Prevention and treatment of gastrointestinal symptoms and complications due to NSAIDs

Gastroesophageal reflux disease in Sri Lanka: An island-wide epidemiological survey assessing the prevalence and associated factors

Gastroesophageal reflux disease (GERD) is commonly encountered in clinical practice in Sri Lanka. However, its prevalence in Sri Lanka is unknown. Our objective was to study the island-wide prevalence of GERD symptoms in Sri Lanka and its associated factors. A total of 1200 individuals aged 18-70 years (male: female 1: 1.16, mean age 42.7 years [SD 14.4 years]). were recruited from all 25 districts of the country, using stratified random sampling. An interviewer-administered, country-validated questionnaire was used to assess the GERD symptom prevalence and associated factors. Weight, height, waist, and hip circumference were measured. Heartburn and/or regurgitation at least once a week, an internationally used criterion for probable GERD was used to diagnose GERD. In this study, GERD symptom prevalence was 25.3% (male 42.1% and female 57.9%). Factors independently associated with GERD were inadequate sleep, snacking at midnight, sleeping within two hours of consuming a meal, skipping breakfast, increased mental stress, and certain medications used such as statins, and antihypertensive medications (p<0.001, univariate and logistic regression analysis). 38.4% of the study population have been using medication for heartburn and regurgitation in the past 3 months and 19.8% were on proton pump inhibitors. To conclude, the prevalence of GERD symptoms in Sri Lanka (25.3%) is higher than its estimated global prevalence of 13.8%. Several meal-related lifestyle habits, mental stress, and the use of some medications are significantly associated with GERD, indicating the importance of lifestyle modification and stress reduction in its management.

Evidence construction of Chinese herbal formulae for the treatment of H. pylori positive peptic ulcer: A Bayesian network Meta-analysis

PURPOSE

Helicobacter pylori (H. pylori) positive peptic ulcer disease (PUD) is a highly prevalent digestive disease with serious consequences of poor prognosis without rational medical intervention. Apparent advantages of Chinese herbal formulae application in PUDs have been appreciated by clinical practitioners recently in China. However, there is no enough viewpoint of evidence-based medicine for them to reach a broad consensus at the more favorable formulae. Therefore, we adopted the method of Bayesian network Meta-analysis (BNMA) in order to get a solution.

METHOD

Literature retrieval of clinical randomized controlled trials (RCTs) was conducted with eight databases of PubMed, Embase, Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure, the VIP medicine information system, the Wanfang Data Knowledge Service Platform and Chinese Biomedical Literature Service System. Review Manager 5.4 software, R project 4.1.1 software and STATA16.0 software were used to carry out this BNMA. The primary outcome indicator is H. pylori eradicated rate. The secondary outcome indicator is clinical effectiveness rate, recurrence rate and adverse reaction report.

RESULT

A total of fifty-one RCTs involving 5172 patients and ten therapeutic strategies were included in this BNMA. The results showed that supplementation with Chinese herbal formulae significantly improved the eradication rate, clinical efficiency and reduced recurrence rate of H. pylori compared with the single conventional triple therapy (CON) group in a relatively safe manner. Comprehensive therapeutic efficacy analysis of H. pylori eradicated rate and clinical effectiveness rate showed that CON combined with Xiangsha Liujunzi decoction (XSD) manifests at the first grade among these ten therapeutic strategies.

CONCLUSION

The efficacy and safety of Chinese herbal formulae and conventional triple therapy were validated by this BNMA. CON+XSD appears to be the most satisfactory therapeutic strategy for H. pylori-positive PUD, reminding clinicians of the potential value of the combination of Chinese herbal formulae and conventional chemotherapy.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021268574.

