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Liberman P, Thorne J, Burkholder B, Berkenstock MK. Effectiveness of difluprednate in addition to systemic therapy for the treatment of anterior scleritis. Br J Ophthalmol 2024; 108:951-955. [PMID: 37666642 DOI: 10.1136/bjo-2022-322841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 08/01/2023] [Indexed: 09/06/2023]
Abstract
AIM To describe the effectiveness and side-effect profile of adding difluprednate therapy to patients with anterior scleritis being treated systemically. METHODS Retrospective chart review. Charts from all patients with anterior scleritis who were treated with topical difluprednate in addition to systemic therapy from 1 January 2018 to 1 January 2020 were reviewed. Data collected included: demographics, scleritis type, systemic diagnosis, presence of nodules or necrosis, changes in scleritis activity, intraocular pressure (IOP), number of difluprednate drops used, type of systemic treatment used, best-corrected visual acuity (BCVA) and lens status. The primary outcome was clinical resolution of scleritis. Secondary outcomes included BCVA loss ≥2 lines, change in lens status or cataract surgery and IOP ≥24 mm Hg. RESULTS Thirty-two patients (44 eyes) were analysed. The median age was 57 years (IQR 52, 72); 59% were female; 72% were Caucasian. An associated systemic disease was present in 59%. Systemic therapies used when difluprednate was added were: 65% immunosuppressive agents, 43% prednisone and 25% non-steroidal anti-inflammatory drugs. The addition of difluprednate resulted in clinical resolution in 79.6% of the treated eyes. Median time to inactivity was 9 weeks (IQR 5, 20). Eyes initially using 2-4 drops per day had a higher response rate (89%, p=0.005). Over a median follow-up of 34 weeks (IQR 21, 74), 11 eyes had IOP elevation; 6 eyes lost ≥2 lines of BCVA, 5 eyes had cataract progression. CONCLUSION Most eyes treated with difluprednate achieved inactivity. The addition of difluprednate to systemic therapies provides an alternative to achieve control of inflammation.
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Affiliation(s)
- Paulina Liberman
- Departamento de Oftalmologia, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Ocular Immunology Division, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Thorne
- Ocular Immunology Division, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Biostatistics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bryn Burkholder
- Ocular Immunology Division, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Meghan K Berkenstock
- Ocular Immunology Division, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Nguyen NT, Nguyen BPT, Ho TN, Tran CND, Tran THH, Nguyen HPH, Nguyen HP, Huynh NT, Li Y, Phan VHG, Thambi T. Orally ingestible medication utilizing layered double hydroxide nanoparticles strengthened alginate and hyaluronic acid-based hydrogel bead for bowel disease management. Int J Biol Macromol 2024; 269:132122. [PMID: 38718992 DOI: 10.1016/j.ijbiomac.2024.132122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/30/2024] [Accepted: 05/04/2024] [Indexed: 05/30/2024]
Abstract
In the treatment of bowel diseases such as ulcerative colitis through oral administration, an effective drug delivery system targeting the colon is crucial for enhancing efficacy and minimizing side effects of therapeutic agents. This study focuses on the development of a novel nanocomposite hydrogel bead comprising a synergistic blend of biological macromolecules, namely sodium alginate (ALG) and hyaluronic acid (HA), reinforced with layered double hydroxide nanoparticles (LDHs) for the oral delivery of dual therapeutics. The synthesized hydrogel bead exhibits significantly enhanced gel strength and controllable release of methylprednisolone (MP) and curcumin (CUR), serving as an anti-inflammatory drug and a mucosal healing agent, compared to native ALG or ALG/HA hydrogel beads without LDHs. The physicochemical properties of the synthesized LDHs and hydrogel beads were characterized using various techniques, including scanning electron microscopy, zeta potential measurement, transmission electron microscopy, X-ray diffraction, and energy-dispersive X-ray spectroscopy. In vitro release studies of MP and CUR under simulated gastrointestinal tract (GIT) conditions demonstrate the superior controlled release property of the nanocomposite hydrogel bead, particularly in minimizing premature drug release in the upper GIT environment while sustaining release of over 82 % of drugs in the colonic environment. Thus, the modularly engineered carrier designed for oral colon targeting holds promise as a potential candidate for the treatment of ulcerative colitis.
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Affiliation(s)
- Ngoc Tuan Nguyen
- Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam.
| | - Bich-Phuong Thi Nguyen
- Biomaterials and Nanotechnology Research Group, Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | - Tuyet-Nhung Ho
- Biomaterials and Nanotechnology Research Group, Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | - Cam-Nhung Dinh Tran
- Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | - Thanh-Han Hoang Tran
- Biomaterials and Nanotechnology Research Group, Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | | | - Hong-Phuc Nguyen
- Biomaterials and Nanotechnology Research Group, Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | - Ngoc-Thuy Huynh
- Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | - Yi Li
- College of Materials and Textile Engineering & Nanotechnology Research Institute, Jiaxing University, Jiaxing 314001, Zhejiang, People's Republic of China.
| | - V H Giang Phan
- Biomaterials and Nanotechnology Research Group, Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam.
| | - Thavasyappan Thambi
- Graduate School of Biotechnology, College of Life Sciences, Kyung Hee University, Yongin-si, Gyeonggi-do 17104, Republic of Korea.
