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Kallumkal G, McCallen J, Contarino M. Recurrent Duodenal Ulceration-More Than Simple Peptic Ulcer Disease? Gastroenterology 2024:S0016-5085(24)00354-8. [PMID: 38531512 DOI: 10.1053/j.gastro.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Govind Kallumkal
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
| | - Justin McCallen
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Michael Contarino
- Division of Hospital Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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2
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Ito T, Ramos-Alvarez I, Jensen RT. Successful Lifetime/Long-Term Medical Treatment of Acid Hypersecretion in Zollinger-Ellison Syndrome (ZES): Myth or Fact? Insights from an Analysis of Results of NIH Long-Term Prospective Studies of ZES. Cancers (Basel) 2023; 15:1377. [PMID: 36900170 PMCID: PMC10000208 DOI: 10.3390/cancers15051377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/09/2023] [Accepted: 02/15/2023] [Indexed: 02/24/2023] Open
Abstract
Analysis of the efficacy/pharmacology of long-term/lifetime medical treatment of acid hypersecretion in a large cohort of ZES patients in a prospective study. This study includes the results from all 303 patients with established ZES who were prospectively followed and received acid antisecretory treatment with either H2Rs or PPIs, with antisecretory doses individually titrated by the results of regular gastric acid testing. The study includes patients treated for short-term periods (<5 yrs), patients treated long-term (>5 yrs), and patients with lifetime treatment (30%) followed for up to 48 years (mean 14 yrs). Long-term/lifelong acid antisecretory treatment with H2Rs/PPIs can be successfully carried out in all patients with both uncomplicated and complicated ZES (i.e., with MEN1/ZES, previous Billroth 2, severe GERD). This is only possible if drug doses are individually set by assessing acid secretory control to establish proven criteria, with regular reassessments and readjustments. Frequent dose changes both upward and downward are needed, as well as regulation of the dosing frequency, and there is a primary reliance on the use of PPIs. Prognostic factors predicting patients with PPI dose changes are identified, which need to be studied prospectively to develop a useful predictive algorithm that could be clinically useful for tailored long-term/lifetime therapy in these patients.
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Affiliation(s)
- Tetsuhide Ito
- Neuroendocrine Tumor Centre, Fukuoka Sanno Hospital, International University of Health and Welfare, 3-6-45 Momochihama, Sawara-Ku, Fukuoka 814-0001, Japan
| | | | - Robert T. Jensen
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA
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3
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Halfdanarson TR, Strosberg JR, Tang L, Bellizzi AM, Bergsland EK, O'Dorisio TM, Halperin DM, Fishbein L, Eads J, Hope TA, Singh S, Salem R, Metz DC, Naraev BG, Reidy-Lagunes DL, Howe JR, Pommier RF, Menda Y, Chan JA. The North American Neuroendocrine Tumor Society Consensus Guidelines for Surveillance and Medical Management of Pancreatic Neuroendocrine Tumors. Pancreas 2020; 49:863-881. [PMID: 32675783 DOI: 10.1097/mpa.0000000000001597] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This article is the result of the North American Neuroendocrine Tumor Society consensus conference on the medical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The guidelines panel consisted of medical oncologists, pathologists, gastroenterologists, endocrinologists, and radiologists. The panel reviewed a series of questions regarding the medical management of patients with pancreatic neuroendocrine tumors as well as questions regarding surveillance after resection. The available literature was reviewed for each of the question and panel members voted on controversial topics, and the recommendations were included in a document circulated to all panel members for a final approval.
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Affiliation(s)
| | | | - Laura Tang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew M Bellizzi
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Emily K Bergsland
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Thomas M O'Dorisio
- Department of Medicine, Division of Endocrinology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Daniel M Halperin
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lauren Fishbein
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, Division of Biomedical Informatics and Personalized Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jennifer Eads
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA
| | - Simron Singh
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago IL
| | - David C Metz
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - James R Howe
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Rodney F Pommier
- Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Yusuf Menda
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Jennifer A Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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4
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Alkhushaym N, Almutairi AR, Althagafi A, Fallatah SB, Oh M, Martin JR, Babiker HM, McBride A, Abraham I. Exposure to proton pump inhibitors and risk of pancreatic cancer: a meta-analysis. Expert Opin Drug Saf 2020; 19:327-334. [PMID: 31928106 DOI: 10.1080/14740338.2020.1715939] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/10/2020] [Indexed: 02/07/2023]
Abstract
Objectives: To estimate the pancreatic cancer risk among subjects exposed versus not exposed to proton pump inhibitors.Methods: The authors searched PubMed, EMBASE, Scopus, Cochrane Library, and clinicaltrials.gov to identify relevant studies. The authors quantified pancreatic cancer risk among subjects exposed versus not exposed to PPIs, expressed as the pooled (adjusted) odds ratio (OR/aOR) and 95% confidence interval (95%CI) in overall and sensitivity analyses.Results: One randomized trial, two cohort, four case-control, and five nested case-control studies with 700,178 subjects (73,985 cases; 626,193 controls) were retained. PPI exposure was associated with pancreatic cancer risk (OR = 1.75, 95%CI = 1.12-2.72, I2 = 99%); confirmed in sensitivity analyses for high-quality studies, observational studies, case-control studies, studies with pancreatic cancer as the primary outcome, and in sensitivity analyses for diabetes and obesity but not for pancreatitis and smoking. This association was independent of the duration and Defined Daily Dose of PPI exposure. Rabeprazole had a singular significant association with pancreatic cancer (OR = 5.40, 95%CI = 1.98-14.703, I2 = 87.9%).Conclusion: The class of PPIs is associated with a 1.75-fold increase in pancreatic cancer risk, confirmed in sensitivity analyses.
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Affiliation(s)
- Nasser Alkhushaym
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
- Department of Clinical Pharmacy, Royal Commission Health Services Program, Jubail, Saudi Arabia
| | - Abdulaali R Almutairi
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
- SFD-Drug sector, Saudi Food and Drug Authority, Riyadh, Saudi Arabia
| | - Abdulhamid Althagafi
- Clinical Pharmacy Department, College of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Saad B Fallatah
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
- Clinical and Hospital Pharmacy Department, College of Pharmacy, Taibah University, Medina, Saudi Arabia
| | - Mok Oh
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Jennifer R Martin
- Arizona Health Sciences Library, The University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Hani M Babiker
- Department of Hematology & Oncology, College of Medicine, The University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Ali McBride
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
- University of Arizona Cancer Center, Tucson, AZ, USA
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
- Department of Family and Community Medicine, College of Medicine, The University of Arizona, Tucson, AZ, USA
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5
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Briganti V, Cuccurullo V, Di Stasio GD, Mansi L. Gamma Emitters in Pancreatic Endocrine Tumors Imaging in the PET Era: Is there a Clinical Space for 99mTc-peptides? Curr Radiopharm 2019; 12:156-170. [DOI: 10.2174/1874471012666190301122524] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/15/2018] [Accepted: 10/19/2018] [Indexed: 12/18/2022]
Abstract
Background:
Pancreatic Neuroendocrine Tumors (PNETs) are rare neoplasms, sporadic or
familial, even being part of a syndrome. Their diagnosis is based on symptoms, hormonal disorders or
may be fortuitous. The role of Nuclear Medicine is important, mainly because of the possibility of a
theranostic strategy. This approach is allowed by the availability of biochemical agents, which may be
labeled with radionuclides suitable for diagnostic or therapeutic purposes, showing almost identical
pharmacokinetics. The major role for radiopharmaceuticals is connected with radiolabeled Somatostatin
Analogues (SSA), since somatostatin receptors are highly expressed on some of the neoplastic
cell types.
Discussion:
Nowadays, in the category of radiolabeled SSA, although 111In-pentetreotide, firstly
commercially proposed, is still used, the best choice for diagnosis is related to the so called DOTAPET
radiotracers labeled with 68-Gallium (Ga), such as 68Ga-DOTATATE, 68Ga-DOTANOC, and
68Ga-DOTATOC. More recently, labeling with 64-Copper (Cu) (64Cu-DOTATATE) has also been
proposed. In this review, we discuss the clinical interest of a SAA (Tektrotyd©) radiolabeled with
99mTc, a gamma emitter with better characteristics, with respect to 111Indium, radiolabeling Octreoscan
©. By comparing both pharmacokinetics and pharmacodynamics of Octreoscan©, Tektrotyd©
and PET DOTA-peptides, on the basis of literature data and of our own experience, we tried to highlight
these topics to stimulate further studies, individuating actual clinical indications for all of these
radiotracers.
Conclusion:
In our opinion, Tektrotyd© could already find its applicative dimension in the daily practice
of NETs, either pancreatic or not, at least in centers without a PET/CT or a 68Ga generator. Because
of wider availability, a lower cost, and a longer decay, compared with respect to peptides labeled
with 68Ga, it could be also proposed, in a theranostic context, for a dosimetry evaluation of patients
undergoing Peptide Receptor Radionuclide Therapy (PRRT), and for non-oncologic indications
of radiolabelled SSA. In this direction, and for a more rigorous cost/effective evaluation, more precisely
individuating its clinical role, further studies are needed.