Global Prevalence and Risk Factors of Gastro-oesophageal Reflux Disease (GORD): Systematic Review with Meta-analysis

Although gastro-oesophageal reflux disease (GORD) is a common medical complaint, there is currently no consensus on the global prevalence of GORD. The aim of this study was to conduct a systematic review and meta-analysis on GORD prevalence and risk factors at a global level. MEDLINE, EMBASE, CINAHL, Scopus, Cochrane library, and Google Scholar were systematically searched, without language restrictions, for studies on the prevalence and risk factors of GORD. Data were pooled using a random effects model (95% confidence interval), and the odds ratio and relative risk for each risk factor were calculated. Out of 34,355 search results, 96 records reporting the results from 102 studies fulfilled the inclusion criteria, representing 37 countries and all regions of the UN geoscheme. The global pooled prevalence of GORD was 13.98% and varied greatly according to region (12.88% in Latin America and the Caribbean to 19.55% in North America) and country (4.16% in China to 22.40% in Turkey). Using the United Nations 2017 Revision of World Population Prospects, the estimated number of individuals suffering from GORD globally is 1.03 billion. Multiple risk factors associated with a significant increase in the risk of GORD were also identified. This systematic review and meta-analysis revealed that although a substantial proportion (13.98%) of the global population suffers from GORD, there are significant variations between regions and countries. Risk factors for GORD were also identified which may allow clinicians to recognise individuals most at risk.

Acute Pain Management

Acute pain management is improving steadily over the past few years, but training and professional education are still lacking in many professions. Untreated or undertreated acute pain could have detrimental effects on the patient in terms of comfort and recovery from trauma or surgery. Acute undertreated pain can decrease a patient's vascular perfusion, increase oxygen demand, suppress the immune system, and possibly risk increased incidence of venous thrombosis. Although acute postoperative pain needs to be managed aggressively, patients are most vulnerable during this period for developing adverse effects, and therefore, patient assessment and careful drug therapy evaluation are necessary processes in therapeutic planning. Acute pain management requires careful and thorough initial assessment and follow-up reassessment in addition to frequent dosage adjustments, and managing analgesic induced side effects. Analgesic selection and dosing must be based on the patient's past and recent analgesic exposure. There is no single acute pain management regimen that is suitable for all patients. Analgesics must be tailored to the individual patient.

A comparative study of DA-9601 and misoprostol for prevention of NSAID-associated gastroduodenal injury in patients undergoing chronic NSAID treatment

Misoprostol is reported to prevent non-steroidal anti-inflammatory drug (NSAID)-associated gastroduodenal complications. There is, however, limited information regarding the efficacy of DA-9601 in this context. We performed a comparative study on the relative efficacy of DA-9601 and misoprostol for prevention of NSAID-associated complications. In this multicenter, double-blinded, active-controlled, stratified randomized, parallel group, non-inferiority trial, 520 patients who were to be treated with an NSAID (aceclofenac, 100 mg, twice daily) over a 4-week period were randomly assigned to groups for coincidental treatment with DA-9601 (60 mg, thrice daily) (236 patients for full analysis) or misoprostol (200 μg, thrice daily) (242 patients for full analysis). A total of 236 patients received DA-9601 and 242 received misoprostol. The primary endpoint was the gastric protection rate, and secondary endpoints were the duodenal protection rate and ulcer incidence rate. Endpoints were assessed by endoscopy after the 4-week treatment period. Drug-related adverse effects, including gastrointestinal (GI) symptoms, were also compared. At week 4, the gastric protection rates with DA-9601 and misoprostol were 81.4 % (192/236) and 89.3 % (216/242), respectively. The difference between the groups was −14.2 %, indicating non-inferiority of DA-9601 to misoprostol. Adverse event rates were not different between the two groups; however, the total scores for GI symptoms before and after administration were significantly lower in the DA-9601 group than in the misoprostol group (−0.2 ± 2.8 vs 1.2 ± 3.2; p < 0.0001). DA-9601 is as effective as misoprostol in preventing NSAID-associated gastroduodenal complications, and has a superior adverse GI effect profile.

Efficacy and gastrointestinal risk of aspirin used for the treatment of pain and cold

AIMS

To analyse major sources of evidence-based information on the efficacy and gastrointestinal tolerability of aspirin, used short-term, in over-the-counter (OTC) doses, to relieve acute pain and cold symptoms, including associated feverishness.

