Epidemiology of NSAID-related gastroduodenal mucosal injury

Drug-induced mucosal alterations observed during esophagogastroduodenoscopy

Several features of drug-induced mucosal alterations have been observed in the upper gastrointestinal tract, i.e., the esophagus, stomach, and duodenum. These include pill-induced esophagitis, desquamative esophagitis, worsening of gastroesophageal reflux, chemotherapy-induced esophagitis, proton pump inhibitor-induced gastric mucosal changes, medication-induced gastric erosions and ulcers, pseudomelanosis of the stomach, olmesartan-related gastric mucosal inflammation, lanthanum deposition in the stomach, zinc acetate hydrate tablet-induced gastric ulcer, immune-related adverse event gastritis, olmesartan-asso-ciated sprue-like enteropathy, pseudomelanosis of the duodenum, and lanthanum deposition in the duodenum. For endoscopists, acquiring accurate knowledge regarding these diverse drug-induced mucosal alterations is crucial not only for the correct diagnosis of these lesions but also for differential diag-nosis of other conditions. This minireview aims to provide essential information on drug-induced mucosal alterations observed on esophagogastroduodenoscopy, along with representative endoscopic images.

Drug-Associated Gastropathy: Diagnostic Criteria

Drugs are widely used to treat different diseases in modern medicine, but they are often associated with adverse events. Those located in the gastrointestinal tract are common and often mild, but they can be serious or life-threatening and determine the continuation of treatment. The stomach is often affected not only by drugs taken orally but also by those administered parenterally. Here, we review the mechanisms of damage, risk factors and specific endoscopic, histopathological and clinical features of those drugs more often involved in gastric damage, namely NSAIDs, aspirin, anticoagulants, glucocorticosteroids, anticancer drugs, oral iron preparations and proton pump inhibitors. NSAID- and aspirin-associated forms of gastric damage are widely studied and have specific features, although they are often hidden by the coexistence of Helicobacter pylori infection. However, the damaging effect of anticoagulants and corticosteroids or oral iron therapy on the gastric mucosa is controversial. At the same time, the increased use of new antineoplastic drugs, such as checkpoint inhibitors, has opened up a new area of gastrointestinal damage that will be seen more frequently in the near future. We conclude that there is a need to expand and understand drug-induced gastrointestinal damage to prevent and recognize drug-associated gastropathy in a timely manner.

Orally Administered NSAIDs-General Characteristics and Usage in the Treatment of Temporomandibular Joint Osteoarthritis-A Narrative Review

Background: Temporomandibular joint osteoarthritis (TMJ OA) is a degenerative joint disease. The aim of this review was to present the general characteristics of orally administered nonsteroidal anti-inflammatory drugs (NSAIDs) and to present the efficacy of NSAIDs in the treatment of TMJ OA. Methods: PubMed database was analyzed with the keywords: "(temporomandibular joint) AND ((disorders) OR (osteoarthritis) AND (treatment)) AND (nonsteroidal anti-inflammatory drug)". After screening of 180 results, 6 studies have been included in this narrative review. Results and Conclusions: Nonsteroidal anti-inflammatory drugs are one of the most commonly used drugs for alleviation of pain localized in the orofacial area. The majority of articles predominantly examined and described diclofenac sodium in the treatment of pain in the course of TMJ OA. Because of the limited number of randomized studies evaluating the efficacy of NSAIDs in the treatment of TMJ OA, as well as high heterogeneity of published researches, it seems impossible to draw up unequivocal recommendations for the usage of NSAIDs in the treatment of TMJ OA. However, it is highly recommended to use the lowest effective dose of NSAIDs for the shortest possible time. Moreover, in patients with increased risk of gastrointestinal complications, supplementary gastroprotective agents should be prescribed.

Alpha-lipoic acid: A promising adjuvant for nonsteroidal anti-inflammatory drugs therapy with improved efficacy and gastroprotection

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in a wide variety of diseases due to their analgesic and anti-inflammatory effects, but their usage have been limited due to significant ulcerogenic side effects. In the present study, we aimed to evaluate the effect of α-lipoic acid (ALA) treatment on the anti-inflammatory activity of indomethacin (Indo) as well as the possible therapeutic effect of ALA on high dose Indo-induced gastropathy in female mice. Mice were treated with Indo (5 or 30 mg/kg, p.o) alone or in combination with ALA (50, 100 or 200 mg/kg, i.p). in vivo anti-inflammatory effect was evaluated by formalin-induced paw edema measured as paw thickness and edema. Gastric damage was evaluated macroscopically and histologically by scoring mucosal hemorrhage, erosion, edema and inflammation. To our results, Indo was ineffective at 5 mg/kg, but co-treatment with Indo and ALA significantly reduced paw edema, implying that ALA augmented the anti-inflammatory effect of subtherapeutic dose of Indo. However, ALA was not able to induce a further increase in the anti-inflammatory effect of Indo at 30 mg/kg. Unlike the treatment with Indo at 5 mg/kg, Indo at 30 mg/kg caused severe gastric damage that prevented by co-treatment with ALA. These results suggest that combination of ALA with NSAIDs can both increase anti-inflammatory effect and prevent NSAIDs-induced gastric damage. ALA would be promising adjuvant that can reduce dose for effective NSAID therapy, which improves safety profile of NSAIDs especially in cases long-term administration of high dose needed.

Thromboelastography-derived parameters for the prediction of acute thromboembolism following non-steroidal anti-inflammatory drug-induced gastrointestinal bleeding: A retrospective study