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Affiliation(s)
- Vittorio Briganti
- Nuclear Medicine Unit - Azienda Ospedaliero Universitaria Careggi Firenze, Italy
| | - Vincenzo Cuccurullo
- Nuclear Medicine Unit, Department of Clinical and Experimental Medicine "F.Magrassi, A.Lanzara" – Università della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Giuseppe Danilo Di Stasio
- Nuclear Medicine Unit, Department of Clinical and Experimental Medicine "F.Magrassi, A.Lanzara" – Università della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Luigi Mansi
- Health and Development Section, Interuniversitary Research Center for Sustainable Development, Napoli-Roma, Italy
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Advances and Current Concepts in the Medical Management of Gastroenteropancreatic Neuroendocrine Neoplasms. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9856140. [PMID: 29349087 PMCID: PMC5733630 DOI: 10.1155/2017/9856140] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/02/2017] [Indexed: 02/07/2023]
Abstract
Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are rare and heterogeneous group of tumors presenting as localised or metastatic disease and in a subset with distinct clinical syndromes. Treatment is aimed at controlling the functional syndrome, eradicating the tumor, and/or preventing further tumor growth. Surgery is the treatment of choice in removing the primary tumor and/or reducing tumor burden but cannot be applied to all patients. Somatostatin analogs (SS-analogs) obtain control of functional syndromes in the majority of GEP-neuroendocrine tumors (NETs); phase III trials have shown that SS-analogs can be used as first-line antiproliferative treatment in patients with slow-growing GEP-NETs. The role of the recently approved serotonin inhibitor, telotristat ethyl, and gastrin receptor antagonist, netazepide, is evolving. Streptozotocin-based chemotherapy has been used for inoperable or progressing pancreatic NENs but the orally administered combination of capecitabine/temozolomide is becoming more popular due to its better tolerability and potential effect in other GEP-NENs. Phase III trials have shown efficacy of molecular targeted therapies in GEP-NETs and of radionuclide treatment in patients with midgut carcinoid tumors expressing somatostatin receptors. Most patients will develop disease progression necessitating further therapeutic options. A combination of currently available treatments along with the molecular signature of each tumor will guide future treatment.
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Abstract
Each month, subscribers to The Formulary® Monograph Service receive five to six researched monographs on drugs that are newly released or are in late Phase III trials. The monographs are targeted to your Pharmacy and Therapeutics Committee. Subscribers also receive monthly one-page summary monographs on the agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation (DUE) is also provided each month. The monographs are published in printed form and on diskettes that allow customization. Subscribers to the The Formulary Monograph Service also receive access to a pharmacy bulletin board called The Formulary Information Exchange (The F.I.X). All topics pertinent to clinical pharmacy are discussed on The F.I.X. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. If you would like information about The Formulary Monograph Service or The F.I.X., call The Formulary at 800-322-4349. The August 2001 Formulary monographs are on almotriptan maleate, crotalidae polyvalent immune fab, drospirenone/ethinyl estradiol, fondaparinux sodium, and alfuzosin. The DUE is on peginterferon alfa-2b.
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Affiliation(s)
- Dennis J. Cada
- The Formulary, College of Pharmacy, Washington State University Spokane, 601 West First Avenue, Spokane, WA 99201-3899
| | - Terri Levien
- College of Pharmacy, Washington State University Spokane, 601 West First Avenue, Spokane, WA 99201-3899
| | - Danial E. Baker
- College of Pharmacy, Washington State University Spokane, 601 West First Avenue, Spokane, WA 99201-3899
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Kaltsas G, Caplin M, Davies P, Ferone D, Garcia-Carbonero R, Grozinsky-Glasberg S, Hörsch D, Tiensuu Janson E, Kianmanesh R, Kos-Kudla B, Pavel M, Rinke A, Falconi M, de Herder WW. ENETS Consensus Guidelines for the Standards of Care in Neuroendocrine Tumors: Pre- and Perioperative Therapy in Patients with Neuroendocrine Tumors. Neuroendocrinology 2017; 105:245-254. [PMID: 28253514 PMCID: PMC5637287 DOI: 10.1159/000461583] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/10/2017] [Indexed: 01/25/2023]
Abstract
Neuroendocrine tumors of the small intestine are the most common causes of the carcinoid syndrome. Carcinoid heart disease occurs in more than half of the patients with the carcinoid syndrome. Patients with carcinoid heart disease who need to undergo surgery should also undergo preoperative evaluation by an expert cardiologist. Treatment with long-acting somatostatin analogs aims at controlling the excessive hormonal output and symptoms related to the carcinoid syndrome and at preventing a carcinoid crisis during interventions. Patients with a gastrinoma require pre- and postoperative treatment with high doses of proton pump inhibitors. Patients with a glucagonoma require somatostatin analog treatment and nutritional supplementation. Patients with a VIPoma also require somatostatin analog treatment and intravenous fluid and electrolyte therapy. Insulinoma patients generally require intravenous glucose infusion prior to operation. In patients with localized operable insulinoma, somatostatin analog infusion should only be considered after the effect of this therapy has been electively studied.
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Affiliation(s)
- Gregory Kaltsas
- Endocrine Unit, Department of Pathophysiology, National and Kapodistrian University of Athens, Athens, Greece
- *Gregory Kaltsas, Sector of Endocrinology, Department of Pathophysiology, National and Kapodistrian University of Athens, Mikras Assias 75, Goudi, GR-11527 Athens (Greece), E-Mail
| | - Martyn Caplin
- Neuroendocrine Tumour Unit, Royal Free Hospital, London, UK
| | | | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties (DiMI), Center of Excellence for Biomedical Research (CEBR), IRCCS AOU San Martino-IST, University of Genova, Genova, Italy
| | | | - Simona Grozinsky-Glasberg
- Neuroendocrine Unit, Endocrinology and Metabolism Service, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Dieter Hörsch
- Gastroenterology and Endocrinology Center for Neuroendocrine Tumors Bad Berka, Bad Berka, Germany
| | - Eva Tiensuu Janson
- Department of Endocrine Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Reza Kianmanesh
- Department of Digestive and Endocrine Surgery, Robert Debré Hospital, Reims, France
| | - Beata Kos-Kudla
- Department of Pathophysiology and Endocrinology, Division of Endocrinology, Medical University of Silesia, Katowice, Poland
| | - Marianne Pavel
- Department of Hepatology and Gastroenterology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin
| | - Anja Rinke
- Department of Gastroenterology, UKGM Marburg and Philipps University Marburg, Marburg, Germany
| | - Massimo Falconi
- Chirurgia del Pancreas, Pancreas Translational and Clinical Research Center, Ospedale San Raffaele, Università “Vita e Salute”, Milano, Italy
| | - Wouter W. de Herder
- ENETS Centre of Excellence, Erasmus MC Cancer Centre, Rotterdam, The Netherlands
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Scarpignato C, Gatta L, Zullo A, Blandizzi C. Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression. BMC Med 2016; 14:179. [PMID: 27825371 PMCID: PMC5101793 DOI: 10.1186/s12916-016-0718-z] [Citation(s) in RCA: 236] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/14/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications. METHODS The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence. RESULTS Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile. CONCLUSIONS Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .
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Affiliation(s)
- Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy.
| | - Luigi Gatta
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy
- Gastroenterology & Endoscopy Unit, Versilia Hospital, Azienda USL Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Angelo Zullo
- Division of Gastroenterology & Digestive Endoscopy, Nuovo Regina Elena Hospital, Rome, Italy
| | - Corrado Blandizzi
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
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10
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Dimitriadis GK, Weickert MO, Randeva HS, Kaltsas G, Grossman A. Medical management of secretory syndromes related to gastroenteropancreatic neuroendocrine tumours. Endocr Relat Cancer 2016; 23:R423-36. [PMID: 27461388 DOI: 10.1530/erc-16-0200] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/26/2016] [Indexed: 12/14/2022]
Abstract
Although recent epidemiological evidence indicates that the prevalence of non-functioning gastroenteropancreatic (GEP) neuroendocrine tumours (NETs) is rising, a significant number of GEP-NETs still present with symptoms related to the secretion of biologically active substances leading to the development of distinct clinical syndromes. In the past, these syndromes were associated with substantial morbidity and mortality due to the lack of specific therapies; however, since the introduction of long-acting somatostatin analogues and medications such as proton pump inhibitors, their control has been greatly improved. As a result, nowadays, the main cause of morbidity and mortality in GEP-NETs is mostly directly related to tumour growth and the extent of metastatic disease. However, in some patients with functioning tumours and extensive disease, control of the secretory syndrome still remains problematic, necessitating the employment of several cytoreductive techniques, which may not always be sufficient. Recently, new agents directed against tumour growth, or exerting increased binding activity to receptors expressed in these tumours, or interfering with the synthetic pathway of some of the compounds secreted by these tumours, have been developed. Since there are no specific guidelines addressing the totality of the management of the secretory syndromes related to GEP-NETs, this review aims at critically analysing the medical management of previously recognised secretory syndromes; it also addresses areas of uncertainty, assesses the newer therapeutic developments and also addresses recently described but poorly characterised secretory syndromes related to GEP-NETs.