METHODS

Evidence was largely collected from published meta-analyses and systematic reviews that focused on randomised, controlled, double-blind clinical trials, in which aspirin was compared to placebo and, in some cases also, to active comparators such as OTC doses of paracetamol or ibuprofen.

RESULTS

Across a large number of comparisons, aspirin was superior to placebo in treating pain, cold or fever. Efficacy was essentially similar to that of comparators used in equivalent doses. There was no serious GI adverse event attributed to ASA in any study, but mild-to-moderate dyspepsia in small percentages of cases was commonly reported.

CONCLUSION

OTC aspirin is safe and effective. Safety concerns should not limit brief use to relieve acute pain, cold or fever.

Interobserver variation in the endoscopic diagnosis of gastroduodenal ulcer scars: implications for clinical management of NSAIDs users

Background

A clinical history of peptic ulcer has been reported to be associated with a high rate of ulcer recurrence in nonsteroidal anti-inflammatory drug (NSAID) users. Therefore, it is a very important issue to precisely know the previous history prior to NSAIDs administration. To clarify the possible difficulty to identify the history, we determined the sensitivity and diagnostic concordance of endoscopy for the identification of ulcer scars indicative of previous clinical history of peptic ulcer diseases.

Methods

The first study enrolled 200 consecutive patients with a clinical history of gastric or duodenal ulcers previously confirmed by esophagogastroduodenoscopy. The sensitivity of endoscopy for identifying scars was determined for these patients. In the second study, the extent of interobserver agreement was determined for 47 endoscopists who identified ulcer scars in endoscopic photographs of 30 sites of previous active gastric ulcers and 30 sites of previous active duodenal ulcers. The kappa coefficient of reliability was calculated to measure the interobserver agreement on the diagnosis of ulcer scars.

Results

Out of 190 patients eligible for analysis, 104 (54.7%) were found to have gastric or duodenal ulcer scars on endoscopy; there were no gastric or duodenal ulcer scars seen in the remaining patients (45%). In the second study, the kappa values for endoscopic diagnosis of gastric and duodenal ulcer scars were 0.14 (95% CI 0.13-0.16) and 0.29 (95% CI 0.27-0.32), respectively. The addition of indigo-carmine chromoendoscopy did not provide a statistically significant improvement in diagnostic concordance in patients with gastric ulcer scar since the kappa value for chromoendoscopic diagnosis was 0.15; 95% CI 0.13-0.17 as low as for un-contrasted scars.

Conclusions

The sensitivity and concordance of endoscopic diagnosis of gastric and duodenal ulcer scars are not satisfactory for the use of endoscopy only to identify previous ulcer disease. To avoid the overlooking the previous clinical history of peptic ulcer diseases, the diagnosis of peptic ulcer scar has to be carefully done prior to NSAIDs administration.

Systematic review of the symptom burden, quality of life impairment and costs associated with peptic ulcer disease

BACKGROUND

Management of peptic ulcer disease has improved over the past few decades. However, the widespread use of nonsteroidal anti-inflammatory drugs and low-dose acetylsalicylic acid means that the burden of peptic ulcer disease remains a relevant issue.

METHODS

We systematically searched PubMed and EMBASE for articles published 1966-2007 that reported symptoms, impairment of well-being or health-related quality of life, and costs associated with peptic ulcer disease.

