Long-term safety concerns with proton pump inhibitors

Continuous PPI Treatment After Gastric Bypass Increases the Risk of Pathological PTH Levels at 10 Years Postoperatively

BACKGROUND

Apart from massive weight loss, metabolic and bariatric surgery, especially gastric bypass (Roux-en-Y gastric bypass [RYGB]), can cause nutritional deficiencies. Proton pump inhibitors (PPI), relatively often used after RYGB, are associated with reduced calcium absorption. We have studied the long-term impact of PPI upon calcium homeostasis among RYGB patients.

METHODS

In the Scandinavian Obesity Surgery Registry (SOReg), 550 primary RYGB patients, with eGFR > 60 mL/min/1.73 m2, had PTH and 25-OH D levels registered at 10 years. To avoid the impact of hypovitaminosis D, those with 25-OH D > 75 nmol/L were selected.

RESULTS

At 10 years, 10.3% of patients reported continuous PPI treatment, i.e., daily use during the last month. In an age adjusted logistic regression model, continuous PPI treatment was associated with a quadruple risk (OR: 4.65 [1.54-14.04]) of having a pathological PTH level (> 7 pmol/L).

CONCLUSION

This unique study has shown a correlation between continuous PPI use and pathological PTH levels, thereby inferring that the medication may have detrimental effects upon calcium homeostasis among gastric bypass patients. The risk of having pathological PTH levels was more than tripled among those with PPI treatment, highlighting the importance of specialized follow-up while also suggesting that a limited duration of PPI treatment is preferable.

Proton pump inhibitors stabilize the expression of PD-L1 on cell membrane depending on the phosphorylation of GSK3β

BACKGROUND

Preclinical and clinical evidence indicates that proton pump inhibitors (PPIs) may indirectly diminish the microbiome diversity, thereby reducing the effectiveness of immune checkpoint inhibitors (ICIs). Conversely, recent publications have shown that PPIs could potentially enhance the response to ICIs. The precise mechanism through which PPIs modulate the ICIs remains unclear. In this study, we discovered a novel molecular function of PPIs in regulating immune invasion, specifically through inducing PD-L1 translocation in various tumor cells.

METHODS

C57BL/6 mice subcutaneous transplantation model is used to verify the potential efficacy of PPIs and PD-L1 antibody. Western blotting analysis and phosphorylated chip are used to verify the alteration of PD-L1-related pathways after being treated with PPIs. The related gene expression is performed by qRT-PCR and luciferase reporter analysis. We also collected 60 clinical patients diagnosed with esophageal cancer or reflux esophagitis and then detected the expression of PD-L1 in the tissue samples by immunohistochemistry.

RESULTS

We observed that the IC50 of tumor cells in response to PPIs was significantly higher than that of normal epithelial cells. PPIs significantly increased the expression of PD-L1 on cell membrane at clinically relevant concentrations. Furthermore, pre-treatment with PPIs appeared to synergize the efficiency of anti-PD-L1 antibodies in mouse models. However, PPI administration did not alter the transcription or total protein level of PD-L1 in multiple tumor cells. Using a phosphorylated protein chip, we identified that PPIs enhanced the phosphorylation of GSK3β, then leading to PD-L1 protein translocation to the cell membranes. The capacity of PPIs to upregulate PD-L1 was negated following GSK3β knockout. Furthermore, our clinical data showed that the PPIs use resulted in increased PD-L1 expression in esophageal cancer patients.

CONCLUSION

We mainly address a significant and novel mechanism that the usage of PPIs could directly induce the expression of PD-L1 by inducing GSK3β phosphorylation and facilitate primary tumor progression and metastasis.

Modification Effects of Albuminuria on the Association Between Kidney Function and Development of Anemia in Diabetes

CONTEXT

Previous studies failed to adjust for estimated glomerular filtration rate (eGFR) in evaluating the association between albuminuria and anemia development, and we aimed to investigate whether albuminuria independently affects anemia development.

METHODS

We conducted a retrospective cohort study and retrospectively identified adults with diabetes from a Japanese nationwide clinical database (JMDC, Tokyo, Japan). To assess the modification effects of albuminuria on the association between eGFR and anemia development, we estimated prevalence of anemia, defined as hemoglobin < 13 g/dL in men and < 12 g/dL in women, using a modified Poisson regression and marginal standardization form of predictive margins, stratified by albuminuria severity after adjusting for eGFR. Hence, we revealed at which eGFR level this modification effect appeared and the extent to which this modification effect increased the prevalence of anemia.

RESULTS

We identified 327 999 data points from 48 056 individuals [normoalbuminuria: 186 472 (56.9%), microalbuminuria: 107 170 (32.7%), and macroalbuminuria: 34 357 (10.5%)]. As eGFR declined, anemia prevalence increased. Albuminuria severity modified this association induced by decreased eGFR among individuals with eGFR <30 mL/min/1.73 m2 after adjusting for multivariable factors, including age, sex, comorbidities, and medication use. Compared with the normoalbuminuric group, the macroalbuminuric group had a 5% to 20% higher anemia prevalence among individuals with eGFR of <30 mL/min/1.73 m2.

CONCLUSION

We revealed that the severity of albuminuria modified the association between eGFR and anemia development among individuals with eGFR <30 mL/min/1.73 m2, highlighting the modification effect of albuminuria on the association between kidney function and anemia development in diabetes.

Evaluation of gastroprotectant administration in hospitalized cats in a tertiary referral hospital

OBJECTIVES

The primary objective of this study was to evaluate the prescription patterns and appropriateness of the use of gastroprotectant medication in cats.

METHODS

Pharmacy dispensation logs from an academic tertiary referral center were reviewed between 1 January 2018 and 31 December 2018. Cats that were administered proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, misoprostol, antacids or a combination were included. Data regarding medication, dosage, formulation, duration of administration, completeness of discharge instructions and clinical rationales for administration were obtained from medical records. The appropriateness of gastroprotectant use was assessed according to the American College of Veterinary Internal Medicine consensus statement guidelines.

RESULTS

Of the 110 cases, 67 (60.9%) were prescribed a gastroprotectant medication without an appropriate indication. The most common reason for prescription was acute kidney injury in 26/67 (38.8%). PPIs were the most common gastroprotectant medication administered in 95/110 (86.3%) cats, followed by sucralfate in 18/110 (16.4%) and H2RAs in 11/110 (10%). Of the 35 cases in which gastroprotectant therapy was indicated, the medication chosen or dosage administered was considered suboptimal in 16 (45.7%). Instructions regarding the duration of administration, potential adverse effects and timing of administration in relation to meals or other medications were inconsistently provided in discharge instructions to pet owners. Of the 29 cases discharged with omeprazole, only 13 (44.8%) instructions included a duration of administration, while 6 (20.7%) recommended continuing gastroprotectants indefinitely until further notice, 16 (55.2%) discussed the timing of the administration in relation to a meal and six (20.7%) mentioned potential adverse effects; none advised tapering of omeprazole before discontinuation.

CONCLUSIONS AND RELEVANCE

When prescribed, gastroprotectant medications were frequently prescribed injudiciously to cats in this referral population over a 12-month period. Discharge instructions to pet owners also often lacked information and recommendations regarding optimal administration, potential adverse effects, and tapering or discontinuation of the medications.

Gastrointestinal Lesions and Its Associated Factors in Adult Males With Iron Deficiency Anaemia: A Cross-Sectional Study From Tertiary Care Centre of North India

Background

Around 30% of the world's population suffers from iron deficiency anaemia (IDA). The standard evaluation for IDA involves upper and lower endoscopy, which allows for the confirmation of pathology of the gastrointestinal tract (GIT) induced due to IDA through iron malabsorption mechanism or loss of blood. Assessing the prevalence of lesions of GIT of significant nature among males having IDA, was the goal of our study.