Efficacy of thromboelastography (TEG)-derived parameters for the prediction of acute thromboembolism (AT) in patients with non-steroidal anti-inflammatory drug (NSAID)-induced gastrointestinal bleeding (GIB) remains to be determined. A retrospective propensity score matching (PSM) study was performed to evaluate this efficacy. Patients with NSAID-induced GIB (98 with AT; 830 without AT) were matched for age, sex and history of cardiovascular and cerebrovascular diseases using PSM. Multivariate logistic regression was used to determine the efficacy of TEG-derived predictors of AT. Mean Decrease Gini (MDG) coefficients were used to rank the importance of the variables from random forest algorithm results. Univariate analysis indicated that the following indexes were significantly different between the two groups: Reaction time (R value), coagulation forming time, solidification angle, maximum amplitude (MA), coagulation index (CI), hemoglobin levels, D-dimer levels, platelet aggregation test (pAgt) results, fibrinogen levels and Acute Physiology and Chronic Health Evaluation II score (all P<0.001). Multifactor logistic regression analysis indicated that the R value (P=0.010), solidification angle (P=0.004), MA (P=0.038), D-dimer levels (P=0.012) and pAgt results (P=0.015) were independent predictors of AT in patients with NSAID-induced GIB, achieving an area under the curve of 0.999 in receiver operating characteristic curve analyses. The five most important parameters according to the MDG scores (MDGS) were: Solidification angle (MDGS=58.14), R value (MDGS=20.42), pAgt results (MDGS=15.61), D-dimer levels (MDGS=12.78) and CI (MDGS=12.61). The results of the present study indicated that TEG-derived parameters including the R value, solidification angle, MA and CI, as well as D-dimer levels and pAgt score were significant predictors of AT in patients with NSAID-induced GIB.

Reduction in postpercutaneous coronary intervention angina in addition to gastrointestinal events in patients on combined proton pump inhibitors and dual antiplatelet therapy: a systematic review and meta-analysis

BACKGROUND

Primary percutaneous coronary intervention (PCI) is a standard treatment in patients with acute coronary syndrome. Studies have shown that proton pump inhibitors (PPIs) can potentially attenuate the antiplatelet effects of P2Y12 inhibitors with associated adverse cardiovascular outcomes.

MATERIALS AND METHODS

Medline was searched using Pubmed from inception to 8 November 2017 for randomized control trials studying the effect of PPIs on coronary artery disease with concomitant use of dual antiplatelet therapy (DAPT). Overall, 692 studies were identified of which five randomized control trials were included. Statistical analysis was done using RevMan, version 5.3.

RESULTS

Five studies with 6239 patients (3113 on PPI with DAPT and 3126 with only DAPT) were included. Our analysis showed that PPI significantly reduced the incidence of gastrointestinal (GI) bleed [22 vs. 66, odds ratio (OR)=0.37, confidence interval (CI)=0.23-0.61, P≤0.0001, I=0%], GI ulcers and GI erosions (7 vs. 18, OR=0.39, CI=0.16-0.94, P=0.04, I=0%), and the incidence of post-PCI unstable angina in patients treated with PPI and P2Y12 agents (46 vs. 67, OR=0.67, CI=0.45-0.99, P=0.05, I=0%). There was an insignificant difference in myocardial infarction, stroke, and cardiovascular cause of mortality. A trend toward decreased all-cause mortality with PPIs was noted. Heterogeneity was calculated using I.

CONCLUSION

Concomitantly administered PPIs with P2Y12 inhibitors have a protective effect on the GI events. It also decreases the post-PCI angina without increased adverse cardiovascular outcomes.

Prevalence and risk factors for upper gastrointestinal diseases in health check-up subjects: a nationwide multicenter study in Korea

OBJECTIVES

The prevalence of upper gastrointestinal disease is expected to change following advances in socioeconomic status and improved hygiene in Korea. The aim of this study was to investigate the recent trends in upper gastrointestinal diseases based on endoscopic findings and Helicobacter pylori (H. pylori) seroprevalence in subjects undergoing health check-up at tertiary centers in Korea.

METHODS

A multicenter cross-sectional study was conducted at nine healthcare centers between September 2016 and June 2017. The subjects were evaluated using questionnaires, upper endoscopy and H. pylori serology tests. The results were compared with previous data in our study group obtained from eight tertiary healthcare centers in 2011 (n = 4023).

RESULTS

In total, we prospectively enrolled 2504 subjects undergoing health check-up. The prevalence of reflux esophagitis (RE) was 9.7%, which showed an increasing but insignificant trend since 2011 (8.8%). The prevalence of active and healing-stage benign gastric ulcer and duodenal ulcer (DU) was 1.6% and 1.2%, respectively, which confirmed a significant decrease since 2011 (4.1%; p < .001 and 2.2%; p = .005, respectively). The prevalence of gastric cancer was 0.5%, representing an increasing trend since 2011 (0.12%; p = .003). H. pylori seroprevalence was 51.3%, which significantly decreased from 2011 (59.8%; p < .001). In multivariate analysis, H. pylori seropositivity was a significant risk factor for DU (p < .001), whereas a significant protective factor against RE (p < .001).

CONCLUSIONS

The significant decrease of H. pylori seroprevalence in the past five years altered the incidence of upper gastrointestinal disease.

Risk factors associated with nonsteroidal anti-inflammatory drugs (NSAIDs)-induced gastrointestinal bleeding resulting on people over 60 years old in Beijing

Gastrointestinal (GI) bleeding is an unwanted side effect common to all chemical types of nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in elderly people. However, the risk factors of GI bleeding associated with NSAIDs for elderly people remain unknown. This study aims to evaluate the risks of GI bleeding associated with NSAIDs in 4728 elderly people over 60 years old based on database from a hospital in Beijing.This retrospective hospital-based study included 4728 patients over 60 years old prescribed with NSAIDs, of which 928 patients had GI bleeding and 3800 did not have. Odds ratios (OR) for the risk of GI bleeding associated with NSAIDs were determined by logistic regression analysis. Mean Decrease Gini (MDG) involved in random forest algorithm was used to rank the associated factors with GI bleeding.In multivariate analysis, family history of GI bleeding (OR, 3.348; P = .000), history of peptic ulcers (OR, 4.068; P = .000), history of cardiovascular and cerebrovascular disease (OR, 1.476; P = .001), diabetes mellitus (OR, 1.408; P = .000), antiplatelet drugs (OR, 3.106; P = .000), Helicobacter pylori infection (OR, 1.312; P = .001), cholesterol level (OR, 0.516; P = .000), upper abdominal discomfort (OR, 3.467; P = .000), anorexia (OR, 2.038; P = .000), and NSAIDs used for 0.5 to 3 months (OR, 0.780; P = .000) were associated with GI bleeding. After ranked the MDG of each factor, the top 5 ranked factors associated with GI bleeding were melena, hematemesis, antiplatelet drugs, cholesterol level, and upper abdominal discomfort.We found that family history of GI bleeding, history of peptic ulcers, history of cardiovascular and cerebrovascular disease, diabetes mellitus, antiplatelet drugs, Helicobacter pylori infection, hypocholesterolemia, and NSAIDs used for 0.5 to 3 months were independent risk factors for GI bleeding on people over 60 years old. Meanwhile, upper abdominal discomfort might be the predictor of GI bleeding associated with NSAIDs elderly users.