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Affiliation(s)
- Georgios K Dimitriadis
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK Division of Translational and Experimental MedicineWarwick Medical School, University of Warwick, Coventry, UK Division of Endocrinology and Investigative MedicineImperial College London, Hammersmith Campus, London, UK
| | - Martin O Weickert
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK Division of Translational and Experimental MedicineWarwick Medical School, University of Warwick, Coventry, UK Centre for Applied Biological and Exercise SciencesCoventry University, Coventry, UK
| | - Harpal S Randeva
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK Division of Translational and Experimental MedicineWarwick Medical School, University of Warwick, Coventry, UK Centre for Applied Biological and Exercise SciencesCoventry University, Coventry, UK
| | - Gregory Kaltsas
- The Arden NET CoEWarwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK Division of PathophysiologyNational and Kapodistrian University of Athens Medical School, Athens, Greece Oxford Center for DiabetesEndocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Ashley Grossman
- Oxford Center for DiabetesEndocrinology and Metabolism, University of Oxford, Oxford, UK
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11
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Mössner J. The Indications, Applications, and Risks of Proton Pump Inhibitors. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:477-83. [PMID: 27476707 PMCID: PMC4973002 DOI: 10.3238/arztebl.2016.0477] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 03/17/2016] [Accepted: 03/17/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPI) are the most effective drugs for inhibiting gastric acid secretion. They have been in clinical use for more than 25 years, In 2014, 3.475 billion daily defined doses (DDD) of PPI were prescribed in Germany. This high number alone calls for a critical analysis of the spectrum of indications for PPI and their potential adverse effects. METHODS This review is based on pertinent publications retrieved by a selective search in the PubMed and Cochrane Library databases, with particular emphasis on randomized, prospective multicenter trials, cohort studies, case-control studies, and meta-analyses. RESULTS The inhibition of gastric acid secretion with PPI is successfully used for the treatment of gastroesophageal reflux disease and of gastric and duodenal ulcers, for the secondary prevention of gastroduodenal lesions that have arisen under treatment with nonsteroidal anti-inflammatory drugs and acetylsalicylic acid, and for the prevention of recurrent hemorrhage from ulcers after successful endoscopic hemostasis. PPI are given along with practically all antibiotic regimens for the eradication of Helicobacter pylori infection. The number of prescriptions for PPI has risen linearly over the past 25 years. As there has been no broadening of indications, one may well ask whether the current, extensive use of PPI is justified. There is evidence that patients taking PPI are at greater risk for fractures. Moreover, the vitamin B12 level should be checked occasionally in all patients taking PPI. CONCLUSION PPI are among the more effective drugs for the treatment of diseases associated with gastric acid. In view of their cost and potential adverse effects, they should only be prescribed for scientifically validated indications.
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Affiliation(s)
- Joachim Mössner
- Division of Gastroenterology and Rheumatology, Department of Internal Medicine, Neurology and Dermatology, University Hospital of Leipzig, Germany: Mössner
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12
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Abstract
OPINION STATEMENT Hypersecretory conditions affecting the stomach account for significant morbidity and mortality manifested in some cases with peptic ulcer, gastrointestinal hemorrhage, and/or gastroesophageal reflux disease (GERD). The diagnosis of gastric acid hypersecretory states can be challenging and relies on the use of quantitative assays to measure gastric acid secretion and serum gastrin. The most common etiology for hypergastrinemia is the use of potent gastric acid inhibitors such as the proton pump inhibitors. The differential diagnosis of this condition is of critical importance, and will dictate management decisions. Conditions such as atrophic gastritis are relatively benign and can lead to hypergastrinemia without the presence of gastric acid hypersecretion. Zollinger-Ellison syndrome, on the other hand, causes hypergastrinemia with profound gastric acid hypersecretion [1]. More common causes of hypergastrinemia include gastric outlet obstruction, ileus, and chronic renal failure [2]. In most cases, proton pump inhibitors will be used to manage these conditions. In some instances, surgical therapy may be required. This chapter will review the important clinical causes of gastric acid hypersecretion and provide insights to the best medical management options to better care for patients with these disorders.
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Mauriello C, Napolitano S, Gambardella C, Candela G, De Vita F, Orditura M, Sciascia V, Tartaglia E, Lanza M, Santini L, Conzo G. Conservative management and parenchyma-sparing resections of pancreatic neuroendocrine tumors: Literature review. Int J Surg 2015; 21 Suppl 1:S10-4. [PMID: 26118605 DOI: 10.1016/j.ijsu.2015.04.089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 03/23/2015] [Accepted: 04/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (pNETs) are uncommon entities. pNETs are often small, slow growing, clinically silent neoplasms. However, they have an almost unpredictable biological behaviour with a not negligible malignant potential. Surgery still represents the treatment of choice, but the high morbidity associated to the enucleation or the formal pancreatectomy should be considered in the decision of the proper treatment. Management of these neoplasms is still debated, and indications for a conservative observational approach and for parenchyma sparing resections are not yet standardized. METHOD We review the state of art on the indications for the conservative management of pNETs. Searches on MEDLINE database were performed to identify articles reporting prognostic systems, biochemical screening, observational management, medical treatment and surgical strategies for pNETs. DISCUSSION Currently, an accurate 'wait-and-see' policy is recommended by the European Neuroendocrine Tumor Society (ENETS) only for non-functioning pNETs (NF-pNETs) <2 cm. A biochemical screening, based on sampling of serum levels of pancreatic polypeptide (PP) and chromogranin A, can address to early conservative surgery for MEN-1 associated NF-pNETs <2 cm to prevent their malignant transformation. The subtotal (80%) distal pancreatectomy first proposed by Thompson, often with the enucleation of possible pancreatic head tumors, still represents a good compromise between oncological radicality and prevention of pancreatic endocrine/exocrine insufficiency caused by standard radical resections for the treatment of inherited syndromes associated with NF-pNETs >2 cm and symptomatic F-pNETs of any size. CONCLUSION More studies are needed to further clarify and predict the biologic behaviour of pNETs and increase the indications for conservative observational management and parenchyma sparing pancreas resections.
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Affiliation(s)
- Claudio Mauriello
- Department of Anaesthesiologic, Surgical and Emergency Sciences, Unit of General and Oncologic Surgery, School of Medicine, Second University of Naples, Italy.
| | - Salvatore Napolitano
- Medical Officer, Italian Air Force Medical Corps, Ministry of Defence, Rome, Italy.
| | - Claudio Gambardella
- Department of Anaesthesiologic, Surgical and Emergency Sciences, Unit of General and Oncologic Surgery, School of Medicine, Second University of Naples, Italy.
| | - Giancarlo Candela
- Department of Anaesthesiologic, Surgical and Emergency Sciences, Unit of General and Oncologic Surgery, School of Medicine, Second University of Naples, Italy.
| | - Ferdinando De Vita
- Department of Clinical and Experimental Medicine, Divisions of Oncology, School of Medicine, Second University of Naples, Italy.
| | - Michele Orditura
- Department of Clinical and Experimental Medicine, Divisions of Oncology, School of Medicine, Second University of Naples, Italy.
| | - Valerio Sciascia
- Department of Anaesthesiologic, Surgical and Emergency Sciences, Unit of General and Oncologic Surgery, School of Medicine, Second University of Naples, Italy.
| | - Ernesto Tartaglia
- Department of Anaesthesiologic, Surgical and Emergency Sciences, Unit of General and Oncologic Surgery, School of Medicine, Second University of Naples, Italy.
| | - Michele Lanza
- Department of Anaesthesiologic, Surgical and Emergency Sciences, Unit of General and Oncologic Surgery, School of Medicine, Second University of Naples, Italy.
| | - Luigi Santini
- Department of Anaesthesiologic, Surgical and Emergency Sciences, Unit of General and Oncologic Surgery, School of Medicine, Second University of Naples, Italy.
| | - Giovanni Conzo
- Department of Anaesthesiologic, Surgical and Emergency Sciences, Unit of General and Oncologic Surgery, School of Medicine, Second University of Naples, Italy.
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Dabiri Y, Fahimi F, Jamaati H, Hashemian SMR. The comparison of extemporaneous preparations of omeprazole, pantoprazole oral suspension and intravenous pantoprazole on the gastric pH of critically ill-patients. Indian J Crit Care Med 2015; 19:21-6. [PMID: 25624646 PMCID: PMC4296406 DOI: 10.4103/0972-5229.148635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Stress-related mucosal disease occurs in many critically ill-patients within 24 h of admission. Proton pump inhibitor therapy has been documented to produce more potent inhibition of gastric acid secretion than histamine 2 receptor antagonists. This study aimed to compare extemporaneous preparations of omeprazole, pantoprazole oral suspension and intravenous (IV) pantoprazole on the gastric pH in intensive care unit patients. Materials and Methods: This was a randomized single-blind-study. Patients of ≥ 16 years of age with a nasogastric tube, who required mechanical ventilation for ≥ 48 h, were eligible for inclusion. The excluded patients were those with active gastrointestinal bleeding, known allergy to omeprazole and pantoprazole and those intolerant to the nasogastric tube. Fifty-six patients were randomized to treatment with omeprazole suspension 2 mg/ml (40 mg every day), pantoprazole suspension 2 mg/ml (40 mg every day) and IV pantoprazole (40 mg every day) for up to 14 days. Gastric aspirates were sampled before and 1-2.5 h after the drug administration for the pH measurement using an external pH meter. Data were analyzed using SPSS (version 21.0). Results: In this study, 56 critically ill-patients (39 male, 17 female, mean age: 61.5 ± 15.65 years) were followed for the control of the gastric pH. On each of the 14 trial days the mean of the gastric pH alteration was significantly higher in omeprazole and pantoprazole suspension-treated patients than in IV pantoprazole-treated patients (P < 0.001). Conclusion: Omeprazole and pantoprazole oral suspension are more effective than IV pantoprazole in increasing the gastric pH.