Methods

Our cross-sectional study was conducted for two years and involved 152 males (adults) with confirmed cases of IDA from the Outpatient (OPD) and In-patient (IPD) in the present hospital. Following collecting consent (both informed and written in nature), patient-specific data was collected in a standardized form, and a blood sample was taken for laboratory testing. The analyses were done at a 5% level of significance; an association was considered significant if the p-value < 0.05.

Results

The average age of the study participants was 59.6 years. The commonest lesions reported were antral gastritis (9.9%) and H. pylori gastritis (7.2%) in upper GI; and haemorrhoid (9.2%) and anal fissure (3.9%) in lower GI. The overall prevalence of any GI lesions was 65.1%. The GI lesions were significantly associated higher among men with age > 50 years (73.7%). The presence of occult blood in stools (p < 0.0001) and parasites in stools (p=0.0001) were significantly related to the presence of GI lesions.

Conclusion

GI lesions are frequently detected in males with IDA. Whether it is symptomatic male or asymptomatic male with anaemia refractory to iron treatment, GIT should be evaluated in them.

De-Prescribing Proton Pump Inhibitors in Patients With End Stage Kidney Disease: A Quality Improvement Project

Background:

Proton pump inhibitors (PPIs) are widely prescribed and may be associated with harm; hypomagnesemia and reduced effectiveness of calcium carbonate phosphate binders may be important in end-stage kidney disease (ESKD).

Objectives:

Our objectives included (1) discontinuing PPIs and H2 blockers and (2) assessing the impact on serum magnesium and markers of mineral metabolism.

Design:

Prospective cohort.

Setting:

Satellite hemodialysis unit of a tertiary care hospital.

Patients:

Incident and prevalent patients with ESKD treated with hemodialysis.

Measurements:

We assessed the impact of stopping PPI/H2 blockers in patients who did not have an absolute indication as per guidelines in the general population; serum magnesium, calcium, and phosphate were measured before and approximately 8 weeks later. Analysis of variance (ANOVA) test and Kruskal-Wallis was used to describe the population. Wilcoxon signed rank test for the paired change scores (from pre to post)

Methods:

The electronic medical record (EMR) was extensively searched for absolute indications for a PPI. Results were reviewed with the primary nephrology team before approaching patients about stopping the PPI. Basic demographic information and select medications were also collected.

Results:

Electronic medical records were reviewed for 179 patients, 74 had a PPI or H2 antagonist or both on their medication list (43%); 23 (31%) were assessed as appropriate. After primary team and patient review, 29 patients agreed to a trial of PPI withdrawal. Fourteen patients restarted their PPI, most for gastroesophageal reflux disease. Three patients had a GI bleed, 1 fatally. Serum calcium (P = .17) and the dose of phosphate binders (P = .075) did not change but serum phosphate increased (1.55 [0.29] to 1.85 [0.34] mmol/L; P = .0005). Serum magnesium also increased (1.01 [0.16] to 1.06 [0.14] mmol/L; P = .01).

Limitations:

Small patient numbers and observational nature of the study does not establish causation in this population at high risk to experience a gastrointestinal bleed.

Conclusions:

Our results suggest that PPI deprescribing as recommended in the general population may be associated with harm in patients with ESKD and requires further study.

Trial Registration:

Not registered.

Evaluation of the effects of the systemic proton pump inhibitor-omeprazole on periimplant bone regeneration and osseointegration: An experimental study

Objective

Investigations of the effects of proton pump inhibitors (PPIs) on bone healing have revealed that they affect bone regeneration negatively. The exact mechanism by which this adverse effect on bone tissue is not known. The aim of this study is to biomechanic and biochemical investigation of the effects of the PPIs on guided periimplant bone regeneration.

Material & methods

Spraque dawley rats were divided controls (n = 8): there is no treatment during 8 week experimental period, PPI- Dosage 1 (n = 8) and Dosage 2 (n = 8): 5 mg/kg and 10 mg/kg omeprazol applied 3 times in a week with oral gavage during 8 weeks respectfully. Bone defects created half of the implant length circumferencial after implant insertion and defects filled with bone grafts. After experimental period the rats sacrified and implants with surrounding bone tissues were removed to reverse torque analysis (Newton), blood samples collected to biochemical analysis (glucose, AST, ALT, ALP, urea, creatinin, calcium, P).

Results

Biomechanic reverse torque values did not revealed any statistical differences between the groups (P > 0,05).

Conclusion

According the biomechanical and biochemical parameters PPIs does not effect the periimplant guided bone regeneration.

Association between proton pump inhibitors and periodontal disease severity

OBJECTIVES

Proton pump inhibitors (PPIs) are commonly prescribed for the management of acid-related gastrointestinal disorders. PPIs modulate osteoclast function, reduce gastric acid secretion, and are associated with the establishment of a more diverse gastrointestinal microbiota. Periodontitis is characterized by microbe-associated host-mediated inflammation that results in loss of periodontal attachment. The aim of this study was to assess whether a relationship exists between PPIs and periodontal disease.

MATERIALS AND METHODS

A retrospective analysis was performed using patient records from a faculty periodontal practice. The proportion of elevated probing depths was used to measure periodontitis severity. Statistical analysis was performed using independent sample t-tests, and Chi-square tests of independence.

RESULTS

Records from 1093 patients were initially assessed. Fourteen percent of teeth were associated with ≥6 mm probing depths among PPI users, in contrast to 24% for patients not using PPIs (P = 0.030). Similarly, 27% of teeth exhibited ≥5 mm probing depths among PPI users versus 40% for non-PPI users (P = 0.039).

CONCLUSIONS

The results suggest that PPIs are associated with a reduced proportion of elevated probing depths. Future prospective studies are indicated to elucidate possible mechanisms through which PPIs might affect, and potentially be used in the treatment of, periodontitis.

Risk of peritonitis after gastroscopy in peritoneal dialysis patients

BACKGROUND

Peritonitis is a common and serious complication of peritoneal dialysis (PD). Translocation of gut bacteria to peritoneum is an important mechanism, which may be enhanced by gastrointestinal endoscopy.

METHODS

In this retrospective observational cohort study, we identified 450 gastroscopies performed in PD patients within a single centre between 2014 and 2019. Gastroscopy-related peritonitis was defined by peritonitis within 1 week after endoscopy.

RESULTS

A total of 408 endoscopic episodes in 216 patients were analysed after excluding 42 cases with either pre-existing peritonitis before endoscopy, or concomitant biliary, small bowel or large bowel endoscopy. There were 16 episodes of peritonitis within 1 week of endoscopy (3.9%). One-quarter of cases were polymicrobial (four episodes, 25.0%). Logistic regression model showed that patient's age, number of endoscopic biopsies, and histamine-2 receptor blocker use were independently associated with peritonitis, while prior antibiotics exposure was associated with lower risk of peritonitis, odds ratio 0.23 (95% confidence interval 0.06-0.95; p = 0.04).

CONCLUSION

Peritonitis can complicate gastroscopy in PD patients and occurs more often in elderly or after repeated biopsy procedures.

Proton Pump Inhibitor Use After Hiatal Hernia Repair: Inhibitor of Recurrent Symptoms and Potential Revisional Surgery

BACKGROUND

Hiatal hernia recurrence after hiatal hernia repair (HHR) is often underdiagnosed and underreported but may present with recurrent gastroesophageal reflux disease (GERD) symptoms. Because of their availability, proton pump inhibitor (PPI) use is common and may mask patients who would benefit from revisional surgery, which has been shown to improve symptoms and quality of life.