Long-Term Recurrence Rates of Peptic Ulcers without Helicobacter pylori

Background/Aims

The purpose of this study is to investigate the recurrence rate of peptic ulcer disease (PUD) over a long follow-up period with PUD patients without Helicobacter pylori.

Methods

We retrospectively reviewed patients diagnosed with PUD on endoscopy and divided them into two groups: a H. pylori-negative group (HP-negative group), and a group of patients with untreated H. pylori (HP noneradicated group). We compared the recurrence rates of PUD in these two groups and analyzed the factors that affected ulcer recurrence.

Results

Total of nine hospitals in Korea participated, and a total of 1,761 patients were retrospectively reviewed. The HP-negative group included 553 patients, and the HP noneradicated group included 372 patients. The 5-year cumulative probabilities of PUD recurrence were 36.4% in the HP-negative group and 43.8% in the HP noneradicated group (p=0.113). The factors that were found to affect recurrence in the HP-negative group were elder, male, and comorbid chronic kidney disease.

Conclusions

The 5-year cumulative probability of PUD recurrence without H. pylori infection after a long-term follow-up was 36.4% and the factors that affected recurrence were elder, male, and comorbid chronic kidney disease.

Risk factors associated with NSAID-induced upper gastrointestinal bleeding resulting in hospital admissions: A cross-sectional, retrospective, case series analysis in valencia, spain

Abstract.

BACKGROUND

NSAIDs are a significant cause of drug-related hospital admissions and deaths. The therapeutic effects of NSAIDs have been associated with the risk for developing adverse events, mainly in the gastrointestinal tract.

OBJECTIVES

The focus of this study was to identify the most common risk factors associated with NSAID-induced upper gastrointestinal bleeding (UGIB) resulting in hospital admissions. A secondary end point was the relationship between use of gastroprotective treatment and relevant risk factors to NSAID-induced UGIB in the selected population.

METHODS

This study was a cross-sectional, retrospective, case-series analysis of NSAID-induced UGIB resulting in hospital admission to the Requena General Hospital, Valencia, Spain, occurring from 1997 to 2005. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify UGIB admissions associated with NSAIDs. To estimate the probability of association between UGIB and the use of NSAIDs, the Naranjo adverse drug reaction probability was used. Patients were categorized as high-risk to develop UGIB if they met ≥1 of the following risk criteria (relevant risk factors): aged ≥65 years (age risk factor); peptic ulcer disease or NSAID gastropathy occurring in the year before their hospital admission (history risk factor); and concomitant use of other NSAIDs, systemic corticoids, oral anticoagulants, or platelet aggregation inhibitors (concomitant medication risk factor). Patients were categorized as candidates to use gastroprotections if they met ≥1 of the relevant risk factors. Patients were categorized as users of gastroprotective treatment if they used proton pump inhibitors, histamine H2-receptor antagonists, or misoprostol at hospital admission.

RESULTS

This study comprised 209 cases of NSAID-induced UGIB (129 men, 80 women: mean [SD] age, 71.5 [13.8] years; 128 [61.2%] receiving acetyl salicylic acid [ASA], with 72 [34.4%] receiving low-dose [80-325 mg] ASA). Prevalence of relevant risk factors for UGIB were as follows: age, 158 (75.6%) patients; history, 37 (17.7%); and concomitant medication, 35 (16.7%). One hundred seventy-eight (85.2%) patients met ≥1 criterion for using a gastroprotective agent; 28 (15.6%) were actually using one. Only the history risk factor was significantly associated with the use of gastroprotective treatment (P = 0.007; odds ratio = 3.17).

CONCLUSIONS

In this study of NSAID-induced UGIB resulting in hospital admission, age was the most common risk factor. However, this criterion was not associated with the use of gastroprotective agents. A large number of cases were associated with the use of ASA, primarily in those receiving low doses. A significant lack of gastroprotective agent use was observed in patients who met the criteria to use them.

Steroid ulcers: Any news?

Steroid ulcers, although a common feature in experimental studies, seldom develop in clinical practice, as observed by the meta-analyses carried out in the 90s. Corticosteroids alone become ulcerogenic only if treatment lasts longer than one month and the total administered dose exceeds 1000 mg. On the other hand concomitant intake of non-steroidal anti-inflammatory drugs results in a synergistic, highly damaging effect on the gastroduodenal mucosa. Thus, despite the survival of the steroid ulcer myth in the medical culture, pharmacological protection against steroid-induced peptic ulcers is a rare necessity while the best prophylactic strategy still remains to be determined.

Comparison of gastrointestinal adverse effects between cyclooxygenase-2 inhibitors and non-selective, non-steroidal anti-inflammatory drugs plus proton pump inhibitors: a systematic review and meta-analysis

BACKGROUND

There are conflicting and inconsistent data regarding the gastrointestinal (GI) protective effect of cyclooxygenase-2 (COX-2) inhibitors and of non-steroidal anti-inflammatory drugs (NSAIDs) plus proton-pump inhibitors (PPI).

AIM

To compare the adverse GI effects between COX-2 inhibitors and NSAIDs plus PPI.

METHODS

We performed a systematic review of randomized trials comparing GI adverse effects between COX-2 inhibitors and NSAID plus PPI. Trials were identified in MEDLINE, EMBASE, and the Cochrane Library. Primary outcomes were major GI complications including hemorrhage, perforation, and obstruction.

RESULTS

A total of nine trials involving 7,616 participants from 2002 to 2011 were included. All trials were randomized, double blinded, and placebo-controlled with moderate to high quality. COX-2 inhibitors were found to have significantly reduced the risk of major GI events, including perforation, obstruction, and bleeding (relative risk or RR 0.38, 95 % confidence interval or CI 0.25-0.56, p < 0.001); however, the benefit was significant only for patients who were at high risk for NSAID-related GI complications and long-term users. Additionally, the risk of diarrhea (RR 0.56, 95 % CI 0.35-0.9, p 0.02) and withdrawal (RR 0.77, 95 % CI 0.62-0.94, p 0.01) was significantly lower in use of COX-2 inhibitors, while the rate of dyspepsia was higher (RR 1.58, 95 % CI 1.26-1.98, p < 0.001).