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Carvajal-Gutiérrez W, Cisneros-Cisneros MA, Calixto OJ, Meneses-Toro MA, Rueda AJP, Vega-Báez MA, Álvarez-Vargas DA, Uscátegui-Ruiz AC, Romero-Sanchez C, Bello-Gualtero JM. Low Frequency of Upper Gastrointestinal Bleeding Despite Non-Steroidal Anti-Inflammatory Drugs and Corticosteroids in Patients with Rheumatoid Arthritis. Curr Rheumatol Rev 2024; 20:555-562. [PMID: 38362696 DOI: 10.2174/0115733971290285240207080745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/19/2024] [Accepted: 01/25/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic inflammatory disease. It has been identified that non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids can be essential risk factors for developing complications such as upper gastrointestinal bleeding (UGIB). OBJECTIVE This study aimed to describe the safety profile of drugs used to treat RA focused in UGIB. METHODS A cross-sectional study of patients with RA between 2015 and 2021, a description of the population, and an evaluation of the relationship with UGIB through bivariate analysis and logistic regression. RESULTS Of 405 individuals, 16 presented UGIB (93.8% women, mean age was 65±13.6 years). No statistically significant differences were found regarding UGIB and medication use, except for the mean dose of corticosteroids. In the multivariate analysis, it was found that the presence of anemia in the last three months had an adjusted OR (AOR) of 16.1 (95% CI 2.74- 24.23) and higher HAQ values during the previous three months had an AOR of 6.17 (95% CI 1.79- 21.24). CONCLUSION This study found a low frequency of UGIB in patients with RA. More significant disability and anemia in the previous months were independently associated with UGIB. The low frequency of NSAID use in this population is noteworthy. In general, reasonable medication use related to this complication is recommended.
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Affiliation(s)
| | | | - Omar-Javier Calixto
- Rheumatology and Immunology Department, Hospital Militar Central, Bogotá, Colombia
- Clinical Immunology Group-Hospital Militar, School of Medicine, Universidad Militar Nueva Granada, Bogotá, Colombia
- Cellular and Molecular Immunology Group / INMUBO, Universidad El Bosque, Bogotá, Colombia
| | - Maria-Alejandra Meneses-Toro
- Rheumatology and Immunology Department, Hospital Militar Central, Bogotá, Colombia
- Clinical Immunology Group-Hospital Militar, School of Medicine, Universidad Militar Nueva Granada, Bogotá, Colombia
| | | | | | | | | | - Consuelo Romero-Sanchez
- Clinical Immunology Group-Hospital Militar, School of Medicine, Universidad Militar Nueva Granada, Bogotá, Colombia
- Cellular and Molecular Immunology Group / INMUBO, Universidad El Bosque, Bogotá, Colombia
| | - Juan-Manuel Bello-Gualtero
- Rheumatology and Immunology Department, Hospital Militar Central, Bogotá, Colombia
- Clinical Immunology Group-Hospital Militar, School of Medicine, Universidad Militar Nueva Granada, Bogotá, Colombia
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Degli Esposti L, Dovizio M, Perrone V, Veronesi C, Andretta M, Bacca M, Barbieri A, Bartolini F, Cavaliere A, Chinellato A, Ciaccia A, Cillo M, Citraro R, Costantini A, Dell'Orco S, Ferrante F, Gentile S, Grego S, Mancini D, Moscogiuri R, Mosele E, Pagliaro R, Procacci C, Re D, Santoleri F, Ubertazzo L, Vercellone A, Ramirez de Arellano A, Gigliotti G, Quartuccio L. Profile, Healthcare Resource Consumption and Related Costs in ANCA-Associated Vasculitis Patients: A Real-World Analysis in Italy. Adv Ther 2023; 40:5338-5353. [PMID: 37787877 PMCID: PMC10611841 DOI: 10.1007/s12325-023-02681-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/07/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are rare autoimmune diseases triggering inflammation of small vessels. This real-world analysis was focused on the most common AAV forms, granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), to describe patients' demographic and clinical characteristics, therapeutic management, disease progression, and the related economic burden. METHODS A retrospective analysis was conducted on administrative databases of a representative sample of Italian healthcare entities, covering approximately 12 million residents. Between January 2010 and December 2020, adult GPA patients were identified by payment waiver code or hospitalization discharge diagnosis, and MPA patients by payment waiver code with or without hospitalization discharge diagnosis. Clinical outcomes were evaluated through AAV-related hospitalizations, renal failure onset, and mortality. Economic analysis included healthcare resource utilization deriving from drugs, hospitalizations, and outpatient specialist services. The related mean direct costs year/patient were also calculated in patients stratified by presence/absence of glucocorticoid therapy and type of inclusion criterion (hospitalization/payment waiver code). RESULTS Overall, 859 AAV patients were divided into GPA (n = 713; 83%) and MPA (n = 146; 17%) cohorts. Outcome indicators highlighted a clinically worse phenotype associated with GPA compared to MPA. Cost analysis during follow-up showed tendentially increased expenditures in glucocorticoid-treated patients versus untreated (overall AAV: €8728 vs. €7911; GPA: €9292 vs. €9143; MPA: €5967 vs. €2390), mainly driven by drugs (AAV: €2404 vs. €874; GPA: €2510 vs. €878; MPA: €1881 vs. €854) and hospitalizations. CONCLUSION Among AAV forms, GPA resulted in a worse clinical picture, higher mortality, and increased costs. This is the first real-world pharmaco-economic analysis on AAV patients stratified by glucocorticoid use on disease management expenditures. In both GPA and MPA patients, glucocorticoid treatment resulted in higher healthcare costs, mostly attributable to medications, and then hospitalizations, confirming the clinical complexity and economic burden for management of patients with autoimmune diseases under chronic immunosuppression.