METHODS

A retrospective analysis was performed to evaluate recurrence patterns of patients who underwent HHR, specifically for the indication of GERD, from 2007 to 2015 at a single Veterans Administration Medical Center. Clinicopathologic parameters were reviewed for association with hiatal hernia recurrence, including postoperative PPI use.

RESULTS

Sixty-four patients were identified with a median follow-up time of 57.8 mo. Thirty-eight patients developed an anatomic recurrence, which did not demonstrate any associated factors on univariate analysis. Seventy percent of patients remained or were restarted on PPI after their initial surgery. For patients with a documented recurrence, the median time to start a PPI was 224 d, but the time to identify recurrence on imaging or endoscopy was 712.5 d. Eleven (39.3%) patients had a reintervention for anatomic recurrence, of which all had developed recurrent symptoms of GERD.

CONCLUSIONS

Most patients who developed recurrent hiatal hernia were restarted on PPI without workup for their symptoms. The time of initiation of PPI was much earlier than the time of identification of a recurrent hiatal hernia. The use of PPIs in patients whom have undergone HHR may delay proper workup to identify recurrent hiatal hernia amenable to surgical repair and should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms.

A retrospective study on prescribing pattern and cost analysis of proton-pump inhibitors used among adults of Saudi Arabia

Objective

To evaluate the use of proton-pump inhibitors (PPIs) for treatment of different gastric disease in Saudi population and their related administration cost.

Materials and methods

It was a cross-sectional retrospective drug utilization study. The utilization rates and cost analysis of each PPIs class of drugs were compared. Study data were obtained from pharmacy database. Data between 1 January 2019 and 31 December 2019 were investigated, including incidence, prevalence and duration of use of proton-pump inhibitors among adults of Saudi Arabia.

Key findings

We observed 26 798 (4.27%) prescription of PPIs were dispensed in the in-patient and out-patient pharmacy department of Al-Mana Group of Hospital (AGH) Al khobar. Among all the PPIs user, more than the half ((53.01%, n = 14 208), 95% CI (52.42–53.62)) were male. 30–40 years age patients (24.57%, 95% CI (24.06–25.09) (n = 6585)) were highest number of PPI users. Nearly, equal number of PPI users belongs between 51–60 years ((20.88%, n = 5596), 95% CI (20.40–21.37)) and &gt;60 years ((20.36%, n = 5456), 95% CI (19.8–20.85)). Among all the dispensed PPIs drugs, Pantoprazole is dispensed to the highest number of patients (79.09% (95% CI, 78.61–79.58) (n = 21 197)) while their average duration of therapy was 18.86 days. Among all PPIs, pantoprazole average unit wise cost was highest SR 8.83 (USD 2.35) in comparison to other PPIs.

Conclusion

In our study, among all the PPIs Pantoprazole was prescribed to the highest number of patients also it was costliest; hence, their safe and effective use must be warranted. Current study will also help in to develop nation database regarding utilization of proton-pump inhibitors.

Patient and Provider Perspectives on Deprescribing Proton Pump Inhibitors

The aim of the current study is to describe proton pump inhibitor (PPI) prescribing trends in an older adult population and elucidate perspectives regarding PPI deprescribing. A retrospective chart review and a prospective cross-sectional analysis of provider and patient surveys were conducted. The retrospective chart review identified 107 patients age ≥65 who were prescribed PPI therapy. Nineteen patients on PPI therapy and 74 providers completed surveys regarding their perspectives on PPI deprescribing. PPI therapy was potentially inappropriate for 66% of patients based on dose, duration, and/or indication. Provider barriers to deprescribing included fear of outcomes, access to documentation, and uncertainty of current guidelines. This study illustrates the prevalence of long-term PPI use in geriatric patients without associated clinical indications, as well as perceived barriers to deprescribing. Long-term PPI use is associated with significant side effects; therefore, successful deprescribing must address these perceived barriers. [Journal of Gerontological Nursing, 45(10), 9-17.].

The impact of laparoscopic anti-reflux surgery on quality of life: do patients with atypical symptoms benefit?

INTRODUCTION

Gastroesophageal reflux disease (GERD) may manifest atypically as cough, hoarseness or difficulty breathing. However, it is difficult to diagnostically establish a cause-and-effect between atypical symptoms and GERD. In addition, the benefit of laparoscopic anti-reflux surgery (LARS) in patients with laryngopharyngeal manifestations of GERD are not well characterized. We report the largest series reported to date assessing operative and quality of life (QOL) outcomes after LARS in patients experiencing extraesophageal manifestations of GERD and discuss recommendations for this patient population.

METHODS

A retrospective review of patients with extraesophageal symptoms and pathologic reflux that underwent LARS between February 2012 and July 2019 was conducted. Inclusion criteria consisted of patients with atypical manifestations of GERD as defined by preoperative survey in addition to physiological diagnosis of pathological reflux. Patient QOL outcomes was analyzed using four validated instruments: the Reflux Symptom Index (RSI), Laryngopharyngeal Reflux QOL, Swallowing QOL (SWAL), and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQOL) surveys.

RESULTS

420 patients (24% male, 76% female) with a mean age of 61.7 ± 13.0 years and BMI of 28.6 ± 5.0 kg/m² were included in this study. Thirty-day wound (0.2%) and non-wound (6.74%) related complication rates were recorded in addition to thirty-day readmission rate (2.6%). Patients reported significant improvements in laryngopharyngeal symptoms at mean follow-up of 18.9 ± 16.6 months post LARS reflected by results of four QOL instruments (RSI - 64%, LPR - 75%, GERD-HRQOL - 80%, SWAL + 18%). The majority of patients demonstrated complete resolution of symptoms upon subsequent encounters with 68% of patients reporting no atypical extraesophageal manifestations during follow-up survey (difficulty breathing - 86%, chronic cough - 81%, hoarseness - 66%, globus sensation - 68%) and 68% of patients no longer taking anti-reflux medication. Seventy-two percent of patients reported being satisfied with their symptom control at latest follow-up.

CONCLUSIONS

In appropriately selected candidates with atypical GERD symptomatology and objective diagnosis of GERD LARS may afford significant QOL improvements with minimal operative or long-term morbidity.

Is administration of proton pump inhibitors in functional dyspepsia worth the risk of developing gastric cancer: a Markov model to bridge the gap between scientific evidence and clinical practice

OBJECTIVE

To formulate a decision analysis model based on recently published data that addresses the dilemma, whether improvement in quality of life rationalises continued proton pump inhibitors (PPI) use despite the risk of gastric cancer (GC) in patients with functional dyspepsia (FD).

DESIGN

A Markov model consisting of an initial decision regarding treatment with PPI (denoting it by PPI strategy) or any other treatment without PPI (denoting it by placebo strategy) was designed.

DATA SOURCES

Data from prospective cross-sectional studies indicating risk stratification for GC after the use of PPI, combined with a Markov model that comprised the following states: Live, GC stages 1-4, Death.

OUTCOME MEASURES

The primary outputs included quality-adjusted life years (QALYs) and life expectancy (LE). The improvement in utility in FD without PPI as compared with PPI use was tested (PPI vs placebo strategies). Sensitivity analyses were performed to evaluate the robustness of the model and address uncertainty in the estimation of model parameters.

SETTING

We considered only patients whose symptoms were relieved with PPIs and thus, had a better quality of life compared with patients who did not receive PPIs.

RESULTS

The base case model showed that PPIs compared with placebo decreased LE by 58.4 days with a gain of 2.1 QALY. If utility (quality of life of patients with FD using PPI compared with patients with FD without PPI) improved by more than 0.8%, PPI use is considered better than placebo. Older patients benefited less from PPI treatment than did younger patients.