CONCLUSIONS

COX-2 inhibitors significantly reduced the risk of perforation, obstruction, bleeding, diarrhea, and withdrawal due to GI adverse events, while the risk of dyspepsia was lower with NSAIDs plus PPI.

Positional isomers of aspirin are equally potent in inhibiting colon cancer cell growth: differences in mode of cyclooxygenase inhibition

We compared the differential effects of positional isomers of acetylsalicylic acid (o-ASA, m-ASA, and p-ASA) on cyclooxygenase (COX) inhibition, gastric prostaglandin E2 (PGE2), malondialdehyde, tumor necrosis factor-alpha (TNF-α) levels, superoxide dismutase (SOD) activity, human adenocarcinoma colon cancer cell growth inhibition, cell proliferation, apoptosis, and cell-cycle progression. We also evaluated the gastric toxicity exerted by ASA isomers. All ASA isomers inhibit COX enzymes, but only the o-ASA exerted an irreversible inhibitory profile. We did not observe a significant difference between ASA isomers in their ability to decrease the in vivo synthesis of PGE2 and SOD activity. Furthermore, all isomers increased the levels of gastric and TNF-α when administered orally at equimolar doses. We observed a dose-dependent cell growth inhibitory effect; the order of potency was p-ASA > m-ASA ≈ o-ASA. There was a dose-dependent decrease in cell proliferation and an increase in apoptosis, with a concomitant Go/G1 arrest. The ulcerogenic profile of the three ASA isomers showed a significant difference between o-ASA (aspirin) and its two positional isomers when administered orally at equimolar doses (1 mmol/kg); the ulcer index (UI) for o-ASA indicated extensive mucosal injury (UI = 38), whereas m-ASA and p-ASA produced a significantly decreased toxic response (UI = 12 and 8, respectively) under the same experimental conditions. These results suggest that the three positional isomers of ASA exert practically the same biologic profile in vitro and in vivo but showed different safety profiles. The mechanism of gastric ulcer formation exerted by aspirin and its two isomers warrants a more detailed and thorough investigation.

Sex differences in effects and use of anti-inflammatory drugs

Gender accounts for important differences in the incidence, prevalence, and course of many immunoinflammatory diseases. However, similar treatment strategies, such as the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and tumor necrosis factor-α (TNF-α) inhibitors, have been advocated for both genders. Experimental studies found that molecular mechanisms of inflammation differ in males and females. In our chapter we summarize the data concerning gender-specific aspects about prevalence of use, drug survival, responsiveness, and adverse drug effects of NSAIDs and TNF-α inhibitors. Gender-related differences in the prevalence and course of many autoimmune diseases as well as differences in effects of anti-inflammatory drugs should be considered for the tailored treatment options for these patients.

Comparison of the Effects on Rib Fracture between the Traditional Japanese Medicine Jidabokuippo and Nonsteroidal Anti-Inflammatory Drugs: A Randomized Controlled Trial

Jidabokuippo is a traditional Japanese medicine used for contusion-induced swelling and pain. This open multicenter randomized study was designed to compare the efficacies of jidabokuippo and nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with rib fracture by analyzing the treatment duration. Our study involved 170 rib fracture patients capable of oral ingestion divided randomly into 2 groups: the jidabokuippo and NSAID groups. We compared the duration of treatment and healthcare expenditure between these 2 groups. Medication was continued in both groups until the visual analogue scale score decreased to less than 50% of the pretreatment score. We excluded the patients in whom medication was prematurely discontinued. We analyzed 81 patients belonging to the jidabokuippo and NSAIDs groups. No significant intergroup differences were observed in age, gender, severity (injury severity score), and presence/absence of underlying disease. The treatment duration was significantly shorter in the jidabokuippo group than in the NSAIDs group (P = 0.0003). Healthcare expenditure was significantly lower in the jidabokuippo group than in the NSAIDs group (P < 0.0001). Our results suggest that compared to NSAIDs, jidabokuippo can shorten the duration of treatment in patients with rib fracture and is a promising analgesic agent based on the medical economic viewpoint.

Analysis of direct medical care costs of peptic ulcer disease in a Korean tertiary medical center

OBJECTIVES

There have been no reported data on the medical care cost of idiopathic peptic ulcer disease (PUD) compared with H. pylori (+) and/or NSAID (+) cases although H. pylori-negative idiopathic ulcers are increasing. The aim of this study was to investigate the direct medical care costs of PUD based on whether it was H. pylori infection/from NSAIDs or idiopathic.

MATERIAL AND METHODS

One hundred and seventy three patients with PUD comprising H. pylori and/or NSAID use-associated PUD (n = 145) and idiopathic PUD (n = 28) were prospectively enrolled in this study. The direct medical care costs were analyzed retrospectively for the patients with PUD during a one-year follow-up period.

RESULTS

The recurrence rate within one year was significantly higher in idiopathic PUD than H. pylori and/or NSAID-associated PUD (p = 0.002). Direct medical care costs of idiopathic PUD ($2483.8) were higher than in patients with H. pylori and/or NSAID-associated PUD ($1751.8) resulting from longer duration of medication and higher proportion of endoscopic hemostasis and hospitalization.

CONCLUSIONS

More clinical research is needed to improve outcome and reduce recurrence rate and medical care costs of idiopathic PUD.

Diagnostic indicators for peptic ulcer perforation at a tertiary care hospital in Thailand

Introduction

Limited data currently exists regarding the diagnostic indicators of peptic ulcer perforation for early detection among patients in Thailand. Delayed diagnosis and treatment for an ulcer can be life-threatening, resulting in shock or death.

Objective

To determine the diagnostic indicators of peptic ulcer perforation.

Material and methods

A cohort study was conducted in a tertiary care hospital in Thailand from 2005 to 2009. Peptic ulcer patients aged 15 years and over admitted to the surgical department were included. The diagnostic indicators used criteria of the patients’ final diagnoses and operations, coded according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, which included patient profiles, gender, age, coexisting illnesses, personal habits, signs and symptoms, laboratory investigations, radiological finding, and treatment role. Exponential risk regression analyses to obtain relative risk (RR) estimates for diagnostic indicators were analyzed using Stata^® statistical software package, version 11 (StataCorp LP, College Station, TX).