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Affiliation(s)
- Luca Degli Esposti
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, Via Murri, 9, 40137, Bologna, Italy.
| | - Melania Dovizio
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, Via Murri, 9, 40137, Bologna, Italy
| | - Valentina Perrone
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, Via Murri, 9, 40137, Bologna, Italy
| | - Chiara Veronesi
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, Via Murri, 9, 40137, Bologna, Italy
| | | | | | | | | | | | | | | | | | - Rita Citraro
- Dipartimento di Scienze della Salute, Università Magna Grecia di Catanzaro, Unità Operativa Di Farmacologia Clinica e Farmacovigilanza, Azienda Ospedaliero-Universitaria "Mater Domini", Catanzaro, Italy
| | | | | | | | - Simona Gentile
- Direzione Generale per la Salute Regione Molise, Campobasso, Italy
| | | | | | | | - Elena Mosele
- Azienda ULSS 7 Pedemontana, Bassano del Grappa, VI, Italy
| | | | | | | | - Fiorenzo Santoleri
- Dipartimento di Scienze della Salute, Università Magna Grecia di Catanzaro, Unità Operativa Di Farmacologia Clinica e Farmacovigilanza, Azienda Ospedaliero-Universitaria "Mater Domini", Catanzaro, Italy
| | | | | | | | | | - Luca Quartuccio
- Dipartimento di Medicina (DAME), Clinica di Reumatologia, Università degli Studi di Udine, Azienda Sanitaria Universitaria del Friuli Centrale, Udine, Italy
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Ramkumar SP, Lal D, Miglani A. Considerations for shared decision-making in treatment of chronic rhinosinusitis with nasal polyps. FRONTIERS IN ALLERGY 2023; 4:1137907. [PMID: 36970067 PMCID: PMC10036764 DOI: 10.3389/falgy.2023.1137907] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/13/2023] [Indexed: 03/12/2023] Open
Abstract
Shared decision-making is an approach where physicians and patients work together to determine a personalized treatment course. Such an approach is integral to patient-centered care in chronic rhinosinusitis with nasal polyps (CRSwNP). CRSwNP is a chronic inflammatory condition of the sinonasal cavity that can severely impact physical health, smell, and quality of life (QOL). Traditional standard-of-care treatment options include topical (i.e. sprays) and oral corticosteroids and endoscopic sinus surgery, but more recently, novel corticosteroid delivery methods (i.e. high volume irrigations, recently-approved exhalation breath-powered delivering devices, and drug-eluting steroid implants) and 3 new FDA approved biologics directed against type II immunomodulators have become available. The availability of these therapeutics offers exciting new opportunities in CRSwNP management but requires personalized and shared-decision making as each modality has variable impacts on CRSwNP and related comorbid conditions. Studies have published treatment algorithms, but the practical use of these lean guidelines is heavily influenced by the lens of the treating physician, the most common being otolaryngologists and allergy immunologists. Clinical equipoise occurs when there is no basis for one intervention to be regarded as “better” than another. While most guidelines, in general, support the use of topical corticosteroids with or without oral corticosteroids followed by ESS for the majority of unoperated CRSwNP patients, there are situations of clinical equipoise that arise particularly in CRSwNP who have failed surgery or those with severe comorbid conditions. In the shared decision-making process, clinicians and patients must consider symptomatology, goals, comfort, compliance, treatment efficacy, and treatment cost when determining the initial choice of therapy and escalation of therapy with the potential use of multiple modalities for recalcitrant CRSwNP. A summary of salient considerations that might constitute shared decision-making is presented in this summary.