CONCLUSION

To bridge the gap between evidence and decision making, we found that even a small improvement in the QALY justified continuing PPI treatment.

Perforated and bleeding peptic ulcer: WSES guidelines

BACKGROUND

Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment.

METHODS

The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached.

CONCLUSIONS

The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Cost-Utility and Budget Impact Analysis for Stopping the Inappropriate Use of Proton Pump Inhibitors After Cessation of NSAID or Low-Dose Acetylsalicylic Acid Treatment

BACKGROUND

In accordance with current guidelines, proton pump inhibitors (PPIs) are now generally prescribed as a protective co-medication in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or low-dose acetylsalicylic acid (LDASA). However, less attention is paid to the corresponding discontinuation of a PPI after cessation of NSAID or LDASA treatment.

OBJECTIVE

The aim of this study was to assess the extent of inappropriate PPI use, as the proportion of patients who started a PPI as a protective co-medication but continued using these drugs after cessation of NSAID and LDASA treatment. We also sought to estimate the potential cost savings and effect gains of discontinuing inappropriate PPI use and the resulting decrease in adverse effects and their detrimental consequences.

METHODS

Pharmacy dispensing data were used to map inappropriate PPI use in 2014 for community-dwelling patients. Strategies with or without PPI continuation were compared in the cost-utility analysis for a time horizon of 5 years from a healthcare perspective. Subsequently, incremental costs and effects (quality-adjusted life-years) were estimated with a Markov model.

RESULTS

Related to NSAID and LDASA treatment, 11.0% and 5%, respectively, of the PPI users were found to inappropriately continue PPI co-treatment. Discontinuation in 71- to 80-year-old patients suggested cost savings of €170.46 (95% confidence interval 75-282) at a 0.003 (95% confidence interval 0.001-0.005) quality-adjusted life-year increase. The total budget impact of stopping inappropriate PPI use related to NSAID/LDASA treatment in the Netherlands would amount to almost €1,050,000 after 1 year. Correspondingly, successful interventions to stop a patient's inappropriate use would cost up to €29 and probably would pay for themselves in the following years.

CONCLUSIONS

A substantial number of patients inappropriately continue to use a PPI after cessation of NSAID or LDASA treatment. Because adverse effects and their detrimental consequences are avoided, interventions to stop inappropriate PPI use, particularly in older patients, are likely to pay for themselves.

Management/Comorbidities of School-Aged Children with Asthma

Asthma is a complex heterogeneous disease characterized by reversible airflow obstruction. After appropriate diagnosis, the management in school-aged children centers on 3 broad domains: pharmacologic treatment, treatment of underlying comorbidities, and education of the patient and caregivers. It is important to understand that the phenotypic differences that exist in the school-aged child with asthma may impact underlying comorbid conditions as well as pharmacologic treatment choices. Following initiation of therapy, asthma control must be continually evaluated in order to optimize management.

Mandibular Osteonecrosis Associated with Antacid Therapy (Esomeprazole)

Introduction

Osteonecrosis of the jaw has been consistently reported in the literature associated to the high-dose intravenous bisphosphonate therapy. However, osteonecrosis can also occur in patients who have other risk factors.

Case description

An unusual case of ONJ in a patient being treated with esomeprazole is reported.

Discussion

The probable association between proton pump inhibitor intake and osteonecrosis of the jaw should alert clinicians. Collaborations between medical and dental doctor and an early diagnosis might prevent or reduce the morbidity resulting from advanced destructive lesions of the jaw bone.

LEARNING POINTS

Osteonecrosis of the jaw (ONJ) can occur in patients treated with bisphosphonates and corticosteroids and is associated with oral surgical procedures involving bone.Antacid drugs commonly used to treat gastro-oesophageal reflux could affect bone metabolism although no cases of ONJ in patients using proton pump inhibitors have been reported.Medical and dental practitioners should collaborate to prevent ONJ, identify previously unreported drug interactions, and treat patients in a more comprehensive manner.

A Cross-Sectional Study on Single-Day Use of Proton Pump Inhibitors in Tertiary Care Hospitals of South India

Background: Proton pump inhibitors (PPIs) are the most potent antacids used in clinical practice with greater safety and efficacy. Limited data are available on the usage of PPIs in Indian health-care settings. Our aim was to understand the usage pattern and potential drug interactions with concurrently administered medications employing a single-day cross-sectional study design. Methods: A prospective observational cross-sectional study conducted on a single day, at two tertiary care teaching hospitals in South India. Inpatients of above 18 years of age were included. Case profiles were reviewed and data were collected in predesigned forms and analyzed. Drug interactions were identified using Micromedex and Medscape drug-interaction databases. Results: A total of 797 case profiles screened from both the centers; 714 were prescribed with PPIs. In intensive care units (ICUs), the use of PPIs was highest with 95% of cases getting these drugs. A PPI was seen in about 93% of patients, who had more than or equal to 4 drugs in their prescriptions. Pantoprazole was the mostly prescribed PPI in around 90% of the cases. Around 33% of the PPIs usage was through IV (intravenous) route, and 75% of that use was seen in wards. Around 134 drug interactions were identified, of which 10 were of major severity. Conclusions: Around 90% of inpatients were prescribed with PPIs. Pantoprazole is the most commonly prescribed PPI (90%). The IV administration was seen more in wards than ICUs, and 10 major drug interactions were observed in this single-day study. Careful monitoring is needed to avoid serious drug interactions involving PPIs, and training programs should sensitize the clinicians on the evidence-based use of PPIs.

The efficacy and safety of irsogladine maleate in nonsteroidal anti-inflammatory drug or aspirin-induced peptic ulcer and gastritis

BACKGROUND/AIMS

Irsogladine maleate, an enhancer of gastric mucosal protective factors, has demonstrated its efficacy for various gastric mucosal injuries. The aim of this study was to evaluate the efficacy and safety of irsogladine for prevention of nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin-induced peptic ulcer and gastritis.

METHODS

In this multicenter, randomized, double-blind, exploratory clinical trial, 100 patients over 50 years of age who needed continuous NSAIDs or aspirin for more than 8 weeks were randomly assigned to either test group (irsogladine maleate 2 mg, twice daily, 39 patients for full analysis) or placebo group (37 patients for full analysis). Primary outcomes were incidence of peptic ulcer and ratio of modified Lanza score (MLS) 2 to 4. Secondary outcome was the number of acute erosions confirmed by endoscopy at 8 weeks. Adverse effects were also compared.

RESULTS

There were no significant differences in gastric protective effects between test and placebo groups. However, two cases of peptic ulcer in the placebo group but none in the test group were observed. These two cases of peptic ulcer were Helicobacter pylori-negative. In addition, H. pylori-negative group showed significant changes in MLS score (p = 0.0247) and edema score (p = 0.0154) after the treatment compared to those before treatment in the test group. There was no significant difference in adverse events between the two groups.

CONCLUSION

The efficacy of irsogladine maleate was found in H. pylori-negative group, suggesting its potential as a protective agent against NSAIDs or aspirin-induced peptic ulcer and gastritis.

A population-based study of prescribing trends in a potentially vulnerable paediatric population from 1999 to 2012

OBJECTIVES

There is a limited understanding of paediatric medication prescribing trends and patterns, thus poorly positioning decision-makers to identify quality and safety concerns related to medication use. The objective of this study was to determine overall medication prescribing trends and patterns among children receiving Ontario Drug Benefits over a thirteen-year period in the province of Ontario, Canada.

METHODS

Administrative health databases housed within the Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada, were used to identify outpatient prescriptions dispensed from 1999 to 2012 through a publicly funded programme to children ≤18 years of age. Medications were classified according to the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system. Descriptive statistics were used to summarize prescribing patterns.

