageal stricture and appropriate controls

Most cases of esophageal stricture are associated with acid/peptic reflux esophagitis. While patients with strictures commonly have disordered lower esophageal sphincters and poor clearance and neutralization mechanisms, it is not known whether they also have abnormal gastric secretion. This study examined fasting, basal, and stimulated acid and pepsin secretion. With an endoscopic diagnosis of esophagitis, patients with stricture (< 12.5 mm) were matched for age, sex, concurrent gastrointestinal disease (duodenal ulcer, N = 9), Zollinger-Ellison syndrome (N = 6), and postgastric surgery state (N = 5), as well as the absence of ulcer disease (non-DU, N = 37). Fasting, basal, and pentagastrin-stimulated acid and pepsin secretion were measured. Overall, the 57 stricture patients had the same acid and pepsin secretion as their matched controls with esophagitis; the same was true for each of the subgroups (ZES, DU, non-DU, and postsurgical). Stricture patients weighed less and had a lower body mass index (P < 0.01). Patients with esophageal peptic stricture have the same acid and pepsin output as control patients matched for sex, age, background gastrointestinal disease, and the presence of esophagitis.

Dysphagia. Evaluation, diagnosis, and treatment

This article reviews the presentation, diagnosis, and treatment of the varied pathologic conditions that result in dysphagia. The description of difficulty swallowing by a patient should direct the physician to an orderly series of diagnostic tests of esophageal function to help determine the cause of dysphagia. Some conditions that cause dysphagia also are presented in this review.

A pilot study of oral corticosteroid therapy for idiopathic esophageal ulcerations associated with human immunodeficiency virus infection

PURPOSE

To evaluate the efficacy and safety of oral prednisone therapy for idiopathic esophageal ulcerations (IEU) associated with human immunodeficiency virus (HIV) infection.

PATIENTS AND METHODS

Over a 14-month period, all HIV-infected patients with IEU as defined by clinical, endoscopic, and pathologic criteria were prospectively identified. Prednisone was initiated at a dose of 40 mg/d orally, tapering 10 mg/wk, for a total of 1 month of therapy. Patients were closely followed to determine the response to therapy as well as the occurrence of any side effects related to prednisone. All patients were requested to undergo endoscopy within 1 week of the completion of therapy.

RESULTS

Of 14 patients identified with IEU, 12 consented to prednisone therapy. The mean duration of esophageal symptoms was 2.9 weeks, and odynophagia was the most common presenting symptom. Ten of 12 patients had the acquired immunodeficiency syndrome. Eleven of the 12 patients (92%) had a complete symptomatic response, usually within the first week of therapy. In some patients, the response was dramatic such that oral intake could be rapidly resumed and discharge from the hospital possible. Two patients completed 2 and 3 weeks of therapy, respectively, prior to death, both with a complete symptomatic response. Endoscopic re-examination in seven patients demonstrated complete ulcer healing in all six symptomatic responders, but a persistent ulceration in the one nonresponder. The oral corticosteroid regimen was well tolerated. Mild asymptomatic Candida esophagitis was identified in three of seven patients undergoing follow-up endoscopy. One patient developed self-limited herpes zoster during therapy. No systemic opportunistic infections were documented during or within 1 month of the completion of therapy.

CONCLUSIONS

Oral corticosteroid therapy appears to be a highly efficacious and safe therapy for HIV-associated IEU. Further controlled studies will be necessary to conclusively establish efficacy, as well as determine the optimal dose and duration of therapy.

Esophageal disease in the acquired immunodeficiency syndrome: etiology, diagnosis, and management

Esophageal disease is a common complication and cause of morbidity in patients with human immunodeficiency virus (HIV) infection. Opportunistic esophageal diseases may occur in patients with long-standing infection or may be the initial manifestation of HIV disease. Although a variety of both opportunistic and nonopportunistic disorders result in esophageal disease in this population, candidal esophagitis is the most common cause of symptomatic disease. Ulcerative esophagitis resulting from cytomegalovirus and idiopathic esophageal ulceration constitute the next most important etiologies. In contrast to other immunocompromised hosts, herpes simplex virus esophagitis appears to be relatively uncommon. Multiple simultaneously discovered esophageal disorders have been documented in up to 50% of patients. Opportunistic neoplasms are an infrequent cause of symptomatic disease. Candidal esophagitis may present with either dysphagia or odynophagia, and oropharyngeal candidiasis is usually present at the time of diagnosis. In contrast, ulcerative esophagitis is usually first manifested by moderate to severe odynophagia. Barium esophagography and upper endoscopy are the most commonly employed diagnostic modalities for the evaluation of the symptomatic patient. Although barium esophagography may identify specific abnormalities, this procedure appears to be relatively insensitive for the detection of mild candidal disease as well as nondiagnostic for ulcerative lesions when compared with endoscopy. In the HIV-infected patient with new-onset esophageal symptoms, an empiric trial of a systemically acting oral antifungal agent should probably be the initial management strategy. If the patient does not respond to standard therapy within 1 to 2 weeks, an endoscopic evaluation appears to be the most cost-effective diagnostic test given the diversity of potential disorders, the possibility of one or more co-pathogens or diseases, the potential for an immediate diagnosis, and the availability of mucosal biopsy to make a definite diagnosis of ulcerative or mass lesions. Given the presently available therapy for these diverse processes, establishing a definitive diagnosis in the symptomatic patient not responsive to empiric antifungal therapy is warranted.