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Affiliation(s)
- Shreya P. Ramkumar
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic Hospital, Phoenix, AZ, United States
- Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Devyani Lal
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic Hospital, Phoenix, AZ, United States
| | - Amar Miglani
- Department of Otolaryngology – Head and Neck Surgery, Mayo Clinic Hospital, Phoenix, AZ, United States
- Correspondence: Amar Miglani
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Varrassi G, Coluzzi F, Fornasari D, Fusco F, Gianni W, Guardamagna VA, Puntillo F, Sotgiu G. New Perspectives on the Adverse Effects of NSAIDs in Cancer Pain: An Italian Delphi Study from the Rational Use of Analgesics (RUA) Group. J Clin Med 2022; 11:7451. [PMID: 36556066 PMCID: PMC9781542 DOI: 10.3390/jcm11247451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed drugs for cancer pain. We used the Delphi methodology to evaluate the opinions of clinicians on NSAIDs and paracetamol, with a specific focus on their safety profile. Consensus was reached on seven statements. A high level of consensus was reached regarding the use of NSAIDs and gastrointestinal, cardiovascular, and renal risk in patients taking low-dose aspirin and assessment of liver function during long-term treatment with paracetamol. Consensus was also reached that assessment and monitoring of eGFR are important in the elderly being administered NSAIDs. It was further agreed that NSAIDs can often play a key role in association with opioids in the treatment of cancer pain and that paracetamol is the analgesic of first choice for patients with mild chronic pain. When NSAIDs are administered in combination with steroids, it was agreed that the risk of gastrointestinal damage is increased since steroids delay the healing of ulcers and that paracetamol can be used during pregnancy and does not affect the health of the fetus. This Delphi study highlights that there is poor agreement on how these drugs are routinely prescribed. However, a consensus was reached for seven key statements and may represent a valid contribution to daily practice.
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Affiliation(s)
- Giustino Varrassi
- Giustino Varrassi, Paolo Procacci Foundation, Via Tacito 7, 00193 Rome, Italy
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, 04013 Latina, Italy
- Anesthesiology, Intensive Care, and Pain Medicine Unit, Sant’Andrea University Hospital, 00189 Rome, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Molecular Medicine, Università degli Studi di Milano, 20121 Milan, Italy
| | - Flavio Fusco
- Palliative Care Unit, Department of Primary and Community Care, ASL3, 16100 Liguria, Italy
| | | | | | - Filomena Puntillo
- Department of Interdisciplinary Medicine (DIM), University of Bari, 70124 Bari, Italy
- Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital, 70124 Bari, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
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Brunetti L, Vekaria J, Lipsky PE, Schlesinger N. Treatment of Acute Gout Flares in the Emergency Department: Prescribing Patterns and Revisit Rates. Ann Pharmacother 2021; 56:422-429. [PMID: 34282640 DOI: 10.1177/10600280211032295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The incidence and health care costs of gout flares have increased in the United States. The increased costs may be a result of a lack of adherence to treatment guidelines and medication knowledge. Identifying causes for this trend is vital to mitigate inappropriate resource use. OBJECTIVES The aim was to identify pharmacotherapy use related to gout treatment before, during hospital visit or stay, and on discharge in patients presenting to the emergency department (ED) with gout flares. Secondary end points included opioid use, revisit rates, and associated risk factors. METHODS We performed a retrospective cohort study at a community teaching hospital ED. All consecutive patients visiting the ED from January 2016 to July 2019 with a primary diagnosis of gout flare were included. Data were extracted from the electronic medical records. RESULTS The analysis included 214 patients. Anti-inflammatory medication was not prescribed in 33.6% during the hospital visit and 29.6% of patients on discharge. History of opioid use (odds ratio [OR] = 3.3; 95% CI = 1.3-8.6; P = 0.014) and gastroesophageal reflux disease (OR = 3.5; 95% CI = 1.09-10.9; P = 0.035) were associated with opioid prescription on discharge. ED revisits within 90 days for any gout-related or non-gout-related cause were recorded in 16.8% of patients. CONCLUSION AND RELEVANCE Roughly 30% of patients did not receive an anti-inflammatory on discharge, and opioids were frequently overused in gout management in the ED. There is an opportunity for further education of health care providers regarding gout treatment.
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Affiliation(s)
| | | | - Peter E Lipsky
- RILITE Research Institute and AMPEL BioSolutions, Charlottesville, VA, USA
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Barbulescu A, Delcoigne B, Askling J, Frisell T. Gastrointestinal perforations in patients with rheumatoid arthritis treated with biological disease-modifying antirheumatic drugs in Sweden: a nationwide cohort study. RMD Open 2021; 6:rmdopen-2020-001201. [PMID: 32669452 PMCID: PMC7425111 DOI: 10.1136/rmdopen-2020-001201] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/07/2020] [Accepted: 06/25/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To compare incidence rates of gastrointestinal (GI) perforations between patients with RA and the general population, and between patients treated with tumour necrosis factor inhibitors (TNFi) and non-TNFi biologics. METHODS In this nationwide cohort study, a total of 63 532 patients with RA, with 26 050 biological treatment episodes (TNFi, rituximab, abatacept or tocilizumab) and 76 304 general population controls, were followed between 2009 and 2017 until the first outcome event. The main outcome was hospitalisation or death due to lower GI perforations, identified according to a prespecified list of ICD-10 (International Classification of Diseases, 10th revision) codes. Inverse probability of treatment weighting was used for adjustment. RESULTS The sex-standardised and age-standardised incidence rates of lower GI perforations were 1.1 (95% CI 1.0 to 1.3) events per 1000 person-years among general population controls, 1.6 (1.5-1.7) among bionaïve patients and ranged from 1.8 (1.4-3.6) (TNFi) to 4.5 (2.7-10.4) (tocilizumab) among biologics-treated patients. After adjustment for glucocorticoid use, the risk in bionaïve, TNFi-treated, abatacept-treated or rituximab-treated patients with RA was no longer different from the general population, while for tocilizumab it remained significantly higher. Comparing tocilizumab to TNFi, the adjusted HR for lower GI perforations was 2.2 (1.3-3.8), corresponding to one additional GI perforation per 451 patient-years treated with tocilizumab instead of TNFi. CONCLUSION Tocilizumab was associated with a higher risk of lower GI perforations compared with alternative biologics. In absolute numbers, the risk remained low on all biologics commonly used to treat RA, but the accumulated evidence across settings and outcome definitions supports that this risk should be considered in treatment guidelines for RA.