KEY FINDINGS

This study identified 457 037 children who were dispensed a new prescription between 1999 and 2012. About 56% received their first prescription before 6.5 years of age, and 85% of the children in this study were from families who received social assistance. The most commonly prescribed drugs were antiinfectives (56.1%). Prescriptions for several central nervous system agents, including antipsychotics and agents for attention-deficit/hyperactivity disorder, increased across the study period. Changes in prescribing patterns within opioids, hormones and autonomic agents were noted. The results suggest that historically, prescribing trends have shifted with public policy, pharmaceutical marketing and diagnostic patterns, thus identifying them as a possible tool to measure the impact of policydriven practice changes. Anti-infective prescribing increased markedly with the global H1N1 pandemic. Pharmaceutical marketing, formulary decisions and diagnostic trends may affect the prescribing of ADHD medications globally. The prescribing of codeine-containing products and medroxyprogesterone appeared to fluctuate in response to important publications in the medical literature, and the use of epinephrine syringes increased after public policy changes in the province of Ontario. The steady rise in the use of medications whose long-term effects in children are unknown, such as antipsychotics and proton pump inhibitors, identifies areas in need of future research.

CONCLUSIONS

This study presents the first overview of Canadian prescribing trends for children, the majority of which are of low socioeconomic status and represent a potentially vulnerable population. Our analysis suggests that future research is required to determine whether prescribing trends could be used as indicators of policy effectiveness, pharmacovigilance and diagnostic trends.

Effect of Gastric Acid Suppressants on Response to a Physical Activity Intervention and Major Mobility Disability in Older Adults: Results from the Lifestyle Interventions for Elders (LIFE) Study

OBJECTIVES

Proton pump inhibitors (PPIs) and histamine2 receptor antagonists (H2 RAs) are associated with pharmacologic effects that may be detrimental to mobility and response to physical activity. Mobility disability and injurious fall outcomes in PPI and H2 RA users were compared with nonusers in this secondary analysis of data from the Lifestyle Interventions for Elders (LIFE) study.

METHODS

Participants ages 70-89 years were randomized to a physical activity (PA) or successful aging intervention and evaluated by medication use. Confounders included baseline demographic characteristics, physical function, cognitive function, sleep quality, and acid reflux symptoms that were adjusted via propensity score weighting. Outcomes were incident and persistent major mobility disability (MMD and pMMD) and injurious falls. Weighted proportional hazard models evaluated independent and interaction effects of PPIs and H2 RAs.

RESULTS

No interaction was found between PPIs and H2 RAs and the PA intervention. Drug use associations were significant for H2 RAs (hazard ratio [HR] 1.74 [95% confidence interval [CI] 1.12-2.68]) and PPIs (HR 1.32 [95% CI 1.02-1.70]) compared with nonusers for pMMD. PPIs were associated with increased injurious falls compared with nonusers (HR 1.44 [95% CI 1.06-1.96]). Pooling of data from the H2 RA and PPI exposure groups showed a 26% increase in MMD (HR 1.26 [95% CI 1.07-1.48]), a 44% increase in pMMD (HR 1.44 [95% CI 1.16-1.77]), and a 48% increase in injurious falls (HR 1.48 [95% CI 1.15-1.91]) compared with nonusers. All direct comparisons between PPIs and H2 RAs were nonsignificant.

CONCLUSIONS

Compared with nonusers, participants using either PPIs or H2 RAs had an increased risk of MMD, pMMD, and injurious falls. It is not known if these effects are related to the individual pharmacology of each medication, reduced acid secretion, or the underlying disease state. Further study is required to determine causality.

Prescribing Pattern of Proton Pump Inhibitors in Qatar Rehabilitation Institute: A Retrospective Study

Objective:

Proton pump inhibitors (PPIs) are still widely used despite increasing reports of their adverse events. This drug use evaluation study was conducted to assess the prescribing pattern of PPIs for patients admitted to the Qatar Rehabilitation Institute (QRI).

Methods:

An observational, retrospective, patients' chart-based study included all patients who received a PPI in QRI between April 1, 2017, and October 1, 2017. A standardized tool was prepared and reviewed by the involved clinical pharmacists to collect appropriate data for the evaluation. Statistical analysis was performed using the 25^th Version of the Statistical Package of the Social Sciences (SPSS^®).

Findings:

A total of 119 patients received PPIs during the audit period, of which esomeprazole was the most frequently prescribed (34%). Majority of the patients (94%) were started on PPI without further investigations for confirming the indication, and the indication was not documented in 78% of the participants. Nonsteroidal anti-inflammatory drugs were the most commonly co-prescribed medications with PPIs (59%). Pantoprazole was co-prescribed with clopidogrel in 42% of the patients.

Conclusion:

This drug utilization study shows the need for a proper prescribing practice considering a clear indication and recommendations about the duration of therapy and the need for reassessment in QRI.

First fungemia case due to environmental yeast Wickerhamomyces myanmarensis: detection by multiplex qPCR and antifungal susceptibility

AIM

Presenting the first clinical case of Wickerhamomyces myanmarensis.

PATIENTS & METHODS

Yeast cells were isolated from blood and central venous catheter of a 5.5-year-old male subject. API 20C AUX, MALDI-TOF MS, ITS and LSU rDNA sequencing, and our qPCR assay were used for identification and the MIC values were determined by CLSI M27-A3.

RESULTS

ITS and LSU rDNA sequencing identified both isolates as W. myanmarensis, while API 20C AUX and MALDI-TOF MS did not identify them correctly. Our qPCR specifically distinguished W. myanmarensis from W. anomalus. Isolate obtained from blood showed a higher MIC value for fluconazole, voriconazole and posaconazole.

CONCLUSION

Utilization of reliable identification tools might reveal the genuine spectrum of opportunistic yeast species.

Depression, Hematologic Parameters, and Blood Levels of Vitamin B12 in Patients With Laryngopharyngeal Reflux Under Use of Proton Pump Inhibitors

Objective

The objective of this study was to evaluate and correlate hematologic indices, vitamin B₁₂ levels, and depression in patients with suspected laryngopharyngeal reflux (LPR) treated with proton pump inhibitor (PPI).

Methods

This was a prospective study with a population (n = 23) consisted of patients with suspected LPR and treated with 2 daily doses of Omeprazole 40 mg (80 mg or full dose). The study volunteers performed a complete blood count and vitamin B₁₂ dosage before and after 3 and 6 months of treatment, as well as depression screening using the Center of Epidemiologic Studies-Depression (CES-D) questionnaire before and after 6 months of treatment. Scores greater than 16 were considered as suggestive of depression.

Results

The mean score on the CES-D scale of study participants at baseline significantly decreased after 6 months of treatment. A significant decrease was observed in the red blood cells count (RBC) after 6 months in relation to 3 months. Significant increases in mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) were observed from 3 months to 6 months in this study. Vitamin B₁₂ levels increased significantly between baseline and after 6 months of treatment.

Conclusion

Decreased scores on the CES-D scale were associated with increased MCV values, with no association with vitamin B₁₂ levels. However, vitamin B₁₂ levels also increased significantly after 6 months of treatment with PPI.

Is There a Reason for the Proton Pump Inhibitor? An Assessment of Prescribing for Residential Care Patients in British Columbia

BACKGROUND

The use of proton pump inhibitors (PPIs) may cause significant harm to patients in the residential care setting, as these patients are often frail with multiple morbidities. The extent of non-evidence-based use of PPIs in residential care sites of the Fraser Health Authority in British Columbia is unknown.

OBJECTIVE

To determine the proportion of non-evidence-based use of PPI therapy for residential care patients of the Fraser Health Authority.