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Affiliation(s)
- Yasamin Dabiri
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fanak Fahimi
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran ; Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Diseases, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamidreza Jamaati
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Reza Hashemian
- Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Kondo NI, Ikeda Y. Practical management and treatment of pancreatic neuroendocrine tumors. Gland Surg 2014; 3:276-83. [PMID: 25493259 DOI: 10.3978/j.issn.2227-684x.2013.12.05] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 12/26/2013] [Indexed: 12/16/2022]
Abstract
Pancreatic neuroendocrine tumors (NETs) are uncommon disease, about which little is known. Pancreatic NETs are usually slow growing and their malignant potential are often underestimated. The management of this disease poses a challenge because of the heterogeneous clinical presentation and varying degrees of aggressiveness. Recently, several guidelines for the management of pancreatic NETs have been established and help to devise clinical strategy. In the treatment algorithms, however, a lot of uncertain points are included. Practical treatment decisions of pancreatic NETs are still sometimes made in a patient- and/or physicians-oriented manner. The tumor grading system proposed by the European Neuroendocrine Tumor Society (ENETS) gives important prognostic information, however, the implication of grading regarding medical treatment strategies to choose has not yet been clarified. Moreover, the place of surgical treatment is unclear in the overall management course of advanced pancreatic NETs. In some cases, practical management and treatment have to be individualized depending on predominant symptoms, tumor spread, and general health of the patients. Current issues and a few points to make a strategy in the management of pancreatic NETs would be reviewed.
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Affiliation(s)
- Naoko Iwahashi Kondo
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka City, Japan
| | - Yasuharu Ikeda
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka City, Japan
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Lenz K, Buder R, Firlinger F, Lohr G, Voglmayr M. Effect of proton pump inhibitors on gastric pH in patients exposed to severe stress. Wien Klin Wochenschr 2014; 127:51-6. [DOI: 10.1007/s00508-014-0637-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 10/07/2014] [Indexed: 12/28/2022]
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17
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Brana I, Ocana A, Chen EX, Razak ARA, Haines C, Lee C, Douglas S, Wang L, Siu LL, Tannock IF, Bedard PL. A phase I trial of pantoprazole in combination with doxorubicin in patients with advanced solid tumors: evaluation of pharmacokinetics of both drugs and tissue penetration of doxorubicin. Invest New Drugs 2014; 32:1269-77. [DOI: 10.1007/s10637-014-0159-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 09/02/2014] [Indexed: 12/11/2022]
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18
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Kidd M, Gustafsson B, Modlin IM. Gastric carcinoids (neuroendocrine neoplasms). Gastroenterol Clin North Am 2013; 42:381-97. [PMID: 23639647 DOI: 10.1016/j.gtc.2013.01.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gastric neuroendocrine neoplasms of the stomach can be divided into the usually well-differentiated, hypergastrinemia-dependent type I and II lesions and the more aggressively behaving gastrin-independent type III lesions. Studying menin and its complex interrelationship with gastrin may provide insight into tumor biology at the clinical level and in terms of basic cell biology (eg, the role of the epigenome in neuroendocrine cell proliferation), and lead to potential consideration of other targets that are known candidates for molecular-based therapies in other adenocarcinomas.
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Affiliation(s)
- Mark Kidd
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
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19
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Abstract
Supportive care of patients with functional neuroendocrine tumors (NETs) has evolved to include the use of multiple targeted agents to control paraneoplastic states and newer surgical and interventional radiologic techniques to reduce tumor bulk. Challenges encountered by the clinician are the recognition of specific symptom complexes, selecting the relevant laboratory tests and radiologic/scintigraphic scans, and the timing of intervention(s). Individual variables such as the severity of symptoms in the context of primary and metastatic disease sites, tumor bulk, comorbidities, and previous treatment are factors determining the prioritization of specific treatment regimens for patients with functional NETs. Symptoms such as flushing, secretory diarrhea, hypercalcemia, hyper /hypoglycemia, hypercortisolism, and peptic ulcers should improve with decreasing the elevated amino acid and/or peptide levels produced by NETs. These paraneoplastic symptoms may be accompanied by complaints related to tumor burden such as fatigue, pain, early satiety, anorexia, weight loss, night sweats, and/or symptoms secondary to adverse drug effects such as mucositis, dysgeusia, diarrhea, rash, hypertension, and myelosuppression. Developing a comprehensive continuum of care plan early in disease management assists in controlling the presenting signs and symptoms, and in minimizing disease- and/or treatment-related side effects. This guide serves as a framework to manage the signs and symptoms of metastatic functional neuroendocrine tumors.
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Affiliation(s)
- Lowell B Anthony
- Department of Medicine, Markey Cancer Center, University of Kentucky, Lexington, KY 40536, USA.
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Ito T, Igarashi H, Uehara H, Jensen RT. Pharmacotherapy of Zollinger-Ellison syndrome. Expert Opin Pharmacother 2013; 14:307-21. [PMID: 23363383 DOI: 10.1517/14656566.2013.767332] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The role of pharmacotherapy in the management of patients with Zollinger-Ellison syndrome (ZES) is often equated with the medical management of acid hypersecretion. However, pharmacotherapy is also increasingly involved in the other management areas of these patients. AREAS COVERED This paper reviews the role of pharmacotherapy in all aspects of the management of patients with ZES. Newer aspects are emphasized. This includes the difficulty of diagnosing ZES in patients taking proton pump inhibitors. Also covered is the role of pharmacotherapy in controlling acid hypersecretion and other hormonal hypersecretory states these patients may develop, including hyperparathyroidism in patients with multiple endocrine neoplasia type 1 and ZES; tumor localization; and the treatment of advanced metastatic disease. The last includes chemotherapy, liver-directed therapies, biotherapy (somatostatin/interferon), peptide radio-receptor therapy and molecular-targeted therapies including the use of mTor inhibitors (everolimus) and tyrosine kinase inhibitors (sunitinib). EXPERT OPINION Pharmacotherapy is now involved in all aspects of the management of patients with ZES, with the result that ZES has progressed from being considered an entirely surgical disease initially to the present where medical treatment plays a major role in almost all aspects of the management of these patients.
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Affiliation(s)
- Tetsuhide Ito
- Kyushu University, Graduate School of Medical Sciences, Department of Medicine and Bioregulatory Science, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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21
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Ro C, Chai W, Yu VE, Yu R. Pancreatic neuroendocrine tumors: biology, diagnosis,and treatment. CHINESE JOURNAL OF CANCER 2012; 32:312-24. [PMID: 23237225 PMCID: PMC3845620 DOI: 10.5732/cjc.012.10295] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatic neuroendocrine tumors (PNETs), a group of endocrine tumors arising in the pancreas, are among the most common neuroendocrine tumors. The genetic causes of familial and sporadic PNETs are somewhat understood, but their molecular pathogenesis remains unknown. Most PNETs are indolent but have malignant potential. The biological behavior of an individual PNET is unpredictable; higher tumor grade, lymph node and liver metastasis, and larger tumor size generally indicate a less favorable prognosis. Endocrine testing, imaging, and histological evidence are necessary to accurately diagnose PNETs. A 4-pronged aggressive treatment approach consisting of surgery, locoregional therapy, systemic therapy, and complication control has become popular in academic centers around the world. The optimal application of the multiple systemic therapeutic modalities is under development; efficacy, safety, availability, and cost should be considered when treating a specific patient. The clinical presentation, diagnosis, and treatment of specific types of PNETs and familial PNET syndromes, including the novel Mahvash disease, are summarized.
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Affiliation(s)
- Cynthia Ro
- Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Abstract
Gastric neuroendocrine neoplasms of the stomach can be divided into the usually well-differentiated, hypergastrinemia-dependent type I and II lesions and the more aggressively behaving gastrin-independent type III lesions. Mainly due to better diagnostics and awareness of this tumor, the observed incidence has increased more than tenfold over the last 30 years. Small (<15-20 mm) localized type I and II lesions that are slowly proliferating (Ki67<2%) can usually be managed conservatively with endoscopic surveillance. Reducing hypergastrinemia by surgical removal of an underlying gastrinoma is important in inhibiting growth and induce reduction of type II lesions, while the specific gastrin receptor antagonist YF476 or gastrin antibodies may become useful for both type I and II lesions. Infiltrating and metastasized tumors and type III lesions require a more aggressive approach with surgical resection and consideration of modalities such as somatostatin analogs, cytotoxics, and peptide receptor targeted treatment.
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Affiliation(s)
- Mark Kidd
- Department of Surgery, Yale University School of Medicine, PO Box 208602, New Haven, CT, USA.
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Ito T, Igarashi H, Jensen RT. Pancreatic neuroendocrine tumors: clinical features, diagnosis and medical treatment: advances. Best Pract Res Clin Gastroenterol 2012; 26:737-53. [PMID: 23582916 PMCID: PMC3627221 DOI: 10.1016/j.bpg.2012.12.003] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 12/27/2012] [Indexed: 01/31/2023]
Abstract
Pancreatic neuroendocrine tumors (pNETs) comprise with gastrointestinal carcinoids, the main groups of gastrointestinal neuroendocrine tumors (GI-NETs). Although these two groups of GI-NETs share many features including histological aspects; over-/ectopic expression of somatostatin receptors; the ability to ectopically secrete hormones/peptides/amines which can result in distinct functional syndromes; similar approaches used for tumor localization and some aspects of treatment, it is now generally agreed they should be considered separate. They differ in their pathogenesis, hormonal syndromes produced, many aspects of biological behaviour and most important, in their response to certain anti-tumour treatment (chemotherapy, molecular targeted therapies). In this chapter the clinical features of the different types of pNETs will be considered as well as aspects of their diagnosis and medical treatment of the hormone-excess state. Emphasis will be on controversial areas or recent advances. The other aspects of the management of these tumors (surgery, treatment of advanced disease, tumor localization) are not dealt with here, because they are covered in other chapters in this volume.