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Affiliation(s)
- Andrei Barbulescu
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | | | - Johan Askling
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frisell
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Ranford D, Hopkins C. Safety review of current systemic treatments for severe chronic rhinosinusitis with nasal polyps and future directions. Expert Opin Drug Saf 2021; 20:1177-1189. [PMID: 33957840 DOI: 10.1080/14740338.2021.1926981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Chronic rhinosinusitis is a common condition characterized by inflammation of the nasal and sinus linings, rhinorrhea, nasal blockage, facial pain, and loss of sense of smell for longer than 12 weeks. CRS can occur with or without nasal polyps.Areas covered: First-line treatment in chronic rhinosinusitis with nasal polyps is long-term intranasal corticosteroids, which have few adverse events associated with their use, as second-generation intranasal corticosteroids having a bioavailability of <0.5%. Systemic corticosteroids are used when intranasal steroids fail to achieve symptom control. However, the repeated use of oral corticosteroids is associated with numerous adverse events and the benefit from a course of oral corticosteroids is lost within three to six months.Expert opinion: Antibiotics are commonly prescribed in nasal polyposis although there is also very little evidence for their use outside of acute infection. Macrolide antibiotics are also associated with a transient increase in the risk of arrhythmias. Biologics offer a steroid-sparing alternative to the treatment of severe nasal polyposis. They have shown to be relatively well tolerated in studies to date; however, studies suggest that there is no disease modifying effect and that any benefit is lost within weeks of finishing treatment.
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Affiliation(s)
- David Ranford
- ENT Department, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Claire Hopkins
- ENT Department, Guy's and St Thomas NHS Foundation Trust, London, UK
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Keller MS, Truong L, Mays AM, Needleman J, Heilemann MSV, Nuckols TK. How do contraindications to non-opioid analgesics and opioids affect the likelihood that patients with back pain diagnoses in the primary care setting receive an opioid prescription? An observational cross-sectional study. BMC FAMILY PRACTICE 2021; 22:41. [PMID: 33610181 PMCID: PMC7896404 DOI: 10.1186/s12875-021-01386-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/08/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Given the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care. METHODS We identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2-4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication. RESULTS In our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1-4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1-3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5-9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0-3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: - 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08-0.23%), 0.44% (95%CI: 0.30-0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03-0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13-0.26%). CONCLUSIONS Patients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.
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Affiliation(s)
- Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA.
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
| | - Lyna Truong
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Allison M Mays
- Division of Geriatrics, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jack Needleman
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | | | - Teryl K Nuckols
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA
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11
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Kaytser V, Zhang P. Non-interacting, Non-opioid, and Non-barbiturate Containing Acute Medication Combinations in Headache: A Pilot Combinatorics Approach Based on DrugBank Database. Front Neurol 2021; 12:632830. [PMID: 33679591 PMCID: PMC7925628 DOI: 10.3389/fneur.2021.632830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/25/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Polypharmacy in abortive medications is often inevitable for patients with refractory headaches. Objective: We seek to enumerate an exhaustive list of headaches abortive medications that are without drug-drug interactions. Methods: We updated a list of acute medications based on the widely used Jefferson Headache Manual with novel abortive medications including ubrogepant, lasmiditan, and rimegepant. Opioids and barbiturate-containing products are excluded. From this resultant list of medications, we then conducted an exhaustive search of all pair-wise interactions via DrugBank's API. Using this interaction list, we filtered all possible two, three, and four drug combinations of abortive medications. The list of medications was then reapplied to DrugBank to verify the lack of known drug-drug interactions. Results: There are 192 medication combinations that do not contain any drug-drug interactions. Most common elements in these combinations are ubrogepant, prochlorperazine, followed by tizanidine. There are 67 three-drug combinations that do not contain interactions. Only two of the four-drug combinations do not yield some form of drug-drug interactions. Conclusion: This list of headaches abortive medications without drug-drug interactions is a useful tool for clinicians seeking to more effectively manage refractory headaches by implementing a rational polypharmacy.