METHODS

This retrospective cross-sectional study was conducted in 6 Fraser Health residential care facilities in British Columbia between April 1, 2015, and March 31, 2016. Two definitions of "evidence-based indications" were used. The first definition encompassed broad evidence-based indications for PPI use, specifically gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), gastritis, esophagitis, Barrett esophagus, and gastrointestinal protection from concurrent oral steroids, oral nonsteroidal anti-inflammatory drugs, antiplatelet agents, and anticoagulants. The second definition involved common evidence-based indications for PPI use, specifically GERD or PUD. Descriptive statistics were used to evaluate the primary outcome: the proportion of PPI orders without a documented broad or common evidence-based indication for PPI treatment.

RESULTS

A total of 331 residential care patients and 407 PPI orders were assessed. The proportion of PPI orders without a documented broad evidence-based indication was 16.2% (66/407). The proportion of PPI orders without a documented common evidence-based indication was 43.7% (178/407). The most frequently documented reason for a PPI order was GERD (214/407 or 52.6%). PPI orders for patients with GERD and gastrointestinal bleeding had the longest duration of therapy during residential care admission, averaging 205.1 and 218.1 days, respectively.

CONCLUSION

About 1 in 6 PPI orders for Fraser Health residential care patients did not have a documented broad evidence-based indication, and about 2 in 5 PPI orders did not have a documented common evidence-based indication. These results indicate a need to assess the appropriateness of therapy for every patient with an active PPI order in residential care facilities.

Proton pump inhibitor use and the risk of fractures among an older adult cohort

PURPOSE

The purpose of the study is to determine if the use of a proton pump inhibitor (PPI) is associated with an increased fracture risk, as some prior studies have suggested.

METHODS

This retrospective cohort study included data on 4438 participants aged 65 and older who had no fracture in the year prior to baseline and had ≥5 years of enrollment history in Kaiser Permanente Washington, an integrated healthcare delivery system in Seattle, WA, during 1994 to 2014. Time-varying cumulative exposure to PPIs was determined from automated pharmacy data by summing standard daily doses (SDDs) across fills, and patients were categorized as no use (reference group, ≤30 SDD), light use (31-540 SDD), moderate use (541-1080 SDD), and heavy use (≥1081 SDD). Incident fractures were assessed using International Classification of Diseases, Ninth Revision codes from electronic medical records. Potential confounders, chosen a priori, were assessed at baseline and at each 2-year follow-up visit. Fracture risk was analyzed using a Cox proportional hazards model.

RESULTS

Over a mean follow-up of 6.1 years, 802 (18.1%) participants experienced a fracture. No overall association was found between PPI use and fracture risk. Adjusted hazard ratios comparing users to the referent category were 1.08 (95% CI 0.83-1.40) for light users, 1.31 (95% CI 0.86-1.95) for moderate users, and 0.95 (95% CI 0.68-1.34) for heavy users. Among patients with SSD > 30, no appreciable increase in fracture risk was present in persons with recent versus distant use (adjusted hazard ratio of 1.14 [95% CI 0.91-1.42]).

CONCLUSIONS

No association was observed between PPI use and fracture risk among older adults.

Iron Deficiency Anemia Due to the Long-term Use of a Proton Pump Inhibitor

A 52-year-old man who had been taking omeprazole, a proton pump inhibitor (PPI), for 25 years developed iron deficiency anemia. An evaluation of the entire gastrointestinal tract did not reveal any possible causes of gastrointestinal blood loss. The cause of the iron deficiency was considered to be a reduction in gastrointestinal iron absorption in association with the reduced secretion of gastric acid due to PPI use. This case demonstrates that long-term PPI use for as long as 25 years may cause iron deficiency anemia and should be considered in the differential diagnosis of iron deficiency anemia in long-term PPI users.

ADAM proteases involved in inflammation are differentially altered in patients with gastritis or ulcer

ADAM metallopeptidase domain (ADAM)9, 10 and 17 have α-secretase activity that regulates ectodomain shedding of factors involved in inflammation, cell proliferation, angiogenesis, and wound healing. The secretase activity of ADAM proteins is known to induce an inflammatory response. However, under certain conditions, a lack of secretase activity may induce inflammation suggesting differential roles of ADAM proteins with secretase activity. To the best of our knowledge, the present study evaluated the changes in α-secretase activity and expression of associated ADAM proteases (ADAM9, 10 and 17) in the gastric mucosa of patients with gastritis and ulcers, for the first time. Gastroduedonal mucosal samples from 42 patients were snap-frozen to determine changes in α-secretase activity. Twenty-four of these patients had gastritis, 9 patients had duedonal ulcers and 9 patients did not have any pathological changes. Paraffin-embedded gastric specimens (n=32) were used for immunohistochemical detection of ADAM9, ADAM10 and ADAM17. α-secretase activity of the gastric mucosa of healthy subjects was significantly higher compared with the uninvolved mucosa of patients with gastritis or ulcer. These results were associated with the immunohistochemical staining results, which demonstrated that ADAM10 expression markedly decreased in glandular epithelial cells and ADAM9 expression was lost in foveolar epithelial cells of gastric mucosa adjacent to ulcer. However, ADAM17 expression was increased in the normal gastric mucosa of patients with bleeding peptic ulcers and in the gastric mucosa adjacent to the ulcer suggesting a counteracting role of ADAM17. Decreased ADAM9 and 10 expression, and an associated decrease in α-secretase activity may predispose to chronic gastritis and ulcer. Further studies are required to determine the possible etiological role of increased ADAM17 expression.

Symptom relief and health-related quality of life in globus patients: a prospective study

Globus may be a persistent symptom impairing patients' quality of life. Diagnostics and treatment are controversial but some globus patients may benefit from reassurance and attention. We investigated how globus symptoms change during a short-term follow-up without any treatment after an examination by an ear, nose and throat (ENT) physician and further diagnostic procedures. We also surveyed whether patients with persistent globus suffer from simultaneous voice problems. The study comprised 30 consecutive globus patients referred to Helsinki University Hospital, Department of Otorhinolaryngology - Head and Neck Surgery. We performed an ENT examination and scored patients' videolaryngostroboscopies using the Reflux Finding Score (RFS). Patients filled in three questionnaires: the Reflux Symptom Index (RSI), the Deglutition Handicap Index (DHI) and the 15-Dimensional Measure of Health-Related Quality of Life (15-D HRQoL). Patients underwent transnasal esophagoscopy, high-resolution manometry, and 24-hour multichannel intraluminal impedance and pH monitoring. After a four-month follow-up, patients re-answered the same questionnaires and a speech and language pathologist (SLP) examined the patients. Baseline and follow-up questionnaires were available from 27 (90%) patients. According to the RSI (p = .001) and the DHI (p = .003), patients' symptoms diminished after four months. The 15-D showed improvement in one subscale measuring discomfort and symptoms (p = .023). The SLP examined 23 (77%) patients, finding functional voice problems in six (26%). The study showed that most globus patients felt their symptoms diminished without any treatment during four months. In some patients, coexisting voice problems may be associated with persistent globus.

We have had a gutful: The need for deprescribing proton pump inhibitors

WHAT IS KNOWN AND OBJECTIVE

Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue.

METHODS

Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review.

RESULTS AND DISCUSSION

Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications.

WHAT IS NEW AND CONCLUSION

Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

New Approaches to Gastroesophageal Reflux Disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder of the esophagus. It is a chronic, progressive disorder that presents most typically with heartburn and regurgitation and atypically with chest pain, dysphagia, chronic cough, globus, or sore throat. The mainstay for diagnosis and characterization of the disorder is esophagoduodenoscopy (EGD), high-resolution esophageal manometry, and symptom-associated ambulatory esophageal pH impedance monitoring. Additional studies that can be useful in certain clinical presentations include gastric scintigraphy and oral contrast upper gastrointestinal radiographic series.