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Affiliation(s)
- Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3- 1-1 Maidashi, Higashiku, Fukuoka 812-8582, Japan,Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804
| | - Hisato Igarashi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3- 1-1 Maidashi, Higashiku, Fukuoka 812-8582, Japan,Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804
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A randomized controlled trial of adding intravenous pantoprazole to conventional treatment for the immediate relief of dyspeptic pain. Am J Emerg Med 2012; 30:1737-42. [PMID: 22463973 DOI: 10.1016/j.ajem.2012.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 01/30/2012] [Accepted: 02/01/2012] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Acute, severe dyspeptic pain is a common condition in the emergency department. Despite the traditional "GI cocktail" (GI indicates gastrointestinal), an intravenous (IV) proton pump inhibitor (PPI), a novel acid-lowering drug, has recently been used to treat this condition. The aim of this study was to evaluate the immediate effect of IV pantoprazole in addition to the conventional GI cocktail in the relief of severe dyspeptic pain. METHODS This double-blind, randomized, controlled study was conducted in the emergency department of an urban tertiary-care hospital from January 2011 to October 2011. Selected patients with severe dyspeptic pain were randomized to treatment with a placebo, antacid, and antispasmodic (conventional group) or IV pantoprazole, antacid, and antispasmodic (pantoprazole group). The self-reported 100-mm visual analog scale score, adverse effects, and overall satisfaction were evaluated in 15-minute intervals for 60 minutes. RESULTS Eighty-seven eligible cases were enrolled in the study. Forty-four and 43 patients were randomized in the conventional group and pantoprazole group, respectively. There was no difference in the mean 60-minute visual analog scale scores between the treatment groups. The rate of "responders," additional drug use, adverse effects, and patient satisfaction were similar between the groups. CONCLUSION Intravenous PPI provides no additional benefit over the conventional GI cocktail in the relief of acute, severe dyspeptic pain. Because of its neutral effect and higher cost, the use of IV PPI to treat such conditions should be discouraged in general clinical practice.
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van Rensburg CJ, Cheer S. Pantoprazole for the treatment of peptic ulcer bleeding and prevention of rebleeding. CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2012; 5:51-60. [PMID: 24833934 PMCID: PMC3987766 DOI: 10.4137/cgast.s9893] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Adding proton pump inhibitors (PPIs) to endoscopic therapy has become the mainstay of treatment for peptic ulcer bleeding, with current consensus guidelines recommending high-dose intravenous (IV) PPI therapy (IV bolus followed by continuous therapy). However, whether or not high-dose PPI therapy is more effective than low-dose PPI therapy is still debated. Furthermore, maintaining pH ≥ 4 appears to prevent mucosal bleeding in patients with acute stress ulcers; thus, stress ulcer prophylaxis with acid-suppressing therapy has been increasingly recommended in intensive care units (ICUs). This review evaluates the evidence for the efficacy of IV pantoprazole, a PPI, in preventing ulcer rebleeding after endoscopic hemostasis, and in controlling gastric pH and protecting against upper gastrointestinal (GI) bleeding in high-risk ICU patients. The review concludes that IV pantoprazole provides an effective option in the treatment of upper GI bleeding, the prevention of rebleeding, and for the prophylaxis of acute bleeding stress ulcers.
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Affiliation(s)
| | - Susan Cheer
- Director, Freelance Writing Works: a division of Creative Ink Ltd, Queenstown 9348, New Zealand
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Bhattacharyya T, Sarbapalli D, Pal R, Sarkar U, Kar S, Kundu KK, Zaman FA. Evaluating ranitidine, pantoprazole and placebo on gastric pH in elective surgery. Saudi J Anaesth 2011; 5:67-72. [PMID: 21655020 PMCID: PMC3101757 DOI: 10.4103/1658-354x.76508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Aim: Concern about the grim nature of postoperative acid aspiration syndrome grew among the anesthesiologist over the years warranting the need for pre-emptive intervention. The aim of the study is to compare the effects of preoperative oral ranitidine versus pantoprazole given in regulating gastric pH in elective surgery. Methods: This prospective, parallel group, controlled, randomized, single-blind study was conducted at a tertiary care postgraduate teaching institute at Kolkata, involving 120 participants of either sex, aged 18-60 years of American Society of Anesthesiologists physical status I and II, who were scheduled for elective surgery under general anesthesia lasting for more than 2 h. The participants were divided into three groups. In group A (n=40) participants received placebo tablet, in group B (n=40) participants received ranitidine tablet while in group C (n=40), participants received pantoprazole tablet and their gastric pH estimated serially. Results: The participants in the three groups were comparable in terms of age, sex, body weight, duration of surgery and type of surgery distribution. In regard to changes in gastric pH trends, there was no statistically significant difference between serial pH values in group A (Friedman test; P>0.05) and group C participants. (P>0.05). However, the mean preoperative gastric pH values (7.140±.7652) were significantly lower than mean pH values (7.253±.7514) after 2 h postoperatively in group B participants (P<0.05). Conclusion: From the observations and analyses of the present study, it can be inferred that ranitidine is more effective than pantoprazole to raise the gastric pH for prevention of aspiration pneumonitis.
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Affiliation(s)
- Tapas Bhattacharyya
- Department of Anaesthesiology, Institute of Postgraduate Medical Education & Research (IPGME&R), Kolkata, India
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Abstract
Well-differentiated neuroendocrine tumors (NETs) of the stomach and pancreas represent 2 major subtypes of gastrointestinal NETs. Historically, there has been little consensus on the classification and management of patients with these tumor subtypes. We provide an overview of well-differentiated NETs of the stomach and pancreas and describe consensus guidelines for the treatment of patients with these malignancies.
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Pancreatic islet cell carcinoma presenting with concurrent Cushing's and Zollinger-Ellison syndromes: case series and literature review. Eur J Gastroenterol Hepatol 2010; 22:246-52. [PMID: 19770666 DOI: 10.1097/meg.0b013e3283314827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Cushing's syndrome and Zollinger-Ellison syndrome occur occasionally as a result of neuroendocrine cancers. The concurrence of the two syndromes has been considered to confer a poor clinical and therapeutic outcome. In this study, we are reviewing two patients with pancreatic islet cell carcinomas and with both Zollinger-Ellison and Cushing's syndromes, one followed up for more than 5 years, and the other still receiving therapy, 5 years since diagnosis. A literature review showed that surgery has limited utility as the majority of these patients had metastases at the time of diagnosis. Proton-pump inhibitors, ketoconazole, and somatostatin antagonists have a major role in controlling symptoms. Interferon and systemic chemotherapeutic agents play a role in the management of metastatic and fast-growing cases. Chemoembolization and bland embolization show encouraging results in controlling liver metastases. The latter was used effectively and more than once in the two patients presented herein. On the basis of recent molecular genetics studies, target therapy may be helpful, however, ongoing trials will define it's utility. As the data confers a worse prognosis versus other pancreatic neuroendocrine tumors, the relatively favorable outcome of the two patients reported herein may reflect the impact of multiple therapeutic modalities.
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Pang SH, Graham DY. A clinical guide to using intravenous proton-pump inhibitors in reflux and peptic ulcers. Therap Adv Gastroenterol 2010; 3:11-22. [PMID: 21180586 PMCID: PMC3002568 DOI: 10.1177/1756283x09352095] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Intravenous (IV) proton-pump inhibitors (PPIs) are potent gastric acid suppressing agents, and their use is popular in clinical practice. Both IV and oral PPIs have similarly short half-lives, and their effects on acid secretion are similar, thus their dosing and dosage intervals appear to be interchangeable. The possible exception is when sustained high pHs are required to promote clot stabilization in bleeding peptic ulcers. Continuous infusion appears to be the only form of administration that reliably achieves these high target pHs. IV PPI is indicated in the treatment of high-risk peptic ulcers, complicated gastroesophageal reflux, stress-induced ulcer prophylaxis, Zollinger-Ellison syndrome, and whenever it is impossible or impractical to give oral therapy. The widespread use of PPIs has been controversial. IV PPIs have been linked to the development of nosocomial pneumonia in the intensive care setting and to spontaneous bacterial peritonitis in cirrhotic patients. This review discusses the use of IV PPI in different clinical scenarios, its controversies, and issues of appropriate use.
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Affiliation(s)
- Sandy H. Pang
- Institute of Digestive Disease, Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - David Y. Graham
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA,
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Hoover JG, Schumaker AL, Franklin KJ. Use of intravenous proton-pump inhibitors in a teaching hospital practice. Dig Dis Sci 2009; 54:1947-52. [PMID: 19034652 DOI: 10.1007/s10620-008-0568-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2008] [Accepted: 09/26/2008] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate intravenous proton-pump inhibitor (IV PPI) prescribing in a single academic teaching hospital. METHODS A retrospective pilot study of 107 patients in a single United States military teaching hospital was conducted over a 1-month period. Clinical data were collected and analyzed for demographic features, prior medication use, admission hemoglobin level, service prescribing the IV PPI, indication for IV PPI, IV PPI treatment duration, gastroenterology consultant use, endoscopic findings, and blood products given. Indications for use were compared with current established guidelines to determine appropriate usage. RESULTS A total of 683 doses of IV pantoprazole were prescribed over a 1-month period. Seventy-six patients (71%; 95% confidence interval [CI], 62-79%) who received IV PPIs did not meet the criteria for an appropriate indication for use. Ninety-nine patients in the study (93%; 95% CI, 86-96%) met criteria for an acceptable dosage given. The most common appropriate indication given was stress ulcer prophylaxis in a high-risk setting (13%; 95% CI, 8-21%) with appropriate use of this indication 45% of the time (95% CI, 29-62%). IV PPIs were appropriately prescribed most often by the medical intensive care unit (66.7%; 95% CI, 43-84%) and least often by the surgical wards services (16%; 95% CI, 7-33%). No discernable indication was given in 52% of cases (95% CI, 43-62%), and patients were not actually nil per os in 46% of these instances (95% CI, 34-59%). CONCLUSIONS Intravenous PPI prescribing habits in this military hospital facility are poor. A multifaceted approach including physician/pharmacist education, IV PPI ordering templates, and a consensus medical position statement from a major gastroenterological or prominent medical association may lead to more appropriate use.