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Affiliation(s)
- Victor Kaytser
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Pengfei Zhang
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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12
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Dwivedi R, Tan YS, Park B, Wei M, Horgan K, Madigan D, Yu B. Stable Discovery of Interpretable Subgroups via Calibration in Causal Studies. Int Stat Rev 2020. [DOI: 10.1111/insr.12427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Raaz Dwivedi
- Department of EECS University of California, Berkeley Berkeley CA USA
| | - Yan Shuo Tan
- Department of Statistics University of California, Berkeley Berkeley CA USA
| | - Briton Park
- Department of Statistics University of California, Berkeley Berkeley CA USA
| | - Mian Wei
- Department of Statistics University of California, Berkeley Berkeley CA USA
| | - Kevin Horgan
- Protypia Inc 111 10th Avenue South, Suite 102 Nashville TN 37023 USA
| | - David Madigan
- Khoury College of Computer Sciences Northeastern University Boston MA USA
| | - Bin Yu
- Department of EECS University of California, Berkeley Berkeley CA USA
- Department of Statistics University of California, Berkeley Berkeley CA USA
- Division of Biostatistics University of California, Berkeley Berkeley CA USA
- Center for Computational Biology University of California, Berkeley Berkeley CA USA
- Chan Zuckerberg Biohub San Francisco CA USA
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13
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Dalal NH, Dores GM, Curtis RE, Linet MS, Morton LM. Cause-specific mortality in individuals with lymphoplasmacytic lymphoma/Waldenström macroglobulinaemia, 2000-2016. Br J Haematol 2020; 189:1107-1118. [PMID: 32090327 DOI: 10.1111/bjh.16492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/24/2019] [Indexed: 02/07/2023]
Abstract
Data on cause-specific mortality after lymphoplasmacytic lymphoma (LPL) and Waldenström macroglobulinaemia (WM) are lacking. We identified causes of death amongst 7289 adults diagnosed with incident first primary LPL (n = 3108) or WM (n = 4181) during 2000-2016 in 17 USA population-based cancer registries. Based on 3132 deaths, 16-year cumulative mortality was 23·2% for lymphomas, 8·4% for non-lymphoma cancers and 14·7% for non-cancer causes for patients aged <65 years at diagnosis of LPL/WM, versus 33·4%, 11·2% and 48·7%, respectively, for those aged ≥75 years. Compared with the general population, patients with LPL/WM had a 20% higher risk of death due to non-cancer causes (n = 1341 deaths, standardised mortality ratio [SMR] 1·2, 95% confidence interval [CI] 1·1-1·2), most commonly from infectious (n = 188; SMR 1·8, 95% CI 1·6-2·1), respiratory (n = 143; SMR 1·2, 95% CI 1·0-1·4), and digestive (n = 80; SMR 1·8, 95% CI 1·4-2·2) diseases, but no excess mortality from cardiovascular diseases (n = 477, SMR 1·1, 95% CI 1·0-1·1). Risks were highest for non-cancer causes within 1 year of diagnosis (n = 239; SMR<1year 1·3, 95% CI 1·2-1·5), declining thereafter (n = 522; SMR≥5years 1·1, 95% CI 1·1-1·2). Myelodysplastic syndrome/acute myeloid leukaemia deaths were notably increased (n = 46; SMR 4·4, 95% CI 3·2-5·9), whereas solid neoplasm deaths were only elevated among ≥5-year survivors (n = 145; SMR≥5years 1·3, 95% CI 1·1-1·5). This work identifies new areas for optimising care and reducing mortality for patients with LPL/WM.
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Affiliation(s)
- Nicole H Dalal
- Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA.,Duke University School of Medicine, Durham, NC, USA
| | - Graça M Dores
- Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA.,United States Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | - Rochelle E Curtis
- Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
| | - Martha S Linet
- Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
| | - Lindsay M Morton
- Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
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14
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Hox V, Lourijsen E, Jordens A, Aasbjerg K, Agache I, Alobid I, Bachert C, Boussery K, Campo P, Fokkens W, Hellings P, Hopkins C, Klimek L, Mäkelä M, Mösges R, Mullol J, Pujols L, Rondon C, Rudenko M, Toppila-Salmi S, Scadding G, Scheire S, Tomazic PV, Van Zele T, Wagemann M, van Boven JFM, Gevaert P. Benefits and harm of systemic steroids for short- and long-term use in rhinitis and rhinosinusitis: an EAACI position paper. Clin Transl Allergy 2020; 10:1. [PMID: 31908763 PMCID: PMC6941282 DOI: 10.1186/s13601-019-0303-6] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 12/02/2019] [Indexed: 02/05/2023] Open
Abstract
Because of the inflammatory mechanisms of most chronic upper airway diseases such as rhinitis and chronic rhinosinusitis, systemic steroids have been used for their treatment for decades. However, it has been very well documented that—potentially severe—side-effects can occur with the accumulation of systemic steroid courses over the years. A consensus document summarizing the benefits of systemic steroids for each upper airway disease type, as well as highlighting the potential harms of this treatment is currently lacking. Therefore, a panel of international experts in the field of Rhinology reviewed the available literature with the aim of providing recommendations for the use of systemic steroids in treating upper airway disease.
