Gastric acid suppressants--too much of a good thing?

Emerging role of mitochondrial DAMPs, aberrant mitochondrial dynamics and anomalous mitophagy in gut mucosal pathogenesis

Gastroduodenal inflammation and ulcerative injuries are increasing due to expanding socio-economic stress, unhealthy food habits-lifestyle, smoking, alcoholism and usage of medicines like non-steroidal anti-inflammatory drugs. In fact, gastrointestinal (GI) complications, associated with the prevailing COVID-19 pandemic, further, poses a challenge to global healthcare towards safeguarding the GI tract. Emerging evidences have discretely identified mitochondrial dysfunctions as common etiological denominators in diseases. However, it is worth realizing that mitochondrial dysfunctions are not just consequences of diseases. Rather, damaged mitochondria severely aggravate the pathogenesis thereby qualifying as perpetrable factors worth of prophylactic and therapeutic targeting. Oxidative and nitrosative stress due to endogenous and exogenous stimuli triggers mitochondrial injury causing production of mitochondrial damage associated molecular patterns (mtDAMPs), which, in a feed-forward loop, inflicts inflammatory tissue damage. Mitochondrial structural dynamics and mitophagy are crucial quality control parameters determining the extent of mitopathology and disease outcomes. Interestingly, apart from endogenous factors, mitochondria also crosstalk and in turn get detrimentally affected by gut pathobionts colonized during luminal dysbiosis. Although mitopathology is documented in various pre-clinical/clinical studies, a comprehensive account appreciating the mitochondrial basis of GI mucosal pathologies is largely lacking. Here we critically discuss the molecular events impinging on mitochondria along with the interplay of mitochondria-derived factors in fueling mucosal pathogenesis. We specifically emphasize on the potential role of aberrant mitochondrial dynamics, anomalous mitophagy, mitochondrial lipoxidation and ferroptosis as emerging regulators of GI mucosal pathogenesis. We finally discuss about the prospect of mitochondrial targeting for next-generation drug discovery against GI disorders.

Effect of electronic medication reconciliation at the time of hospital discharge on inappropriate medication use in the community: an interrupted time-series analysis

BACKGROUND

It is unclear if enhanced electronic medication reconciliation systems can reduce inappropriate medication use and improve patient care. We evaluated trends in potentially inappropriate medication use after hospital discharge before and after adoption of an electronic medication reconciliation system.

METHODS

We conducted an interrupted time-series analysis in 3 tertiary care hospitals in London, Ontario, using linked health care data (2011-2019). We included patients aged 66 years and older who were discharged from hospital. Starting between Apr. 13 and May 21, 2014, physicians were required to complete an electronic medication reconciliation module for each discharged patient. As a process outcome, we evaluated the proportion of patients who continued to receive a benzodiazepine, antipsychotic or gastric acid suppressant as an outpatient when these medications were first started during the hospital stay. The clinical outcome was a return to hospital within 90 days of discharge with a fall or fracture among patients who received a new benzodiazepine or antipsychotic during their hospital stay. We used segmented linear regression for the analysis.

RESULTS

We identified 15 932 patients with a total of 18 405 hospital discharge episodes. Before the implementation of the electronic medication reconciliation system, 16.3% of patients received a prescription for a benzodiazepine, antipsychotic or gastric acid suppressant after their hospital stay. After implementation, there was a significant and immediate 7.0% absolute decline in this proportion (95% confidence interval [CI] 4.5% to 9.5%). Before implementation, 4.1% of discharged patients who newly received a benzodiazepine or antipsychotic returned to hospital with a fracture or fall within 90 days. After implementation, there was a significant and immediate 2.3% absolute decline in this outcome (95% CI 0.3% to 4.3%).

INTERPRETATION

Implementation of an electronic medication reconciliation system in 3 tertiary care hospitals reduced potentially inappropriate medication use and associated adverse events when patients transitioned back to the community. Enhanced electronic medication reconciliation systems may allow other hospitals to improve patient safety.