RESULTS

Thirty studies reported the prevalence of patient-reported gastrointestinal symptoms in individuals with endoscopically diagnosed symptomatic peptic ulcer disease. Average prevalence estimates, weighted by sample size, were 81% (95% confidence interval [CI], 77%-85%) for abdominal pain (11 studies), 81% (95% CI, 76%-85%) for pain specifically of epigastric origin (14 studies), and 46% (95% CI, 42%-50%) for heartburn or acid regurgitation (11 studies). On average, 29% (95% CI, 25%-34%) of patients with peptic ulcer disease presented with bleeding, often as the initial symptom (11 studies). Patients with peptic ulcer disease had significantly lower health-related quality of life than the general population, as measured by the Psychological General Well-Being index (P <.05; 7 studies) and the Short-Form-36 questionnaire (P <.05; 2 studies). Direct medical costs of peptic ulcer disease based on national estimates from several countries were USD163-866 per patient. The most costly aspects of peptic ulcer disease management were hospitalization and medication. Complicated peptic ulcer disease is particularly costly, estimated to be USD1883-25,444 per patient.

CONCLUSION

Peptic ulcer disease significantly impairs well-being and aspects of health-related quality of life, and is associated with high costs for employers and health care systems.

Aspirin in cardiology--benefits and risks

AIMS

To review the current knowledge of the benefits and risks of long-term aspirin therapy for the prevention of cardiovascular disease.

METHODS

Relevant articles published in English between 1996 and 2006 were obtained from the Current Contents Science Edition, EMBASE and MEDLINE databases.

RESULTS

Secondary aspirin prophylaxis is effective in reducing the risk of ischaemic events in patients with cardiovascular disease. However, its utility in reducing primary ischaemic events is more controversial; it appears to reduce the incidence of ischaemic stroke, but increase the incidence of haemorrhagic stroke. Aspirin therapy can also lead to an increased risk of gastrointestinal ulcers, upper gastrointestinal bleeding and other haemorrhagic complications. Lower doses of aspirin are associated with a reduced risk of gastrointestinal side effects and are equally effective in reducing cardiovascular risk. Co-therapy with non-steroidal anti-inflammatory drugs, clopidogrel or warfarin increases the risk of gastrointestinal side effects, while co-therapy with proton pump inhibitors reduces it.

CONCLUSIONS

Both the benefits and risks need to be considered carefully when prescribing aspirin, particularly in primary prevention. Patients should be prescribed lower doses rather than higher doses of aspirin in line with prescribing guidelines. Co-prescription of a proton pump inhibitors may be necessary in patients at high risk for upper gastrointestinal complications.

Efficacy of esomeprazole for resolution of symptoms of heartburn and acid regurgitation in continuous users of non-steroidal anti-inflammatory drugs

BACKGROUND

The use of non-steroidal anti-inflammatory drugs (NSAIDs) is often associated with upper gastrointestinal symptoms such as heartburn and acid regurgitation.

AIM

To assess the efficacy of esomeprazole 20 and 40 mg for resolution of heartburn and acid regurgitation in continuous NSAIDs.

METHODS

A post hoc analysis of five clinical trials was performed. Two identically designed, placebo-controlled, 4-week studies (NASA1, SPACE1) enrolled non-ulcer, NSAIDs-treated patients with upper abdominal pain, discomfort or burning. PLUTO and VENUS were identically designed, placebo-controlled, 6-month studies that enrolled patients at risk of NSAIDs-induced ulcers. Study 285 was an 8-week comparative study with ranitidine (300 mg/day) in patients with NSAIDs-induced gastric ulcers. Resolution of investigator-assessed heartburn and acid regurgitation was defined as symptom severity of 'none' in the last 7 days.

RESULTS

In NASA1/SPACE1, heartburn resolved in 61% and 62% of patients taking esomeprazole 20 and 40 mg, respectively (vs. 36% on placebo, P < 0.001), and acid regurgitation resolved in 65% and 67% (vs. 48%, P < 0.001). Resolution of both symptoms was greater with esomeprazole than with placebo in PLUTO/VENUS (P <or= 0.001), and than with ranitidine in study 285 (P < 0.05 for esomeprazole 20 mg).

CONCLUSION

Heartburn and regurgitation are common in patients taking NSAIDs and esomeprazole is efficacious for resolution of these symptoms.

Clinical implications of cyclo-oxygenase-2 inhibitors for acute dental pain management: benefits and risks

BACKGROUND; Cyclo-oxygenase-2 inhibitors (COX-2i) demonstrate analgesic efficacy for patients who require gastrointestinal safety. The authors discuss the potential benefits and risks of these novel, but expensive, analgesics when used in dentistry.