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Affiliation(s)
- Valerie Hox
- 1Cliniques Universitaires Saint-Luc Brussels, Av. Hippocrate 10, 1200 Brussels, Belgium
| | - Evelijn Lourijsen
- 2Department of Otorhinolaryngology, Amsterdam University Medical Centres, AMC, Amsterdam, The Netherlands
| | - Arnout Jordens
- 3Upper Airway Research Laboratory, Dep. of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
| | | | - Ioana Agache
- Faculty of Medicine, Transsylvania University, Brasov, Romania
| | - Isam Alobid
- 6Hospital Clínic, IDIBAPS, CEBERES Universitat de Barcelona, Catalonia, Spain.,7Centro Medico Teknon, Barcelona, Spain
| | - Claus Bachert
- 3Upper Airway Research Laboratory, Dep. of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium.,8Department of Ear, Nose and Throat Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Koen Boussery
- 9Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Paloma Campo
- 10Allergy Unit, Hospital Regional Universitario of Málaga, IBIMA, ARADyAL, Malaga, Spain
| | - Wytske Fokkens
- 2Department of Otorhinolaryngology, Amsterdam University Medical Centres, AMC, Amsterdam, The Netherlands
| | - Peter Hellings
- 11Department of Ear, Nose and Throat Disease, University Hospitals, Louvain, Belgium
| | - Claire Hopkins
- 12ENT Department, Guy's & St Thomas' Hospital, London, UK
| | - Ludger Klimek
- Center of Rhinology and Allergology, Wiesbaden, Germany
| | - Mika Mäkelä
- 14Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Joaquim Mullol
- 6Hospital Clínic, IDIBAPS, CEBERES Universitat de Barcelona, Catalonia, Spain
| | - Laura Pujols
- 6Hospital Clínic, IDIBAPS, CEBERES Universitat de Barcelona, Catalonia, Spain
| | - Carmen Rondon
- 10Allergy Unit, Hospital Regional Universitario of Málaga, IBIMA, ARADyAL, Malaga, Spain
| | | | - Sanna Toppila-Salmi
- 14Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Sophie Scheire
- 9Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | | | - Thibaut Van Zele
- 3Upper Airway Research Laboratory, Dep. of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
| | | | - Job F M van Boven
- 20Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, The Netherlands
| | - Philippe Gevaert
- 3Upper Airway Research Laboratory, Dep. of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
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15
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Gamelas V, Salvado V, Dias L. Prescription Pattern of Proton Pump Inhibitors at Hospital Admission and Discharge. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:114-120. [PMID: 30976616 PMCID: PMC6454380 DOI: 10.1159/000488506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/05/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPI) have reportedly been used in inappropriate clinical settings, often leading to an increased risk of adverse effects, drug interactions, and costs. AIM The aim of this study was to evaluate the adequacy of PPI prescription in an internal medicine ward. METHODS The discharged home inpatients of a segment in the medicine department of a central hospital in the first trimester of 2017 were evaluated; those who died or were transferred to another unit were excluded. Data on gender, age, admission, and discharge therapy and diagnoses which could support PPI use were collected from clinical records. Statistical analysis was performed using Microsoft Excel 2013® and IBM SPSS Statistics 20®. RESULTS A total of 318 hospitalizations were included, corresponding to 301 patients; 171 (56.8%) were female and the average age was 75.4 ± 14.6 years. Among the 318 hospitalizations, 148 patients (46.5%) were on PPI at admission and 175 (55%) at discharge, the majority of them without indication (n = 91, 61.5% vs. n = 109, 62.3%). The main inappropriate indication was anticoagulation alone (n = 33, 36.3% vs. n = 43, 39.4%). There was indication for PPI therapy in 93 (29.2%) of the cases at admission and 111 (34.9%) at discharge, mostly for prophylaxis of gastrointestinal bleeding in high-risk patients (n = 82, 88.2% vs. n = 96, 86.5%). Among those with indication, 57 (61.3%) were medicated at admission versus 66 (59%) at discharge. The association between PPI therapy and an indication for its prescription was lost by the time of discharge (p = 0.245). CONCLUSIONS PPI prescription is not in agreement with existing recommendations, which is why it should be revised at hospital discharge. The primary indication for PPI therapy is the prophylaxis of gastrointestinal bleeding in high-risk patients and the main inappropriate indication is prophylaxis in low-risk patients. A large proportion of the patients indicated for PPI use were discharged without prescription.