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Affiliation(s)
- Jacob G Hoover
- Department of Internal Medicine, Wilford Hall Medical Center, Lackland AFB, San Antonio, TX 78236-5300, USA.
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Duodenal bulb mucosa with hypertrophic gastric oxyntic heterotopia in patients with zollinger ellison syndrome. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2009; 2009:298381. [PMID: 19587828 PMCID: PMC2705831 DOI: 10.1155/2009/298381] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2009] [Accepted: 05/07/2009] [Indexed: 01/19/2023]
Abstract
Objectives.
Zollinger-Ellison Syndrome (ZES) results in
hypersecretion of gastric acid (via gastrinoma)
leading to peptic ulcers, diarrhea, and abdominal
pain. We describe the novel discovery of
hypertrophic, heterotopic gastric mucosa in the
proximal duodenal bulb in patients with ZES,
which we hypothesize results in an increased
incidence of postbulbar ulcers in patients with
ZES (a mechanism previously unreported). We
determined the incidence of the novel finding of
duodenal gastric oxyntic hypertrophic
heterotopia (GOH) in patients with ZES.
Methods. Seven patients with
ZES were enrolled. The diagnosis of ZES was
established by hypergastrinemia, gastric acid
hypersecretion, and a positive secretin test or
based on biopsy specimens (evaluated via tissue
staining). Basal acid output (BAO) and baseline
gastrin secretion were determined by established
methods. Endoscopic examinations with methylene
blue staining and biopsy of the gastric and
duodenal mucosa were conducted in all patients
every 3–6 months for an average of 5
years. Results. The duodenal
mucosa demonstrated hypertrophic GOH in 5 out of
7 patients with ZES and an intact stomach and
duodenum. Biopsies from the bowel mucosa
demonstrated patchy replacement of surface
epithelium by gastric-type epithelium with
hypertrophic oxyntic glands in the lamina
propria in 5 patients. Two of the patients had
no evidence of GOH in the duodenal bulb.
Patients with GOH had an average serum gastrin
level of 1245 pg/mL and BAO of
2.92 mEq/hr versus 724 pg/mL and
0.8 mEq/hr in patients without GOH.
Conclusions. This study
demonstrated the presence of duodenal mucosa
with GOH in 5 out of 7 patients with ZES and an
intact stomach and duodenum. The presence of
hypertrophic and heterotopic gastric mucosa is
proposed to result from increased gastrin levels
and may contribute to the increased incidence of
postbulbar ulcers in these
patients.
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Abstract
Refractory PUD is a diagnostic and therapeutic challenge. Optimal management of severe or refractory PUD requires a multidisciplinary team approach, using primary care providers, gastroenterologists, and general surgeons. Medical management has become the cornerstone of therapy. Identification and eradication of H pylori infection combined with acid reduction regimens can heal ulceration and also prevent recurrence. Severe, intractable or recurrent PUD and associated complications mandates a careful and methodical evaluation and management strategy to determine the potential etiologies and necessary treatment (medical or surgical) required.
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Affiliation(s)
- Lena Napolitano
- Department of Surgery, University of Michigan Health System, University of Michigan School of Medicine, Room 1C421, University Hospital, 1500 East Medical Drive, Ann Arbor, MI 48109-0033, USA.
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Pisegna JR, Karlstadt RG, Norton JA, Fogel R, Oh DS, Graepel GJ, Dorr MB. Effect of preoperative intravenous pantoprazole in elective-surgery patients: a pilot study. Dig Dis Sci 2009; 54:1041-9. [PMID: 18754096 PMCID: PMC6736543 DOI: 10.1007/s10620-008-0445-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2008] [Accepted: 07/02/2008] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study evaluated the effects of intravenous pantoprazole on gastric volume and acid output in elective-surgical patients. METHODS This is a multicenter, randomized, pilot study of adult patients receiving intravenous pantoprazole: 40 mg every 24 h, 40 mg every 12 h (q12h) or 80 mg q12h. The first dose was administered 1 h before general anesthesia for surgery. All gastric fluid was aspirated through a nasogastric tube 1 h before dosing and through the postoperative period. Aspirate volume was recorded; pH and H(+) concentrations were measured. RESULT Twenty-six patients were enrolled and 21 were evaluable. Pantoprazole was well tolerated. All regimens decreased gastric acid output and volume, and increased pH within 1 h of dosing. Effects were sustained for up to 12 h following single-dose administration. CONCLUSIONS Intravenous pantoprazole administered prior to anesthesia induction may be efficacious for the reduction of gastric volume and acid output, and for pulmonary aspiration prophylaxis in surgical patients.
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Affiliation(s)
- Joseph R. Pisegna
- CURE: Digestive Diseases Research Center, University of California, Los Angeles, CA, USA; Division of Gastroenterology and Hepatology (691/111C), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA; Department of Medicine, University of California, Los Angeles, CA, USA
| | | | - Jeffrey A. Norton
- Department of Surgery, Stanford University School of Medicine, San Francisco, CA, USA
| | - Ronald Fogel
- Division of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - David S. Oh
- CURE: Digestive Diseases Research Center, University of California, Los Angeles, CA, USA; Division of Gastroenterology and Hepatology (691/111C), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA; Department of Medicine, University of California, Los Angeles, CA, USA
| | - G. Jay Graepel
- Global Medical Affairs, Wyeth Pharmaceuticals, Collegeville, PA, USA
| | - Mary Beth Dorr
- Global Medical Affairs, Wyeth Pharmaceuticals, Collegeville, PA, USA
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Jensen RT, Berna MJ, Bingham DB, Norton JA. Inherited pancreatic endocrine tumor syndromes: advances in molecular pathogenesis, diagnosis, management, and controversies. Cancer 2008; 113:1807-43. [PMID: 18798544 DOI: 10.1002/cncr.23648] [Citation(s) in RCA: 283] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pancreatic endocrine tumors (PETs) can occur as part of 4 inherited disorders, including Multiple Endocrine Neoplasia type 1 (MEN1), von Hippel-Lindau disease (VHL), neurofibromatosis 1 (NF-1) (von Recklinghausen disease), and the tuberous sclerosis complex (TSC). The relative frequency with which patients who have these disorders develop PETs is MEN1>VHL>NF-1>TSC. Over the last few years, there have been major advances in the understanding of the genetics and molecular pathogenesis of these disorders as well in the localization and the medical and surgical treatment of PETs in such patients. The study of PETs in these disorders not only has provided insights into the possible pathogenesis of sporadic PETs but also has presented several unique management and treatment issues, some of which are applicable to patients with sporadic PETs. Therefore, the study of PETs in these uncommon disorders has provided valuable insights that, in many cases, are applicable to the general group of patients with sporadic PETs. In this article, these areas are reviewed briefly along with the current state of knowledge of the PETs in these disorders, and the controversies that exist in their management are summarized briefly and discussed.
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Affiliation(s)
- Robert T Jensen
- Digestive Diseases Branch, National Institutes of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA.
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Metz DC, Jensen RT. Gastrointestinal neuroendocrine tumors: pancreatic endocrine tumors. Gastroenterology 2008; 135:1469-92. [PMID: 18703061 PMCID: PMC2612755 DOI: 10.1053/j.gastro.2008.05.047] [Citation(s) in RCA: 501] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 03/25/2008] [Accepted: 05/12/2008] [Indexed: 12/14/2022]
Abstract
Pancreatic endocrine tumors (PETs) have long fascinated clinicians and investigators despite their relative rarity. Their clinical presentation varies depending on whether the tumor is functional or not, and also according to the specific hormonal syndrome produced. Tumors may be sporadic or inherited, but little is known about their molecular pathology, especially the sporadic forms. Chromogranin A appears to be the most useful serum marker for diagnosis, staging, and monitoring. Initially, therapy should be directed at the hormonal syndrome because this has the major initial impact on the patient's health. Most PETs are relatively indolent but ultimately malignant, except for insulinomas, which predominantly are benign. Surgery is the only modality that offers the possibility of cure, although it generally is noncurative in patients with Zollinger-Ellison syndrome or nonfunctional PETs with multiple endocrine neoplasia-type 1. Preoperative staging of disease extent is necessary to determine the likelihood of complete resection although debulking surgery often is believed to be useful in patients with unresectable tumors. Once metastatic, biotherapy is usually the first modality used because it generally is well tolerated. Systemic or regional therapies generally are reserved until symptoms occur or tumor growth is rapid. Recently, a number of newer agents, as well as receptor-directed radiotherapy, are being evaluated for patients with advanced disease. This review addresses a number of recent advances regarding the molecular pathology, diagnosis, localization, and management of PETs including discussion of peptide-receptor radionuclide therapy and other novel antitumor approaches. We conclude with a discussion of future directions and unsettled problems in the field.
