Sucralfate therapy in NSAID bleeding gastropathy

Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review

BACKGROUND

Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situations will be addressed (from the ENT/pulmonary sphere, gastrointestinal - urogenital tract and cutaneous ulcers). Finally, an algorithm pertaining to the management of catastrophic bleeding is proposed.

METHODS

Electronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were studied as primary resources, in association with local guidelines, to identify papers exploring platelet transfusions and alternative management of site-specific bleeding in palliative care patients.

RESULTS

Haemorrhagic complications are frequent in palliative care patients in the internal medicine ward. Current guidelines propose a therapeutic-only platelet transfusion policy. Nonetheless, prophylactic and/or therapeutic transfusion remains a physician-dependent decision. Site-specific therapeutic options are based on expert opinion and case reports. While invasive measures may be pertinent in certain situations, their application must be compatible with patient goals. Catastrophic bleeding requires caregivers' comforting presence; pharmacological management is secondary.

CONCLUSION

Literature is lacking regarding management of bleeding in the palliative care population hospitalised in an acute medical setting. Recommendations are of limited quality, the majority based on case reports or expert opinion. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication.

Gastroprotectants in small animal veterinary practice - a review of the evidence. Part 1: cyto-protective drugs

Diverse drugs with presumed cytoprotective effect have been used therapeutically in small animal veterinary practice for various gastro-intestinal conditions such as oesophagitis, gastric ulceration, gastritis or chronic gastro-enteropathies. Their efficacy has been doubted in human medicine, raising similar questions in the veterinary field. The aim of this review was to assess the current evidence on the efficacy and safety of these drugs in dogs and cats. Through a systematic review of the literature, we identified 37 articles on the use of misoprostol, sucralfate and other gastroprotectants in dogs and cats. There was evidence to support use of misoprostol in the prevention of aspirin-induced gastroduodenal mucosal injury in dogs, and for use of sucralfate in the prevention of acid-induced oesophagitis in cats. However, the overall quality of evidence supporting the use of these drugs in small animal patients was poor. In contrast, there was evidence of important adverse effects, especially drug interaction and gastro-intestinal signs. We therefore recommend prescribing these drugs with caution until further well-conducted studies reveal a useful gastroprotectant effect.

Complementarity of in vitro and in vivo models for the evaluation of gastro-protective effects of pharmacological substances

Gastric mucosa is frequently exposed to various gastric irritants, and there is a continuing requirement to develop new gastro-protective agents. This study compares the effects of three such agents, sucralfate, rebamipide, and cimetidine in both in vivo and in vitro indomethacin-induced gastric damage models. For the in vivo approach, rats were orally administered sucralfate, rebamipide, and cimetidine at 300 mg/kg before an acute dose of indomethacin (30 mg/kg). Gastric lesions were then macroscopically examined. For the in vitro approach, gastric mucosal cells were incubated with sucralfate (3 and 5 mg/mL), rebamipide (0.3 and 1 mm), and cimetidine (10 and 50 μg/mL) before exposure to indomethacin (3.8 mm). The release of lactate dehydrogenase (LDH) and mitochondrial function were then measured. Sucralfate, rebamipide, and cimetidine displayed gastro-protective effects in vivo (decreased number of gastric ulcers: -50% P < 0.05, -22% NS, and -69% P < 0.05, respectively, and reduced length of gastric lesions: -62% P < 0.05, -29% NS, and -70% P < 0.001, respectively). Cell damage induced by indomethacin in vitro was inhibited by sucralfate (LDH release) and by rebamipide and cimetidine (mitochondrial function and LDH release). In contrast, sucralfate accentuated the indomethacin-induced decrease in mitochondrial function. Although cultured gastric cells offer a promising tool for evaluating the cytotoxic or protective effects of test compounds, data from in vivo models are still needed to confirm in vitro data. Using both approaches provides more comprehensive insight into the effects of test compounds on the gastric mucosa.

Minimizing risks of NSAIDs: cardiovascular, gastrointestinal and renal

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating inflammation, pain and fever, but their cardiovascular, renal and gastrointestinal toxicity can result in significant morbidity and mortality to patients. Techniques for minimizing the adverse risks of NSAIDs include avoiding use of NSAIDs where possible, particularly in high-risk patients; keeping NSAID dosages low; prescribing modified-release and enteric-coated NSAIDs; prescribing cyclooxygenase-2-selective inhibitors where appropriate; monitoring for early signs of side effects; prescribing treatments designed to minimize NSAID side effects; and developing new therapeutic strategies beyond the inhibition of cyclooxygenase. All of the above strategies can be useful in reducing the risk of NSAID complications. The optimal use and management of NSAIDs involves an individualized paradigm approach to establish efficacy with optimal tolerability given the patient risk factors for adverse events.

Burden of nonsteroidal anti-inflammatory and antiplatelet drug use in Asia: a multidisciplinary working party report

BACKGROUND & AIMS

We established a working group to examine the burden of atherothrombotic and musculoskeletal diseases in Asia and made recommendations for safer prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin.

METHODS

By using a modified Delphi process, consensus was reached among 12 multidisciplinary experts from Asia. Statements were developed by the steering committee after a literature review, modified, and then approved through 3 rounds of anonymous voting by using a 6-point scale from A+ (strongly agree) to D+ (strongly disagree). Agreement (A+/A) by ≥ 80% of panelists was defined a priori as consensus.

RESULTS

We identified unique aspects of atherothrombotic and musculoskeletal diseases in Asia. Asia has a lower prevalence of degenerative arthritis and coronary artery disease than Western countries. The age-adjusted mortality of coronary artery disease is lower in Asia; cerebrovascular accident has higher mortality than coronary artery disease. Ischemia has replaced hemorrhage as the predominant pattern of cerebrovascular accident. Low-dose aspirin use is less prevalent in Asia than in Western countries. Traditional Chinese medicine and mucoprotective agents are commonly used in Asia, but their efficacy is not established. For Asian populations, little is known about complications of the lower gastrointestinal tract from use of NSAIDs and underutilization of gastroprotective agents. Our recommendations for preventing ulcer bleeding among users of these drugs who are at high risk for these complications were largely derived from Asian studies and are similar to Western guidelines.

CONCLUSIONS

By using an evidence-based, multidisciplinary approach, we have identified unique aspects of musculoskeletal and atherothrombotic diseases and strategies for preventing NSAID-related and low-dose aspirin-related gastrointestinal toxicity in Asia.

A fixed dose combination of ibuprofen and famotidine

The NSAID class of medications is frequently used for mild to moderate pain. While overall safe, NSAIDs have several important adverse effects including esophageal, gastric and duodenal ulceration which limit their use. This has led to the development of NSAIDs with either less gastrointestinal side effects or concurrent use of medications to prevent NSAID gastrointestinal side effects. While several classes of medications exist for the prevention of gastrointestinal side effects, few combination treatments are available in a single pill. Towards this end, a combination pill of ibuprofen and famotidine (HZT-501, Horizon Therapeutics, Skokie, IL. USA) has been developed.