DISCUSSION

Refractory GERD can be surgically managed with various techniques. In obese individuals, laparoscopic Roux-en-Y gastric bypass should be considered due to significant symptom improvement and lower incidence of recurrent symptoms with weight loss. Otherwise, laparoscopic Nissen fundoplication is the preferred surgical technique for treatment of this disease with concomitant hiatal hernia repair when present for either procedure. The short-term risks associated with these procedures include esophageal or gastric injury, pneumothorax, wound infection, and dysphagia. Emerging techniques for treatment of this disease include the Linx Reflux Management System, EndoStim LES Stimulation System, Esophyx® and MUSE™ endoscopic fundoplication devices, and the Stretta endoscopic ablation system. Outcomes after surgical management of refractory GERD are highly dependent on adherence to strict surgical indications and appropriate patient-specific procedure selection.

Update of EULAR recommendations for the treatment of systemic sclerosis

The aim was to update the 2009 European League against Rheumatism (EULAR) recommendations for the treatment of systemic sclerosis (SSc), with attention to new therapeutic questions. Update of the previous treatment recommendations was performed according to EULAR standard operating procedures. The task force consisted of 32 SSc clinical experts from Europe and the USA, 2 patients nominated by the pan-European patient association for SSc (Federation of European Scleroderma Associations (FESCA)), a clinical epidemiologist and 2 research fellows. All centres from the EULAR Scleroderma Trials and Research group were invited to submit and select clinical questions concerning SSc treatment using a Delphi approach. Accordingly, 46 clinical questions addressing 26 different interventions were selected for systematic literature review. The new recommendations were based on the available evidence and developed in a consensus meeting with clinical experts and patients. The procedure resulted in 16 recommendations being developed (instead of 14 in 2009) that address treatment of several SSc-related organ complications: Raynaud's phenomenon (RP), digital ulcers (DUs), pulmonary arterial hypertension (PAH), skin and lung disease, scleroderma renal crisis and gastrointestinal involvement. Compared with the 2009 recommendations, the 2016 recommendations include phosphodiesterase type 5 (PDE-5) inhibitors for the treatment of SSc-related RP and DUs, riociguat, new aspects for endothelin receptor antagonists, prostacyclin analogues and PDE-5 inhibitors for SSc-related PAH. New recommendations regarding the use of fluoxetine for SSc-related RP and haematopoietic stem cell transplantation for selected patients with rapidly progressive SSc were also added. In addition, several comments regarding other treatments addressed in clinical questions and suggestions for the SSc research agenda were formulated. These updated data-derived and consensus-derived recommendations will help rheumatologists to manage patients with SSc in an evidence-based way. These recommendations also give directions for future clinical research in SSc.

A Retrospective Study to Assess the Effect of Proton Pump Inhibitors on Renal Profile in a South Indian Hospital

INTRODUCTION

Proton Pump Inhibitors (PPIs) are arguably among the most commonly prescribed drugs in clinical practice, either as part of treatment or prophylaxis. Many clinicians prescribe these drugs as part of any prescription, without a proper rationale. Recent studies done outside India have shown that these drugs are not entirely safe, and they can result in the development of acute renal injury.

AIM

To assess the effect of PPIs on blood urea and serum creatinine, when administered for at least seven consecutive days.

MATERIALS AND METHODS

The study was conducted in a retrospective manner, using data from the medical records department. Values of blood urea and serum creatinine were taken twice, first before start of therapy and then after at least one week of therapy.

RESULTS

A total of 175 subjects were selected for the study. When their case files were analysed, acute kidney injury was identified in 19 (10.86%) of them. Pantoprazole was the most common drug involved (84.21%). Renal injury was more common in the age group of over 50 years of age.

CONCLUSION

PPIs are not entirely free of adverse effects, as assumed by several practitioners. A vigilant eye has to be maintained on the patient's renal profile so as to avoid any untoward decline in renal function, as evidenced in the current study.

The Safety of Appropriate Use of Over-the-Counter Proton Pump Inhibitors: An Evidence-Based Review and Delphi Consensus

The availability of over-the-counter (OTC) proton pump inhibitors (PPIs) for the short-term (2 weeks) management of frequent heartburn (≥2 days/week) has increased markedly, yet evidence-based recommendations have not been developed. A panel of nine international experts in gastroesophageal reflux disease developed consensus statements regarding the risks and benefits of OTC PPIs using a modified Delphi process. Consensus (based on ≥80% approval) was reached through multiple rounds of remote voting and a final round of live voting. To identify relevant data, the available literature was searched and summarized. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system terminology was used to rate the quality of evidence and strength of recommendations; consensus was based on ≥2/3 agreement. After 4 rounds of review, consensus was achieved for 18 statements. Notably, the available data did not directly reflect OTC use, but instead, prescription use; therefore, extrapolations to the OTC setting were often necessary. This limitation is regrettable, but it justifies performing this exercise to provide evidence-based expert opinion on a widely used class of drugs. The panel determined that using OTC PPIs according to label instructions is unlikely to mask the symptoms of esophageal or gastric cancer or adversely impact the natural history of related precursor conditions. OTC PPIs are not expected to substantially affect micronutrient absorption or bone mineral density or cause community-acquired pneumonia, Clostridium difficile infection, or cardiovascular adverse events. However, OTC PPI use may be associated with slightly increased risks for infectious diarrhea, certain idiosyncratic reactions, and cirrhosis-related spontaneous bacterial peritonitis. The available evidence does not suggest that OTC PPI use consistent with label instructions is associated with substantial health risks. To minimize potential risks, healthcare professionals and consumers must actively participate in decision making when managing reflux-related symptoms in the self-care setting.

A retrospective analysis of the role of proton pump inhibitors in colorectal cancer disease survival

BACKGROUND

Proton pump inhibitors (ppis) are a commonly used medication. A limited number of studies have identified a weak-to-moderate association between ppi use and colorectal cancer (crc) risk, but none to date have identified an effect of ppi use on crc survival. We therefore postulated that an association between ppi use and crc survival might potentially exist.

METHODS

We performed a retrospective chart review of 1304 crc patients diagnosed from January 2005 to December 2011 and treated at the Cancer Centre of Southeastern Ontario. Kaplan-Meier analysis and Cox proportional hazards regression models were used to evaluate overall survival (os).

RESULTS

We identified 117 patients (9.0%) who were taking ppis at the time of oncology consult. Those taking a ppi were also more often taking asa or statins (or both) and had a statistically significantly increased rate of cardiac disease. No identifiable difference in tumour characteristics was evident in the two groups, including tumour location, differentiation, lymph node status, and stage. Univariate analysis identified a statistically nonsignificant difference in survival, with those taking a ppi experiencing lesser 1-year (82.1% vs. 86.7%, p = 0.161), 2-year (70.1% vs. 76.8%, p = 0.111), and 5-year os (55.2% vs. 62.9%, p = 0.165). When controlling for patient demographics and tumour characteristics, multivariate Cox regression analysis identified a statistically significant effect of ppi in our patient population (hazard ratio: 1.343; 95% confidence interval: 1.011 to 1.785; p = 0.042).

CONCLUSIONS

Our results suggest a potential adverse effect of ppi use on os in crc patients. These results need further evaluation in prospective analyses.

Use of Proton Pump Inhibitors and Risks of Fundic Gland Polyps and Gastric Cancer: Systematic Review and Meta-analysis

BACKGROUND & AIMS

There have been increasing numbers of case reports and observational studies of adverse events in patients receiving long-term therapy with proton pump inhibitors (PPIs). The effects of PPI therapy on risks of fundic gland polyps (FGPs) and gastric cancer have received considerable attention. We performed a systematic review with a meta-analysis of randomized controlled trials and observational studies that assessed these risks.