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Affiliation(s)
- David C Metz
- Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Intermittent intravenous pantoprazole and continuous cimetidine infusion: effect on gastric pH control in critically ill patients at risk of developing stress-related mucosal disease. ACTA ACUST UNITED AC 2008; 64:1202-10. [PMID: 18469642 DOI: 10.1097/ta.0b013e31815e40b5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study aimed to assess intermittent intravenous (IV) pantoprazole for control of gastric acid and the possible prevention of upper gastrointestinal (UGI) bleeding in intensive care units (ICU) patients. METHODS This was a multicenter, randomized, open-label, dose-ranging pilot study of IV pantoprazole (40 mg q24 hour; 40 mg q12 hour; 80 mg q24 hour; 80 mg q12 hour; 80 mg q8 hour) or continuously infused cimetidine (300 mg bolus; 50 mg/h) in patients at risk for UGI bleeding. The primary endpoint was percent time gastric pH >/=4.0. UGI bleeding and pneumonia were measured as secondary endpoints. RESULTS Two hundred two ICU patients were randomized. Gastric pH was well controlled by all treatments. Gastric pH control improved from day 1 to day 2 in all pantoprazole groups, whereas there was decreased pH control in the cimetidine group. There were no cases of protocol defined UGI bleeding in any treatment group. Adverse event frequency and pneumonia incidence were similar between pantoprazole and cimetidine treated patients. CONCLUSIONS This pilot study indicates that intermittent IV pantoprazole effectively controls gastric pH and may protect against UGI bleeding in high risk ICU patients without the development of tolerance.
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Cai Q, Barrie M, Olejeme H, Rosenberg MD. A pilot study of efficacy and safety of continuous intravenous infusion of pantoprazole in the treatment of severe erosive esophagitis. Dig Dis Sci 2008; 53:1500-5. [PMID: 17985242 DOI: 10.1007/s10620-007-0044-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Accepted: 09/26/2007] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Reflux esophagitis is a common disease. Erosive reflux esophagitis is a more advanced stage of reflux esophagitis. Although death from reflux disease is uncommon, significant morbidity and mortality from complications, such as esophageal ulcer, stricture, and cancer, are not uncommon. Proton pump inhibitors are the popular medication for reflux esophagitis. The objective of this study was to determine the efficacy and safety of continuous intravenous infusion of pantoprazole in the treatment of severe erosive esophagitis. METHODS From February 2005 to November 2006, all patients with grade 4 erosive reflux esophagitis were screened for the study. Eligible patients were randomized into two groups. Each patient in the study group received intravenous pantoprazole 80 mg loading dose over 5 min, followed by 8 mg/h intravenous infusion for 72 h, then 40 mg orally once a day for 4 days. Each patient in the control group received 40 mg pantoprazole intravenously once a day for 72 h, then orally once a day for 4 days. A second endoscopic gastrointestinal examination (EGD) was performed on treatment days 6-8 (+/-1 day if day 7 was on a weekend) to document any healing of esophagitis in either the study or the control group. RESULTS In the study group, severe erosive esophagitis healed completely in three patients and significantly in the other three by the time of the second endoscopy. In the control group, severe erosive esophagitis healed partially in five patients, and no improvement was seen at all in one patient by the time of second endoscopy. The difference in the intervention between those two groups was statistically different (P = 0.015). There were no significant complications in either group. CONCLUSIONS Severe erosive esophagitis can be completely healed in a few days if pantoprazole is given intravenously and continuously for 72 h. It is safe to give pantoprazole intravenously and continuously for treatment of severe erosive esophagitis.
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Affiliation(s)
- Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, 1365 Clifton Road, Suite B1262, Atlanta, GA 30322, USA.
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Banasch M, Schmitz F. Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors. Wien Klin Wochenschr 2008; 119:573-8. [PMID: 17985090 DOI: 10.1007/s00508-007-0884-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The Zollinger-Ellison syndrome is characterized pathophysiologically by a significant hypergastrinemia derived from a gastrin-secreting neuroendocrine tumor with a primary location in the pancreas or duodenum. Chronic hypergastrinemia in turn triggers gastric acid hypersecretion yielding in chronic or recurrent or refractory peptic ulcer disease and/or chronic diarrhea. One half of patients with ZES will have distant metastases in the liver by the time the diagnosis is established and one half of all patients with ZES will experience chronic diarrhea as chief complaint rather than peptic ulcer-related symptoms and signs. Gastrinomas have been reported to either manifest sporadically or to occur in conjunction with the genetic background of the MEN-I syndrome. Diagnosis is based on the patients history which is typically characterized by recurrent episodes of peptic ulcer disease or by severe reflux esophagitis and/or diarrhea or by acid-related symptoms which fail to respond to standard treatment regimens. Upper gastrointestinal tract endoscopy will provide evidence for peptic ulcer disease in anatomical regions located aborally the duodenal bulb within the descending part of the duodenum or even farther distally within the jejunum. Peptic ulcers frequently occur in groups indicating some substantial acid hypersecretion. A gastric pH > 2 is mutually exclusive for ZES. Increased serum gastrin levels confirm the diagnosis biochemically. Gastrin secretion can be determined in the basal state or following stimulation with secretin or calcium. High sensitivity and specificity for the diagnosis of ZES is provided by determining the ratio of basal versus pentagastrin-stimulated gastric acid secretion: The ratio of BAO / MAO > 0.6 is highly specific for gastrinoma. To localize the gastrin-secreting tumor computer-assisted tomography, endoscopic ultrasound, and somatostatin receptor scintigraphy provide useful help but most recently, endoscopic ultrasound with high resolution transducers appear to improve preoperative site localization. If modern imaging techniques fail to elucidate the site of the tumor, intraoperative diaphany may help to detect gastrinomas within the duodenal wall. Definitive treatment will only be achieved by total surgical resection of the gastrin-producing tumor in the pancreas or duodenum including dissection of the regional lymph nodes. Control of symptoms will have to be achieved by administration of highly potent proton pump inhibitors in up to 2-3-fold increased standard doses to inhibit gastric acid hypersecretion. Elevation of gastric pH > 4 will be the therapeutic target to protect the mucosa of the upper gastrointestinal tract. Basal acid output should be reduced to less than 10 mEq H(+) per hour which requires administration of highly potent proton pump inhibitors with a recommended starting dose of 60 mg omeprazole equivalents per day.
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Affiliation(s)
- Matthias Banasch
- Department of Medicine I, St. Josef-Hospital, University of Bochum, Bochum, Germany
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39
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Devault KR. Pantoprazole: a proton pump inhibitor with oral and intravenous formulations. Expert Rev Gastroenterol Hepatol 2007; 1:197-205. [PMID: 19072410 DOI: 10.1586/17474124.1.2.197] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Proton pump inhibitors (PPI) are a significant part of therapy for most acid-related diseases including gastroesophageal reflux disease, peptic ulcer disease and acute gastrointestinal bleeding. Pantoprazole is one of several available proton pump inhibitor agents and provides dose-dependent control of gastric acid secretion. Pantoprazole has indications in gastroesophageal reflux disease and peptic ulcer disease, along with indications as co-therapy in the eradication of Helicobacter pylori infection and in the control of the acid secretion associated with the Zollinger-Ellison syndrome, as well as in NSAID ulcer prevention. Pantoprazole is available in both oral and intravenous formulations. It is effective across all age groups, although only indicated in adults (and adolescents in Europe). It has been approved for use in over 100 countries and has been used for over 13 years. Pantoprazole has an excellent safety profile and a low potential for drug-drug interactions. While still widely prescribed, pantoprazole and the other branded proton pump inhibitors are under considerable market pressure from the less expensive but similarly effective generic and over-the-counter formulations of omeprazole.
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Affiliation(s)
- Kenneth R Devault
- Mayo Clinic, Division of Gastroenterology and Hepatology, 4500 San Pablo Road, Jacksonville, FL 32233, USA.
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40
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Fendrich V, Langer P, Waldmann J, Bartsch DK, Rothmund M. Management of sporadic and multiple endocrine neoplasia type 1 gastrinomas. Br J Surg 2007; 94:1331-41. [PMID: 17939142 DOI: 10.1002/bjs.5987] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastrinomas are functional endocrine duodenopancreatic tumours and are responsible for Zollinger-Ellison syndrome (ZES). Clinical presentation, localization techniques and operative management were reviewed. METHODS An electronic search of the Medline database was undertaken for articles published in English between January 1987 and May 2007. This timeframe was chosen because of the fundamental changes in operative strategy, antisecretory therapy and localization techniques during this period. RESULTS AND CONCLUSION Most gastrinomas are located in the 'gastrinoma triangle', comprising the head of the pancreas, and the first and second parts of the duodenum. Some 20 per cent of gastrinomas occur in association with multiple endocrine neoplasia type 1 (MEN1) and 50-60 per cent of tumours are malignant at the time of diagnosis. Biochemical evidence justifies operation of which duodenotomy is an essential part. Only complete tumour resection allows 5- and 10-year survival rates of 90 per cent. Pylorus-preserving pancreaticoduodenectomy may be the procedure of choice for MEN1-ZES.
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Affiliation(s)
- V Fendrich
- Department of Surgery, Philipps University Marburg, Marburg, Bielefeld, Germany.
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41
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Mueller T, Barkun AN. A time and motion analysis: potential costs savings associated with a 72-hour intravenous infusion of pantoprazole using the new 24-hour stable solution. DRUGS & THERAPY PERSPECTIVES 2007. [DOI: 10.2165/00042310-200723030-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Pratha V, Hogan DL, Lynn RB, Field B, Metz DC. Intravenous pantoprazole as initial treatment in patients with gastroesophageal reflux disease and a history of erosive esophagitis: a randomized clinical trial. Dig Dis Sci 2006; 51:1595-601. [PMID: 16927137 DOI: 10.1007/s10620-006-9108-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Accepted: 01/12/2006] [Indexed: 12/09/2022]
Abstract
We sought to evaluate safety and efficacy of IV pantoprazole when used as initial therapy in patients with gastroesophageal reflux disease (GERD) and a history of erosive esophagitis (EE) in a double-blind, placebo-controlled, randomized, parallel-group study. Patients were randomized to 7 days of once-daily IV or oral pantoprazole (40 mg) or placebo. Efficacy variables included maximal acid output, basal acid output, and changes from baseline in frequency/severity of GERD symptoms, and frequency of antacid usage. Seventy-eight patients were randomized (n=26/27/25 [IV/oral/placebo]). Mean maximal acid output was 8.4, 6.3, and 20.9 mEq/h for IV or oral pantoprazole, and placebo, respectively. For pantoprazole versus placebo, maximal and basal acid output were significantly lower (P<.001) and there was a numerical trend toward improved GERD and antacid usage. Both treatments were well tolerated. In conclusion, IV/oral pantoprazole were similarly effective in suppressing basal and pentagastrin-stimulated gastric acid secretion in GERD patients with a history of EE.