METHODS

The authors conducted a MEDLINE search focused on the subject headings of common analgesic drugs and COX-2i, using peer-reviewed journals limited to the English language. They selected for review 127 articles that met the criteria. They also tried to identify any randomized controlled trials pertinent to dentistry and indicative of evidence-based medicine. RESULTS. When comparing COX isoforms (COX-1 and COX-2), the authors found that overlapping and mutually exclusively properties coexist. COX-2i originally were developed to minimize interference with the gastroprotective properties of the COX-1 isoform, while selectively preventing prostanoid synthesis expressed solely at sites of bodily trauma or other inflammation. COX-2i were found to provide pain relief equal to or slightly exceeding that offered by many mild narcotics. They may avoid some of the serious side effects that can occur with even short-term use of nonselective nonsteroidal anti-inflammatory drugs.

CONCLUSIONS

The pharmacodynamics of COX-2i reveal an agent that includes analgesic, anti-inflammatory and gastroprotective properties but also allows for an undesirable disruption of the delicate hemodynamic balance.

CLINICAL IMPLICATIONS

Symptomatic and asymptomatic gastroparietic patients who do not have severe cardiovascular, cerebral or renal ischemic disease benefit from use of COX-2i. Long-term use of these agents in medically compromised patients may prove disastrous.

Lansoprazole prevents experimental gastric injury induced by non-steroidal anti-inflammatory drugs through a reduction of mucosal oxidative damage

AIM: This study investigated the mechanisms of protection afforded by the proton pump inhibitor lansoprazole against gastric injury induced by different non-steroidal anti-inflammatory drugs (NSAIDs) in rats.

METHODS: Male Sprague-Dawley rats were orally treated with indomethacin (100 µmol/kg), diclofenac (60 µmol/kg), piroxicam (150 µmol/kg) or ketoprofen (150 µmol/kg). Thirty minutes before NSAIDs, animals were orally treated with lansoprazole 18 or 90 µmol/kg. Four hours after the end of treatments, the following parameters were assessed: gastric mucosal PGE2, malondialdehyde (MDA), myeloperoxidase (MPO) or non-proteic sulfhydryl compounds (GSH) levels; reverse transcription-polymerase chain reaction (RT-PCR) of mucosal COX-2 mRNA; gastric acid secretion in pylorus-ligated animals; in vitro effects of lansoprazole (1-300 µmol/L) on the oxidation of low density lipoproteins (LDLs) induced by copper sulphate.

RESULTS: All NSAIDs elicited mucosal necrotic lesions which were associated with neutrophil infiltration and reduction of PGE2 levels. Increments of MPO and MDA contents, as well as a decrease in GSH levels were detected in the gastric mucosa of indomethacin- or piroxicam-treated animals. Indomethacin enhanced mucosal cyclooxygenase-2 expression, while not affecting cyclooxygenase-1. At the oral dose of 18 µmol/kg lansoprazole partly counteracted diclofenac-induced mucosal damage, whereas at 90 µmol/kg it markedly prevented injuries evoked by all test NSAIDs. Lansoprazole at 90 µmol/kg reversed also the effects of NSAIDs on MPO, MDA and GSH mucosal contents, without interfering with the decrease in PGE2 levels or indomethacin-induced cyclooxygenase-2 expression. However, both lansoprazole doses markedly inhibited acid secretion in pylorus-ligated rats. Lansoprazole concentration-dependently reduced the oxidation of LDLs in vitro.

CONCLUSION: These results suggest that, besides the inhibition of acid secretion, lansoprazole protection against NSAID-induced gastric damage depends on a reduction in mucosal oxidative injury, which is also responsible for an increment of sulfhydryl radical bioavailability. It is also suggested that lansoprazole does not influence the down-regulation of gastric prostaglandin production associated with NSAID treatment.