Acid-suppressive agents and survival outcomes in patients with cancer: a systematic review and meta-analysis

BACKGROUND

Patients with cancer often receive acid-suppressive agents (ASAs) to treat common gastroesophageal reflux and peptic ulcer diseases. Our systematic review addresses the association between ASAs and survival outcomes in these patients.

METHODS

We searched MEDLINE, EMBASE, and Cochrane until December 2019, including randomized controlled trials (RCTs), quasi-RCTs, and observational studies concerning ASAs that reported progression-free survival (PFS) and/or overall survival (OS). We estimated hazard ratios (HRs) with 95% confidence intervals (CIs) using the random-effects model, and assessed heterogeneity with I² statistic.

RESULTS

We included 45,626 patients from 7 RCTs and 18 observational studies, including esophageal/gastric, colorectal, pancreatic, lung, breast, prostate, kidney, and other cancers. Five studies showed that ASAs in lung cancer patients received tyrosine kinase inhibitors (TKIs) had significantly worse PFS (HR 1.64, 95% CI 1.14 - 2.37, I² = 57%) and OS (HR 1.13, 95% CI 1.05 - 1.21, I² = 0%) than nonusers. Each of five studies found no significant association between ASAs and OS in esophageal/gastric (HR 0.91, 95% CI 0.77 - 1.09, I² = 32%) or colorectal cancer patients (HR 1.33, 95% CI 0.96- 1.85, I² = 0%). ASAs were not significantly associated with an OS in patients with kidney cancer (HR 1.04, 95% CI 0.96 - 1.13, I² = 28%).

CONCLUSIONS

Meta-analysis showed that ASAs significantly associated with an increased mortality risk in lung cancer patients treated TKIs, but not in patients with esophageal/gastric, colorectal, or kidney cancer. Until further studies confirm these results, caution should be used when administering ASAs and TKIs to patients with lung cancer.

We have had a gutful: The need for deprescribing proton pump inhibitors

WHAT IS KNOWN AND OBJECTIVE

Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue.

METHODS

Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review.

RESULTS AND DISCUSSION

Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications.

WHAT IS NEW AND CONCLUSION

Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

Confounding in the association of proton pump inhibitor use with risk of community-acquired pneumonia

BACKGROUND

Use of proton pump inhibitors (PPIs) is associated with community-acquired pneumonia (CAP), an association which may be confounded by unobserved patient and prescriber characteristics.

OBJECTIVE

We assessed for confounding in the association between PPI use and CAP by using a 'falsification approach,' which estimated whether PPI use is also implausibly associated with other common medical conditions for which no known pathophysiologic link exists.

DESIGN

Retrospective claims-based cohort study.

SETTING

Six private U.S. health plans.

SUBJECTS

Individuals who filled at least one prescription for a PPI (N = 26,436) and those who never did (N = 28,054) over 11 years.

INTERVENTIONS

Multivariate linear regression of the association between a filled prescription for a PPI and a diagnosis of CAP in each 3-month quarter. In falsification analyses, we tested for implausible associations between PPI use in each quarter and rates of osteoarthritis, chest pain, urinary tract infection (UTI), deep venous thrombosis (DVT), skin infection, and rheumatoid arthritis. Independent variables included an indicator for whether a prescription for a PPI was filled in a given quarter, and quarterly indicators for various co-morbidities, age, income, geographic location, and marital status.

KEY RESULTS

Compared to nonusers, those ever using a PPI had higher adjusted rates of CAP in quarters in which no prescription was filled (68 vs. 61 cases per 10,000 persons, p < 0.001). Similar associations were noted for all conditions (e.g. chest pain, 336 vs. 282 cases, p < 0.001; UTI, 151 vs. 139 cases, p < 0.001). Among those ever using a PPI, quarters in which a prescription was filled were associated with higher adjusted rates of CAP (111 vs. 68 cases per 10,000, p < 0.001) and all other conditions (e.g. chest pain, 597 vs. 336 cases, p < 0.001; UTI, 186 vs. 151 cases, p < 0.001), compared to quarters in which no prescription was filled.

CONCLUSION

PPI use is associated with CAP, but also implausibly associated with common medical conditions. Observed associations between PPI use and CAP may be confounded.