Results

The study included 1290 patients. Of these, 57% reported perforated peptic ulcer. Multivariate analysis showed five diagnostic indicators: signs and symptoms including intense abdominal pain (RR = 1.53, 95% confidence interval [CI] 1.14–2.06), tenderness (RR = 1.94, 95% CI 1.17–3.21), and guarding (RR = 1.52, 95% CI 1.05–2.20); X-ray with free air (RR = 2.80, 95% CI 2.08–3.77); and referral from other hospitals (RR = 1.37, 95% CI 1.03–1.82).

Conclusion

Five diagnostic indicators for peptic ulcer perforation monitoring were suggested from this study. Improving diagnostic indicators for medical care may improve the outcome of patients that have perforated peptic ulcer.

[Risk factors for development and recurrence of peptic ulcer disease]

BACKGROUND/AIMS

Peptic ulcer disease (PUD) is one of the common gastrointestinal diseases, and its medical management has been developed so much that the incidence of its serious complications, such as bleeding and perforation, are declining significantly. Its prevalence in Korea is not definitely decreased, probably due to increasing proportion of elderly patients and their rising usage of non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin. This study was conducted to identify the risk factors for development and recurrence of peptic ulcer disease in Korea.

METHODS

From 2003 to 2008, upper gastrointestinal endoscopy and detailed personal questionnaires were performed for patients who visited Department of Gastroenterology at Seoul National University Bundang Hospital. In total, 475 PUD patients and 335 non-ulcer dyspepsia patients were included. The results of questionnaires and repeated upper gastrointestinal endoscopy at initial diagnosis time and follow-up periods were analyzed.

RESULTS

Multivariable analysis showed that male, H. pylori infection, NSAIDs use and smoking were risk factors for the development of PUD. The use of proton pump inhibitors (PPIs) and H2 receptor antagonists has significantly reduced the risk of PUD in patients who had taken NSAIDs and/or aspirin. H. pylori infection was found as the only risk factor for the recurrence of PUD.

CONCLUSIONS

For the old patients who are taking drugs, such as NSAIDs and aspirin, concomitant use of PPIs or H2 receptor antagonists should be considered to protect from the development of PUD. H. pylori eradication has been confirmed again to be essential for the treatment of PUD patients infected with H. pylori.

Systematic review: Helicobacter pylori and the risk of upper gastrointestinal bleeding risk in patients taking aspirin

BACKGROUND

Aspirin is widely used to modify the risk of recurrent vascular events. It is, however, associated with increased upper gastrointestinal bleeding risk. The influence of Helicobacter pylori on this risk is uncertain.

AIM

To determine the influence of H. pylori on upper gastrointestinal bleeding risk in patients taking aspirin.

METHODS

MEDLINE and EMBASE databases were searched. All studies providing data regarding H. pylori infection in adults taking aspirin and presenting with upper gastrointestinal bleeding were included.

RESULTS

A total of 13 studies that included 1 case-control, 10 cohort studies and 2 randomized-controlled trials (RCTs) were analysed. The case-control study (n = 245) determined H. pylori to be a significant independent risk factor for upper gastrointestinal bleeding. The cohort studies were heterogeneous, varying in inclusion criteria, doses and duration of aspirin used, mode of H. pylori testing and causative GI pathology considered. Comprising 5465 patients, H. pylori infection was tested for in 163 (0.03%) aspirin users with upper gastrointestinal bleeding. The RCTs yielded no significant results.

CONCLUSIONS

The current data are not sufficient to allow meta-analyses. The widely held belief that H. pylori is a risk factor for upper gastrointestinal bleeding in regular aspirin users is not supported by the very limited evidence available.

Comparison between 3-Nitrooxyphenyl acetylsalicylate (NO-ASA) and O2-(acetylsalicyloxymethyl)-1-(pyrrolidin-1-yl)diazen-1-ium-1,2-diolate (NONO-ASA) as safe anti-inflammatory, analgesic, antipyretic, antioxidant prodrugs

Chronic inflammation is an underlying etiological factor in carcinogenesis; nonsteroidal anti-inflammatory drugs (NSAIDs) and their chemically modified NO-releasing prodrugs (NO-NSAIDs) are promising chemopreventive agents. The aim of this study was to conduct a head-to-head comparison between two NO-ASAs possessing different NO donor groups, an organic nitrate [3-nitrooxyphenyl acetylsalicylate (NO-ASA; NCX-4016)] and an N-diazeniumdiolate [NONO-ASA, O(2)- (acetylsalicyloxymethyl)-1-(pyrrolidin-1-yl)diazen-1-ium-1,2-diolate (NONO-ASA; CVM-01)], as antiulcerogenic, analgesic, anti-inflammatory, and antipyretic agents. All drugs were administered orally at equimolar doses. For antiulcerogenic study, 6 h after administration, the number and size of hemorrhagic lesions in stomachs from euthanized animals were counted. Tissue samples were frozen for prostaglandin E(2) (PGE(2)), superoxide dismutase (SOD), and malondialdehyde determination. For anti-inflammatory study, 1 h after drug administration, the volume of carrageenan-induced rat paw edemas was measured for 6 h. For antipyretic study, 1 h after dosing, fever was induced by intraperitoneal LPS, and body core temperatures measured for 5 h. For analgesic study, time-dependent analgesic effect of prodrugs was evaluated by carrageenan-induced hyperalgesia. Drugs were administered 30 min after carrageenan. NO-ASA and NONO-ASA were equipotent as analgesic and anti-inflammatory agents but were better than aspirin. Despite a drastic reduction of PGE(2) in stomach tissue, both prodrugs were devoid of gastric side effects. Lipid peroxidation induced by aspirin was higher than that observed by prodrugs. SOD activity induced by both prodrugs was similar, but approximately 2-fold higher than that induced by aspirin. CVM-01 is as effective as NCX-4016 in anti-inflammatory, analgesic, and antipyretic assays in vivo, and it showed an equivalent safety profile in the stomach. These results underscore the use of N-diazeniumdiolate moieties in drug design.

