Failure to renew prescriptions for gastroprotective agents to patients on continuous nonsteroidal anti-inflammatory drugs increases rate of upper gastrointestinal injury

Epidemiology and diagnosis of acute nonvariceal upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (UGIB) is a common gastroenterological emergency. A vast majority of these bleeds have nonvariceal causes, in particular gastroduodenal peptic ulcers. Nonsteroidal antiinflammatory drugs, low-dose aspirin use, and Helicobacter pylori infection are the main risk factors for UGIB. Current epidemiologic data suggest that patients most affected are older with medical comorbidit. Widespread use of potentially gastroerosive medications underscores the importance of adopting gastroprotective pharamacologic strategies. Endoscopy is the mainstay for diagnosis and treatment of acute UGIB. It should be performed within 24 hours of presentation by skilled operators in adequately equipped settings, using a multidisciplinary team approach.

Sex differences in stroke prevention in atrial fibrillation in French primary care. Results of the AFIGP (Atrial Fibrillation In General Practice) database

BACKGROUND AND OBJECTIVES

Most of the French patients diagnosed with atrial fibrillation (AF) are managed by general practitioners (GPs). The objective was to evaluate stroke prevention in AF patients ahead of the arrival of the non vitamin K oral anticoagulant in France.

METHODS

A cross-sectional study using a French GPs database of all patients with a diagnosis of AF consulting their GP between July-2010 and June-2011. Multivariate analyses were used to identify determinants of prevention prescription.

RESULTS

Among 15,623 AF patients, 42.5 % were ≥75 years and 40.5 % women, 59.2 % had hypertension, 17.2 % diabetes, 11.4 % heart failure, 4.9 % stroke history. CHADS2 score was ≥1 for 83.1 % and ≥2 for 50.9 % of patients (CHA2DS2-VASc score ≥1 for 93.7 % and ≥2 for 82.3 %). Antithrombotic therapies were vitamin K antagonists (VKA) for 50.7 % of patients, followed by aspirin for 19.9 %, clopidogrel ± aspirin for 4.3 % and none for 25.1 %. For patients with CHADS2 scores ≥1, 73.3 % received an antithrombotic and for those with CHADS2 scores ≥2, 54.9 % were treated by a VKA. An age-stratified multivariate analysis showed that women had an odds ratio to be treated with VKA compared to 0.83 (95 % CI: 0.72-0.95) and 0.66 (95 % CI: 0.59-0.74) when aged <75 years and ≥75 years, respectively.

CONCLUSIONS

Most AF patients followed by French GPs required stroke prevention according to European guidelines, but many of them did not receive the recommended antithrombotic treatment. Women over 75 were a third less likely to be treated with recommended anticoagulants than men of similar age.

Hair analysis in the detection of long-term use of non-steroidal anti-inflammatory drugs and its relation to gastrointestinal hemorrhage: an examination of 268 hair and blood samples from autopsy cases

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used as analgesics and antipyretics in Western countries. Gastrointestinal (GI) disorders are common side effects of NSAIDs and other drugs. This study investigated the correlation between chronic use of these substances and GI lesions by analyzing postmortem blood and hair samples from autopsy cases. This study included 268 hair and blood samples from autopsy cases. Deceased individuals with GI lesions were selected for the case group (n = 132) and those without any GI lesions were placed in the control group (n = 136). Collection of the samples took place from 2008 until 2010 at the Institute of Legal Medicine and Forensic Sciences, Charité-Universitätsmedizin Berlin, Germany. HPLC-DAD was used to analyze the blood samples while hair samples were analyzed using LC-quadrupole-time-of-flight-MS. The proximal 0-6 cm hair segment was analyzed. The full length of shorter hair samples was analyzed when longer segments were unavailable. Method validation was performed according to the guidelines of the German Society of Toxicological and Forensic Chemistry (GTFCh). Twenty-three per cent of the case group blood samples included one or more NSAIDs while 19 % of the control group blood samples included one or more NSAIDs. In contrast, the hair analysis results demonstrated that samples from the control and case group differed significantly; 67 % of the case group tested positive for one or more NSAIDs while 38 % of the control group tested positive for one or more NSAIDs. Hair analysis results provided a strong indication of a relationship between frequent NSAID consumption and GI lesions.

Co-prescription of gastroprotective agents and their efficacy in elderly patients taking nonsteroidal anti-inflammatory drugs: a systematic review of observational studies

BACKGROUND & AIMS

Guidelines recommend prescribing gastroprotective agents (proton pump inhibitors, misoprostol) to older patients (primarily ≥65 years old) taking nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent gastrointestinal ulcers. Older individuals are underrepresented in clinical trials of these agents. We systematically reviewed evidence from observational studies on the use of gastroprotective agents in elderly patients and their ability to prevent NSAID-related ulcers in this population.

METHODS

We performed a systematic search of Embase and MEDLINE and identified 23 observational studies that focused on elderly patients and reported data on co-prescription of gastroprotective agents and NSAIDs and/or the effectiveness of the agents in preventing gastrointestinal events in NSAID users. We collected data on rates of co-prescription and NSAID-related gastrointestinal events in patients with and without gastroprotection.

RESULTS

A median of 24% (range, 10%-69%) of elderly patients taking NSAIDs received a co-prescription for gastroprotective agents; this percentage was only slightly higher in the oldest age groups. All studies of efficacy showed a positive effect of gastroprotection. However, the adjusted results were not suitable for synthesis, and the 5 studies reporting unadjusted results were too heterogeneous for meta-analysis (I(2) = 97%). The studies differed in outcomes, definitions of co-prescription, and differences in baseline risk factors between patients with and without gastroprotection. None of the studies assessed adverse effects of gastroprotective agents. The 2 cost-effectiveness studies reached opposing conclusions.

CONCLUSIONS

In a systematic review, the observational evidence for the efficacy of gastroprotective agents in preventing NSAID-associated gastrointestinal events was in agreement with results of randomized controlled trials. However, because of heterogeneity of included studies, it is not clear what the effect would be if more patients were treated, or at what age gastroprotection should be recommended. We offer suggestions to facilitate comparison with other work and address the questions of risk and benefit in relation to age.