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Affiliation(s)
- Vijaya Pratha
- Clinical Applications Laboratories, 3330 Third Ave, Suite 330, San Diego, California 92103, USA
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43
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Nieto JM, Pisegna JR. The role of proton pump inhibitors in the treatment of Zollinger-Ellison syndrome. Expert Opin Pharmacother 2006; 7:169-75. [PMID: 16433582 DOI: 10.1517/14656566.7.2.169] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Zollinger-Ellison syndrome is characterised by refractory peptic ulcer disease, diarrhoea and gastric acid hypersecretion associated with a gastrin-secreting tumour. The incidence is unknown, but, in the US, the frequency is 0.1-3.0 million people. Zollinger-Ellison syndrome is associated with multiple endocrine neoplasia type 1 in 25-35% of the cases. The diagnosis of Zollinger-Ellison syndrome is suggested when plasma gastrin is > 1000 pg/ml and the basal acid output is > 15 mEq/h or when associated with a pH < 2. The treatment is focused on controlling gastric acid hypersecretion and localisation of the tumour and its metastases. Proton pump inhibitors are the most effective antisecretory drugs and can be administered at high dosages. This review focuses on the role of the proton pump inhibitors in the management of gastric acid hypersecretion in Zollinger-Ellison syndrome.
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Affiliation(s)
- Jose M Nieto
- Division of Gastroenterology and Hepatology, Greater Los Angeles Veterans Medical Center, USA
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44
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45
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Guzzo JL, Duncan M, Bass BL, Bochicchio GV, Napolitano LM. Severe and refractory peptic ulcer disease: the diagnostic dilemma: case report and comprehensive review. Dig Dis Sci 2005; 50:1999-2008. [PMID: 16240207 DOI: 10.1007/s10620-005-2999-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2004] [Accepted: 01/28/2005] [Indexed: 02/08/2023]
Abstract
The recognition of Helicobacter pylori infection as a cause of peptic ulcer disease, medical regimens to eradicate the organism, and the widespread use of proton pump inhibition to suppress gastric acid secretion have revolutionized the management of peptic ulcer disease. As a result, successful medical management of peptic ulcer disease has largely supplanted the need for gastric surgery by general surgeons. Surgery is reserved for complications of the disease, refractory disease, or rare causes of ulcer disease such as gastrinoma and Zollinger-Ellison syndrome. In this report, we describe a case of intractable peptic ulcer disease that progressed to gastric outlet obstruction despite maximal medical therapy. We review the diagnostic studies utilized to evaluate the potential etiologies of peptic ulcer disease and the difficulty in diagnosing gastrinoma and Zollinger-Ellison in the setting of potent medical acid suppression therapy.
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Affiliation(s)
- James L Guzzo
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
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46
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Devlin JW, Welage LS, Olsen KM. Proton pump inhibitor formulary considerations in the acutely ill. Part 2: Clinical efficacy, safety, and economics. Ann Pharmacother 2005; 39:1844-51. [PMID: 16204393 DOI: 10.1345/aph.1g176] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To review, using an evidence-based approach, the clinical efficacy, safety, and cost-effectiveness of proton pump inhibitors (PPIs) for treatment of common acid peptic disorders in the acutely ill and provide clinicians with guidance when making hospital formulary decisions with this class of agents. DATA SOURCES MEDLINE (1966-May 2005) and the Cochrane Library databases were searched using the key words proton pump inhibitor, acid suppression, peptic ulcer disease, gastrointestinal bleeding, stress ulcer prophylaxis, critical care, safety, and cost-effectiveness. Bibliographies of cited references were reviewed, and a manual search of abstracts from recent gastroenterology, critical care, and surgery scientific meetings was completed. STUDY SELECTION AND DATA EXTRACTION All articles identified from the data sources were evaluated, and all information deemed relevant was included for this review. DATA SYNTHESIS PPIs have become a mainstay for acute acid suppression in hospitalized patients. Various commercially available PPI products are available either enterally or parenterally for administration to patients unable to swallow a tablet or capsule. The results of studies comparing the clinical efficacy of different PPI dosage forms and routes of administration, safety considerations, and cost-effectiveness analyses are among the factors to consider when making formulary decisions for this class of drugs. CONCLUSIONS While the introduction of new PPI products has expanded the therapeutic options for acid suppression in acutely ill patients, a number of unresolved questions remain surrounding the interchangeability of these products, the clinical significance of one PPI formulation over the other, and how oral/enteral therapy should be used as step-down therapy after parenteral therapy.
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Affiliation(s)
- John W Devlin
- School of Pharmacy, Northeastern University; Medical Intensive Care Unit, Tufts-New England Medical Center, Boston, MA 02115-5000, USA.
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Hoffmann KM, Furukawa M, Jensen RT. Duodenal neuroendocrine tumors: Classification, functional syndromes, diagnosis and medical treatment. Best Pract Res Clin Gastroenterol 2005; 19:675-97. [PMID: 16253893 DOI: 10.1016/j.bpg.2005.05.009] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Duodenal neuroendocrine tumors (NETs) comprise 2-3% of all GI endocrine tumors and are increasing in frequency. These include gastrinomas, somatostatinomas, nonfunctional NETs, gangliocytic paragangliomas, and poorly differentiated NE carcinomas. Although, the majority are nonfunctional, these tumors are a frequent cause of Zollinger-Ellison syndrome and can cause other clinical hormonal syndromes (carcinoid, Cushing's, etc.). In this chapter, their epidemiology, clinical aspects, localization, diagnosis and medical treatment are reviewed including the latest advances in each area.
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Affiliation(s)
- K Martin Hoffmann
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bldg. 10, Rm. 9C-103, 10 Center Dr, MSC 1804, Bethesda, MD 20892-1804, USA
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Tomassetti P, Campana D, Piscitelli L, Mazzotta E, Brocchi E, Pezzilli R, Corinaldesi R. Treatment of Zollinger-Ellison Syndrome. World J Gastroenterol 2005; 11:5423-32. [PMID: 16222731 PMCID: PMC4320348 DOI: 10.3748/wjg.v11.i35.5423] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In this article, we have reviewed the main therapeutic measures for the treatment of Zollinger-Ellison syndrome (ZES). Review of the literature was based on computer searches (Pub-Med, Index Medicus) and personal experiences. We have evaluated all the measures now available for treating patients with sporadic gastrinomas or gastrinomas associated with Multiple Endocrine Neoplasia Type 1, (MEN 1) including medical therapy such as antisecretory drugs and somatostatin analogs (SST), chemotherapy and chemoembolization, and surgical procedures. In ZES patients, the best therapeutic procedure is surgery which, if radical, can be curative. Medical treatment can be the best palliative therapy and should be used, when possible, in association with surgery, in a multimodal therapeutic approach.
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Affiliation(s)
- Paola Tomassetti
- Department of Internal Medicine and Gastroenterology, University of Bologna, Policlinico S.Orsola-Malpighi, Via Massarenti, 9, 40138, Bologna, Italy.
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Devlin JW. Proton pump inhibitors for acid suppression in the intensive care unit: Formulary considerations. Am J Health Syst Pharm 2005; 62:S24-30. [PMID: 15905598 DOI: 10.1093/ajhp/62.10_supplement_2.s24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The rationale for limiting the proton pump inhibitor (PPI) products included in an institutional formulary, factors to consider when making formulary decisions about PPI products, the results and limitations of cost-effectiveness analyses of PPI therapy in critically ill patients, the role of clinical practice guidelines in improving PPI use in the intensive care setting, and how these guidelines can be developed are discussed. SUMMARY Therapeutic interchange may make it possible to limit the number of PPI products included in the formulary and reduce costs without compromising the efficacy or safety of drug therapy. The results of studies comparing the pharmacokinetics, pharmacodynamics, and efficacy of different PPI dosage forms and routes of administration; practical considerations; safety; and costs are among the factors to consider when making formulary decisions. Some of the newer oral PPI products offer advantages over older ones in improved palatability and ease of preparation, storage, and administration. The cost-effectiveness of intravenous (i.v.) PPIs for preventing the recurrence of peptic ulcer bleeding has been demonstrated, but the cost-effectiveness of oral therapy for this indication and both oral and i.v. therapy for preventing stress-related mucosal bleeding has not been well established. CONCLUSION Intravenous PPIs are cost-effective for patients at risk for the recurrence of peptic ulcer bleeding. The introduction of new oral PPI products that can be administered as a suspension has expanded the therapeutic options for critically ill patients. The use of clinical practice guidelines can optimize the use of PPIs in the intensive care setting.
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Affiliation(s)
- John W Devlin
- Northeastern University School of Pharmacy, and Medical Intensive Care Unit, Tufts-New England Medical Center, Mugar #206, 360 Huntington Avenue, Boston, MA 02115, USA.
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Granberg D, Öberg K. Neuroendocrine tumours. CANCER CHEMOTHERAPY AND BIOLOGICAL RESPONSE MODIFIERS ANNUAL 2005. [DOI: 10.1016/s0921-4410(04)22021-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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