METHODS

We searched the PUBMED, EMBASE, and Cochrane Central Register of Controlled Trials databases for relevant studies published through July 2015. We calculated pooled odds ratio for FGPs and the risk ratio for gastric cancer in PPI users compared with PPI nonusers using fixed- and random-effects models.

RESULTS

We analyzed data from 12 studies, comprising more than 87,324 patients: 1 randomized controlled trial reporting the effect of PPIs on gastric polyps (location not specified), 6 cohort and 1 case-control studies on FGPs, and 1 cohort and 3 case-control studies on gastric cancer. Pooled odds ratios for FGPs were 1.43 (95% confidence interval, 1.24-1.64) and 2.45 (95% confidence interval, 1.24-4.83) from fixed- and random-effects models, respectively. The pooled risk ratio for gastric cancer was 1.43 (95% confidence interval, 1.23-1.66) from each model. We observed significant heterogeneity among studies reporting on FGPs, but not among studies reporting on gastric cancer.

CONCLUSIONS

Based on a systematic review with meta-analysis, long-term use of PPIs (≥12 months) is associated with an increased risk of FGPs. PPI therapy might also increase the risk of gastric cancer, but this association could be biased, because of the limited number of studies and possible confounding factors.

[Systemic sclerosis : What is currently available for treatment?]

Systemic sclerosis (scleroderma) is a rheumatologic disease characterised not only by inflammation/autoimmunity, but also by tissue fibrosis and vascular lesions. The therapeutic approach to patients is dictated by the organ involvement and includes treatment of vascular and fibrotic disease features beyond mere immunosuppression. Fibrotic features in particular, are still inadequately treated, whereas many drugs have been tested for vascular complications within recent years. In this review, the currently available treatment options for this rare disease are presented. Therapy options in systemic sclerosis have changed over the past 10 years and this trend will also continue in the future.

Secretagogue-dependent and -independent transport of zinc hydration forms in rat parietal cells

Prolonged exposure to gastric acid is a leading cause of gastroesophageal reflux disease (GERD) and esophagitis. With the ever increasing number of patients showing insensitivity to proton-pump-inhibitor (PPI) therapy with recurrence of symptoms over time, alternative treatment options remain an important issue. Previous studies from our laboratory have shown that a zinc sulfate salt can inhibit HCl generation at the cellular level of the parietal cell. In this paper, we examine the difference between two hydration forms of ZnSO₄ (monohydrate H₂O and heptahydrate 7H₂O) in their entry characteristics into the parietal cell under several physiological conditions associated with acid secretion. Using the Zn sensitive fluorochrome Newport Green, we examined the rate of Zn entry in Δfluorescent units/second (ΔFU/second), at two different concentrations for both hydration states on both fasted and non-fasted animals. In a separate series of studies, we examined the effects of secretagogues on the entry rates and transport mechanisms. Exposure of the secretagogue carbachol transformed the resting parietal cell to an activated state and represents a stimulated condition through the neuronal pathway. The hormonal activation of the parietal cell was achieved by using histamine. Non-fasted conditions were considered to be a state between hormonal and neuronal activation. To demonstrate that ZnSO₄ enters the parietal cell through the NKCC1 co-transporter, the inhibitor bumetanide was applied during secretagogue-stimulated acid secretion. Both salts, monohydrate and heptahydrate ZnSO₄, show a concentration-dependent cell entry under all conditions studied. During stimulated acid secretion, induced through either the neuronal or the hormonal pathway, heptahydrate ZnSO₄ enters the parietal cell significantly faster than monohydrate ZnSO₄, whereas monohydrate ZnSO₄ exhibits faster entry during resting conditions in fasted animals. At 30 μM following stimulation with histamine, heptahydrate ZnSO₄ enters the cell faster than monohydrate ZnSO₄ (ΔFU/second 30 μM _{ZnSO4*7H2O + histamine} = 1.782, ΔFU/second 30 μM _{ZnSO4*H2O+histamine} = 1.038, respectively). Three hundred micromolar, heptahydrate ZnSO₄ shows a faster entry into the cells (ΔFU/second _{ZnSO4*7H2O300μM + carbachol} = 4.02407) compared to monohydrate ZnSO₄ (ΔFU/second _{ZnSO4*H2O300μM + carbachol} = 3.225) following exposure to carbachol. The mechanism of entry of both salts was found to be predominantly via the basolateral NKCC1 transporter with the rate of zinc entry decreasing to minimal values (ΔFU/second = 0.275) after application of bumetanide during stimulated conditions.

Esomeprazole use is independently associated with significant reduction of BMD: 1-year prospective comparative safety study of four proton pump inhibitors

Because of the efficacy of proton pump inhibitors (PPIs), their the use is increasing dramatically. The risk of adverse effects of short-term PPI therapy is low, but there are important safety concerns for potential adverse effects of prolonged PPI therapy. Findings from studies assessing the association between PPI use and bone mineral density (BMD) and/or fracture risk are contradictory. The aim of this study was to prospectively assess potential association of PPI treatment with the 12-month change in BMD of the lumbar spine, femur neck, and total hip. The study was performed in 200 PPI users and 50 PPI nonusers. Lumbar spine (L1-L4), femur neck, and total hip BMD were measured by dual-energy X-ray absorptiometry at the baseline and at 12 months. A total of 209 subjects completed the entire 12 months of the study and were included in the final analysis. A Wilcoxon signed-rank test showed that at 12 months PPI use was associated with statistically significant reductions in femur neck and total hip T scores (Z = -2.764, p = 0.005 and Z = -3.281, p = 0.001, respectively). A multiple linear regression analysis showed that only esomeprazole added significantly to the prediction of total lumbar spine and femur neck T scores (p = 0.048 and p = 0.037, respectively). Compared with the baseline, 12 months of PPI treatment resulted in lower femur neck and total hip BMD T scores. Among the four PPIs studied, esomeprazole was independently associated with significant reduction of BMD, whereas omeprazole had no effects on BMD. Considering the widespread use of PPIs, BMD screening should be considered in the case of prolonged PPI use.

Proton pump inhibitors utilisation in older people in New Zealand from 2005 to 2013

BACKGROUND

The prescriptions for proton pump inhibitors (PPI) to treat acid-related disorders continue to rise internationally and in New Zealand. Concerns have been raised regarding its widespread use, costs and potential adverse effects in older people.

AIMS

This study aimed to characterise the utilisation of PPI by older people (aged 65 years and older) in New Zealand from 2005 to 2013.

METHODS

Repeated cross-sectional analysis of population-level dispensing data was conducted from 1 January 2005 to 31 December 2013. Dispensing data for all PPI prescriptions from 2005 to 2013 were obtained from the Ministry of Health, New Zealand. Utilisation was measured in defined daily doses (DDD) per 1000 older people per day using the World Health Organization Collaborating Centre for Drug Statistics Methodology anatomic, therapeutic and chemical classification system. Utilisation was standardised by sex, age, ethnicity and district health board.

RESULTS

Overall PPI utilisation showed a 26.7% increase from 2005 to 2013, from 273.41 to 346.53 DDD/1000/day. The greatest utilisation was observed in individuals aged between 80 and 84 years. Middle Eastern/Latin American/African utilised more PPI compared with other ethnic groups.

CONCLUSIONS

Utilisation of PPI among older people in New Zealand increased by a fifth from 2005 to 2013. Given the concerns surrounding the long-term PPI use in older people, the appropriateness of the increased utilisation needs to be continuously re-evaluated by prescribers and health policy makers.