[Guidelines of prevention and treatment for NSAID-related peptic ulcers]

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used medications in Korea. Gastrointestinal toxicity, including peptic ulcer, is a common adverse effect of NSAIDs. Risk factors for NSAID-related peptic ulcer include a previous history of peptic ulcer, advanced age, high dose, concomitant use of corticosteroids, anticoagulants, other NSAIDs including low-dose aspirin. Preventive measure(s), such as COX-2 inhibitor, proton pump inhibitor or misoprostrol, should be done for patients requiring NSAID therapy who have high-risk factor(s) for peptic ulcer. Low dose aspirin also increases the risk of peptic ulcer, so preventive measure(s) should be done for high-risk patients. The eradication of Helicobacter pylori is recommended for high-risk NSAID-users. Treatment strategies for peptic ulcers in NSAID users are mostly the same for peptic ulcers in NSAID non-users.

Prevention of chronic gastritis by fermented milks made with exopolysaccharide-producing Streptococcus thermophilus strains

Acetyl-salicylic acid (ASA) is a nonsteroidal antiinflammatory/analgesic drug, which may cause gastritis or stomach ulcers if intensively employed. Exopolysaccharide (EPS)-producing lactic acid bacteria have been claimed to induce immunostimulatory/antiulcer effects in the host. This study investigated the potential preventive effect of fermented milks (FM) with EPS-producing Streptococcus thermophilus strains (CRL 1190 and CRL 804) on an in vivo model of chronic gastritis. Fermented milks (2 EPS(+) and 1 EPS(-), separately) were fed to BALB/c mice for 7 d before inducing gastritis with ASA (400 mg/kg of body weight per day for 10 d; gastritis group, n = 5). Appropriate control groups (ASA administered but not given FM, n = 5; and ASA not administered but given FM) were included in this study. Gastric inflammatory activity was evaluated through the stomach's histology and the number of IFNgamma(+) and IL-10(+) cytokine-producing cells in the gastric mucosa. Only mice preventively treated with the EPS-producing Strep. thermophilus CRL 1190 FM and later administered ASA did not develop gastritis, showing a conserved gastric mucosa structure similar to those of healthy mice. A marked decrease of IFNgamma(+)- and increase of IL-10(+)-producing cells compared with the gastritis group mice were observed. Purified EPS from Strep. thermophilus CRL 1190 resuspended in autoclaved milk was also effective for gastritis prevention. The EPS-protein interaction might be responsible for the observed gastroprotective effect; such interactions may be affected by industrial manufacturing conditions. The results indicate that the FM with Strep. thermophilus CRL 1190 or its EPS could be used in novel functional foods for preventing chronic gastritis.

Endoscopic and histopathological evaluation of acute gastric injury in high-dose acetaminophen and nonsteroidal anti-inflammatory drug ingestion with suicidal intent

AIM: To evaluate endoscopic and histopathologic aspects of acute gastric injury due to ingestion of high-dose acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) with respect to some risk factors and patient characteristics.

METHODS: The study group consists of 50 patients admitted to emergency department with high dose analgesic ingestion (group I) with suicidal intent. Thirty patients with or without mild complaints of dyspepsia (group II) were selected as the control group. The study group was stratified according to the use of type and number of analgesics. Endoscopic findings were evaluated according to the Lanza score (LS), expressing the severity of the gastroduodenal damage and biopsies according to a scoring system based on histopathologic findings of acute erosive gastritis.

RESULTS: Gastroduodenal damage was signifi-cantly more severe in group I compared to group II (P < 0.01). The LS was similar in both groups Ia and Ib. However LS was significantly higher in patients who had ingested multiple NSAIDs (group Ic) compared to other patients (P < 0.01). The LS was correlated to age (P < 0.01) and total amount of drug ingested (P < 0.05) in group I; but it was not correlated with Helicobacter pylori (H pylori) infection or duration of exposure (P > 0.05). The biopsy score (BS) was higher in group I than group II (P < 0.01), and higher in group Ib than group Ia (P < 0.05).

CONCLUSION: The histopathologic damage was more severe among NSAID ingesting patients compared to those ingesting only acetaminophen and there is no significant difference in the endoscopic findings between the groups. There is no significant difference in the LS between the groups. This lack of significance is remarkable in terms of the gastric effects of high-dose acetaminophen.

Early use of omeprazole benefits patients with acute myocardial infarction

BACKGROUND

Bleeding complications are not uncommon in patients with acute myocardial infarction (AMI) during treatments. How to prevent the occurrence of upper gastrointestinal bleeding in AMI patients has become one of the most intractable problems. And there are conflicting data on the efficacy and complication rate of omeprazole treatment. We conducted an intervention study to determine whether using omeprazole could benefit AMI patients.

METHODS

A total of 237 patients with AMI were divided into two groups at random: omeprazole group including 114 patients and control group including 123 patients. Omeprazole 40 mg by intravenous drip was given to the patients in omeprazole group when they were admitted to the hospitals. From the second day they were given omeprazole 20 mg per day by oral administration for 7 days. In contrast, no gastric acid inhibitor was given to the patients in control group. The incidence of upper gastrointestinal bleeding, the recanalization rate and overall mortality in both groups were observed.

RESULTS

The incidence of upper gastrointestinal bleeding in omeprazole group was 5.3% (6/114) which was much lower than 14.6% (18/123) in control group (P = 0.017), but the recanalization rate had no significant difference between the two groups (P = 0.681). The overall mortality in omeprazole group was lower than that of control group (3.5% vs. 10.6%, P = 0.035).

CONCLUSIONS

Our findings suggest that early use of omeprazole in AMI patients could decrease the incidence of upper gastrointestinal bleeding and the overall mortality, without influencing the recanalization rate. Early use of omeprazole might benefit AMI patients.

Hydroxyurea in old patients with essential thrombocythemia

BACKGROUND AND AIMS

A previous thrombotic event and advanced age are well-known risk factors for thrombosis in essential thrombocythemia (ET). In these patients, therefore, cytotoxic drugs are needed to reduce platelet count. In spite of this convincing idea, in clinical practice, some old patients do not use platelet-reducing drugs, for a variety of causes, and few specific studies in old patients with ET are available. Our retrospective study reports single-center experience in 54 old ET patients with long follow-ups.

METHODS

We compared the clinical outcome of 27 ET old patients not taking cytotoxic drugs (group A) with 27 cases treated with hydroxyurea (HU) (group B), evaluating the incidence of thrombosis and thrombosis-free survival. In 16 patients in group A and in 18 in group B, V617FJak2 mutation was sought. About 20% of HU-treated patients developed major side-effects.

RESULTS

No significant difference was found in the occurred thrombosis between the 2 groups in either clinical or laboratory features. V617FJak2 was equally common in groups A and B, and in patients with or without thrombosis.

CONCLUSIONS

This study is not randomised and includes a small number of patients. However, it shows that it is necessary to identify better patients who really need treatment, as the side-effects of HU are relatively common in old people and their treatment should be discontinued. V617FJak2 does not define the thrombotic risk in old ET patients.

Chiropractic Care of Musculoskeletal Disorders in a Unique Population Within Canadian Community Health Centers

OBJECTIVE

This study was part of a larger demonstration project integrating chiropractic care into publicly funded Canadian community health centers. This pre/post study investigated the effectiveness of chiropractic care in reducing pain and disability as well as improving general health status in a unique population of urban, low-income, and multiethnic patients with musculoskeletal (MSK) complaints.

METHODS

All patients who presented to one of two community health center-based chiropractic clinics with MSK complaints between August 2004 and December 2005 were recruited to participate in this study. Outcomes were assessed by a general health measure (Short Form-12), a pain scale (VAS), and site-specific disability indexes (Roland-Morris Questionnaire and Neck Disability Index), which were administered before and after a 12-week treatment period.

RESULTS

Three hundred twenty-four patients with MSK conditions were recruited into the study, and 259 (80.0%) of them were followed to the study's conclusion. Clinically important and statistically significant positive changes were observed for all outcomes (Short Form-12: physical composite score mean change = 4.9, 95% confidence interval [CI] = 3.8-6.0; VAS: current pain mean change = 2.3, 95% CI = 1.9-2.6; Neck Disability Index: mean change = 6.8, 95% CI = 5.4-8.1; Roland-Morris Questionnaire: mean change = 4.3, 95% CI = 3.6-5.1). No adverse events were reported.

CONCLUSIONS

Patients of low socioeconomic status face barriers to accessing chiropractic services. This study suggests that chiropractic care reduces pain and disability as well as improves general health status in patients with MSK conditions. Further studies using a more robust methodology are needed to investigate the efficacy and cost-effectiveness of introducing chiropractic care into publicly funded health care facilities.

Ageing and the gut

The current concepts on diagnosis, clinical features, and management of common gastrointestinal conditions in the elderly population, taking into account physiological aspects of ageing, are evaluated. Gastrointestinal (GI) disorders are discussed with an emphasis on oesophageal problems, Helicobacter pylori infection, malabsorption, diverticular disease, and cancer. GI problems are acquiring greater importance in hospitals and in the community and their incidence is increasing. Newer treatments have less impact on patients' wellbeing and meticulously planned investigation and treatment is needed. Careful selection of patients and application of modern techniques has improved survival and outcomes, with comparable results to those in younger age groups.

Interaction or relationship between Helicobacter pylori and non-steroidal anti-inflammatory drugs in upper gastrointestinal diseases

According to a meta-analysis, H pylori and non-steroidal anti-inflammatory drugs (NSAID) independently and significantly increase the risk of gastroduodenal ulcer and ulcer bleeding. Their coincidence is frequent, demonstration of a possible relationship and consequent attitude is of important implications. But unfortunately, no consensus has been approved in the past years and their interactions are still controversial. H pylori and NSAID are known to share a number of pathogenic mechanisms, but there is no evidence for the significant synergic action between these two risk factors. Their relationship is independent, additive, synergistic or antagonistic without considering the influence of other factors because studies on this subject are different in almost all aspects of their methodology, including the definition of a NSAID user as well as the types, doses, duration and their indications for NSAID use, as well as their end-points, definition of dyspepsia and regimes used for eradication of H pylori. These might contribute to the conflicting results and opinions. H pylori infection in humans does not act synergistically with NSAID on ulcer healing, and there is no need to eradicate it. This notion is supported by the finding that the eradication of H pylori does not affect NSAID-induced gastropathy treated with omeprazole and that H pylori infection induces a strong cyclooxygenase-2 (COX-2) expression resulting in excessive biosynthesis of gastroprotective prostaglandin which in turn counteracts NSAID-induced gastropathy and heals the existing ulcer. Other investigators claimed that H pylori infection acts synergistically with NSAID on ulcer development, and H pylori should be eradicated, particularly at the start of long-term NSAID therapy. Eradication of H pylori prior to NSAID treatment does not appear to accelerate ulcer healing or to prevent recurrent ulcers in NSAID users. However, some recommendations can be drawn from the results of clinical trails.

Improving the gastrointestinal tolerability of aspirin in older people

Interventions to reduce mortality and disability in older people are vital. Aspirin is cheap and effective and known to prevent cardiovascular and cerebrovascular disease, many cancers, and Alzheimer dementia. The widespread use of aspirin in older people is limited by its gastrointestinal side effects. Understanding age-related changes in gastrointestinal physiology that could put older people at risk of the side effects of aspirin may direct strategies to improve tolerance and hence lead to greater numbers of older people being able to take this effective intervention.

Inadequate use of acid-suppressive therapy in hospitalized patients and its implications for general practice

Acid-suppressive therapy (AST) is largely prescribed in both hospital and general practice setting but few data are available on appropriateness of AST use in hospitalized patients and its fallout on prescribing in general practice. We assessed AST in patients consecutively admitted to an internal medicine department to determine the type and timing of prescription and indication for use according to widely accepted guidelines. Prescriptions were rated as indicated, acceptable, or not indicated. Overall, 58.7% of 834 admitted patients received AST, mainly proton pump inhibitors. The prescriptions were indicated in 50.1% of patients, not indicated in 41.5%, and acceptable in 6.5%. The main reason for inappropriate use was prophylaxis in low-risk patients (64.8%). On admission, 35.7% of 112 patients already on AST were judged to receive inappropriate prescription; of 348 patients discharged on AST, overuse was identified in 38.5%. No significant difference was observed for inappropriate use at admission, during hospitalization, and at discharge. In 64 inpatients (7.7%) AST, although indicated, mainly for ulcer prophylaxis in high-risk patients, was not prescribed. In conclusion, AST is substantially over-used in both hospital and general practice settings, mainly for ulcer prophylaxis in low-risk patients. On the other hand, AST is underused in a small, but not negligible proportion of high-risk patients.

Nonselective Nonaspirin Nonsteroidal Anti-Inflammatory Drugs and Gastrointestinal Bleeding: Relative and Absolute Risk Estimates From Recent Epidemiologic Studies

Gastrointestinal bleeding (GIB) is known to be associated with use of nonselective nonaspirin nonsteroidal anti-inflammatory drugs (NNANSAIDs), but it is less clear whether and to what extent variation in GIB risk exists according to the characteristics of exposure. To assess the consistency of data on the relative and absolute risks of GIB among NNANSAID users, we reviewed epidemiologic studies conducted around the world for data on NNANSAID use categorized by dose, timing, and type of exposure. US mortality rates for GIB were obtained and used to estimate national rates of GIB death attributable to NNANSAID use in the 1990s. The average relative increase in risk of GIB among NNANSAID users was found to be fourfold or slightly higher, regardless of the demographic characteristics of the studied population. There were approximately twofold increases associated with over-the-counter doses and sixfold or higher increases at heavy prescription levels. Variation in risk exists by type of NNANSAID, although differences by preparation seem at least partly dose-related. GIB risk declines following cessation of NNANSAID use, with current rather than prior cumulative exposure the key determinant of risk. The baseline rate of GIB in all studied populations rises markedly with advancing age. Annual hospitalization rates for GIB exceed one per 1000 among the elderly, with the large majority of cases occurring among persons age 65 years and older. NNANSAID use may account for nearly 34% of all GIB cases in the United States, and may have resulted in over 32,000 GIB hospitalizations and 3200 GIB deaths per year in the 1990s.

Review article: the ageing bowel and intolerance to aspirin

Aspirin has a role in the prevention of cardiovascular and cerebrovascular disease, Alzheimer's dementia and several cancers. Encouraging all 50 year olds to take low-dose aspirin doubles their chances of living a healthy life into their nineties. The widespread use of aspirin, however, is limited as many older subjects are currently unable to take aspirin because of gastrointestinal side-effects. This review explores why gastrointestinal events occur with aspirin use and how a net benefit from prophylactic aspirin might be achieved in older subjects. It is suggested that, by understanding the age-related changes in upper gastrointestinal physiology and the mechanisms by which aspirin leads to the risk reductions associated with its use, it may be possible to direct interventions to improve tolerability in older subjects. This would allow greater numbers of older subjects to gain the benefits associated with aspirin use.

Observational study of upper gastrointestinal haemorrhage in elderly patients given selective cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs

OBJECTIVE

To compare rates of upper gastrointestinal haemorrhage among elderly patients given selective cyclo-oxygenase-2 (COX 2) inhibitors and non-selective non-steroidal anti-inflammatory drugs (NSAIDs).

DESIGN

Observational cohort study.

SETTING

Administrative data from Ontario, Canada, used from 17 April 2000 to 31 March 2001 to identify population based, NSAID-naive cohorts of patients.

PATIENTS

Subjects aged > or =66 years who started taking non-selective NSAIDs (n=5391), diclofenac plus misoprostol (n=5087), rofecoxib (n=14 583), or celecoxib (n=18 908) and a randomly selected control cohort not exposed to NSAIDs (n=100 000).

MAIN OUTCOME MEASURES

Rate ratios of hospital admission for upper gastrointestinal haemorrhage in each drug cohort with adjustment for potential confounders.

RESULTS

Relative to controls, the multivariate model revealed an increased short term risk of upper gastrointestinal haemorrhage for users of non-selective NSAIDs (adjusted rate ratio 4.0 (95% confidence intervals 2.3 to 6.9)), diclofenac plus misoprostol (3.0 (1.7 to 5.6)), and rofecoxib (1.9 (1.3 to 2.8)) but not celecoxib (1.0 (0.7 to 1.6)). Relative to celecoxib, significantly higher risks of upper gastrointestinal haemorrhage were observed for non-selective NSAIDs (4.4 (2.3 to 8.5)), diclofenac plus misoprostol (3.2 (1.6 to 6.5)), and rofecoxib (1.9 (1.2 to 2.8)). Relative to rofecoxib, non-selective NSAID users were at significantly higher risk of upper gastrointestinal haemorrhage (1.9 (1.0 to 3.5)).

CONCLUSIONS

This population based observational study found a lower short term risk of upper gastrointestinal haemorrhage for selective COX-2 inhibitors compared with non-selective NSAIDs.

The different patterns of blood pressure elevation by rofecoxib and nabumetone

Hypertension and knee osteoarthritis (OA) are frequent comorbidities. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to relieve pain in such patients. In the last decade selective NSAIDs are used more commonly since they lead to less gastrointestinal complications. As has been shown, the treatment with NSAIDs may cause a mild rise of arterial blood pressure (BP). The influence of selective NSAIDs on BP, particularly in hypertensive patients has still to be investigated. The aim of this study was to determine arterial BP changes in patients suffering from stable arterial hypertension and knee OA and treated with rofecoxib or nabumetone. Two groups of patients with knee OA and stable arterial hypertension received either 25 mg rofecoxib once daily or namebutone 2000 mg once daily during the first week of treatment and 1000 mg for the following 3 weeks. Twenty-four hour arterial BP monitoring was performed prior to initiation of treatment and at the end of a 4-week period. The results were that no changes were found in the mean systolic and diastolic characteristics of BP in the rofecoxib treatment group during day time (delta systolic BP -0.4 mm Hg and delta diastolic BP -0.4 mm Hg), while nocturnal BP increased significantly: delta systolic BP +15.7 mm Hg and delta diastolic BP +8.5 mm Hg. The mean systolic arterial pressure in the nabumeton group raised delta systolic BP 2.9 mm Hg in the daytime and 5 mm Hg during the night-time after the treatment. The mean diastolic arterial pressure also rose delta diastolic 3.2 mm Hg and 4.9 mm Hg at day and night hours respectively. In conclusion rofecoxib treatment did not change arterial BP during day time hours, however, there was a distinct increase in night-time systolic and diastolic BP leading to a disappearance of the physiological diurnal variation. Nabumetone caused a moderate increase of day and night BP, without changes in biological diurnal variation.