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Affiliation(s)
- Verónica Gamelas
- aGastrenterologia, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Vera Salvado
- bMedicina Interna, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Luís Dias
- bMedicina Interna, Centro Hospitalar Lisboa Central, Lisbon, Portugal
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16
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Savarino V, Marabotto E, Zentilin P, Furnari M, Bodini G, De Maria C, Pellegatta G, Coppo C, Savarino E. Proton pump inhibitors: use and misuse in the clinical setting. Expert Rev Clin Pharmacol 2018; 11:1123-1134. [PMID: 30295105 DOI: 10.1080/17512433.2018.1531703] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The introduction of proton pump inhibitors (PPIs) into clinical practice has greatly improved our therapeutic approach to acid-related diseases for their efficacy and safety. Areas Covered: The following evidence-based indications for PPI use are acknowledged by many scientific societies: treatment of the various forms and complications of gastroesophageal reflux disease, eradication of H. pylori infection in combination with two or more antibiotics, short- and long-term therapy of H. pylori-negative peptic ulcers, healing, and prevention of NSAID/COXIB-associated gastric ulcers, co-therapy with endoscopic procedures to control upper digestive bleeding and medical treatment of Zollinger Ellison syndrome. Expert Commentary: Despite the above well-defined indications, however, the use of PPIs continues to grow every year in both western and eastern countries and the endless expansion of the PPI market has created important problems for many regulatory authorities for two relevant features: the progressive increase of the costs of therapy and the greater potential harms for the patients. The major reasons for the misuse of PPIs are the prevention of gastro-duodenal ulcers in patients without risk factors and the stress ulcer prophylaxis in non-intensive care units, steroid therapy alone, anti-platelet or anti-coagulant treatment in patients without risk of gastric injury and the overtreatment of functional dyspepsia.
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Affiliation(s)
- Vincenzo Savarino
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Elisa Marabotto
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Patrizia Zentilin
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Manuele Furnari
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Giorgia Bodini
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Costanza De Maria
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Gaia Pellegatta
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Claudia Coppo
- a Gastrointestinal Unit, Department of Internal Medicine , University of Genoa , Genoa , Italy
| | - Edoardo Savarino
- b Gastrointestinal Unit, Department of Surgery , Oncology and Gastroenterology, University of Padua , Padua , Italy
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17
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Butler E, Møller MH, Cook O, Granholm A, Penketh J, Rygård SL, Aneman A, Perner A. Corticosteroids and risk of gastrointestinal bleeding in critically ill adults: Protocol for a systematic review. Acta Anaesthesiol Scand 2018; 62:1321-1326. [PMID: 29797714 DOI: 10.1111/aas.13159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Corticosteroids are frequently prescribed to critically ill patients. However, their use may increase the risk of gastrointestinal (GI) bleeding, which is associated with morbidity and mortality. Accordingly, we aim to assess whether continued administration of corticosteroids for >24 hours increases the rate of GI bleeding in adult critically ill patients compared to placebo or no treatment. METHODS/DESIGN We will conduct a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis. The participants will be adult (as defined in the included trials) critically ill patients. The intervention will be any corticosteroid administered systematically for >24 hours and the comparator will be placebo or no treatment. The primary outcome will be rate of clinically important GI bleeding. We will systematically search EMBASE, MEDLINE, Medline In-Process, Cochrane Library, Epistemonikos and trial registries for relevant literature, as well as perform a hand search. We will follow the recommendations by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The risk of systematic errors (bias) and random errors will be assessed and the overall quality of evidence will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION The risk of GI bleeding in adult critically ill patients treated with corticosteroids is unknown. Hence, there is need for a robust systematic review to assess this risk and provide clinicians with a clearer understanding of the strength and limitations of existing data.
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Affiliation(s)
- E. Butler
- University of New South Wales; Sydney NSW Australia
| | - M. H. Møller
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - O. Cook
- Intensive Care Unit; Liverpool Hospital; Sydney NSW Australia
| | - A. Granholm
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - J. Penketh
- Intensive Care Unit; Liverpool Hospital; Sydney NSW Australia
| | - S. L. Rygård
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - A. Aneman
- Intensive Care Unit; Liverpool Hospital; Sydney NSW Australia
- South Western Sydney Clinical School; University of New South Wales; Sydney NSW Australia
- Ingham Institute for Applied Medical Research; Sydney NSW Australia
| | - A. Perner
- Department of Intensive Care 4131; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
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18
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The availability of health information to patients with newly diagnosed polymyalgia rheumatica: results from the Polymyalgia Rheumatica (PMR) Cohort study. Prim Health Care Res Dev 2018; 20:e8. [PMID: 30088472 PMCID: PMC6476385 DOI: 10.1017/s1463423618000543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aim The aim of this study was to assess the provision of information to, and seeking of information by, patients newly diagnosed with polymyalgia rheumatica (PMR) in primary care. Background PMR is an inflammatory rheumatological condition of older people that can be treated with long-term oral glucocorticoids. Management usually requires the patient to understand the potential complications of treatment and the disease, as well as involvement in reducing treatment dose. This may be complex for patients to understand. Method Data are taken from the baseline phase of the PMR Cohort study, which recruited newly diagnosed patients with PMR from UK primary care. Participants provided information on their PMR symptoms, general health and sociodemographics. They also completed items regarding information provision by their doctor at diagnosis, its usefulness and their own search for information. Findings A total of 652 people responded to the baseline survey. In all, 399 (62.7%) had received written information from their doctor; 237 (98%) found it useful; 265 (42.9%) would have liked more information; and 311 (48.4%) sought out more information. Those who were not given information and did not seek it out tended to be older and have poorer internet access. Information provided at diagnosis to patients with PMR is useful, but more than a third did not receive any. This is concerning when PMR requires self-management and vigilance for red flags. Doctors should make use of the resources already available to them to support patients and should specifically ensure that these are available to more elderly patients and those without internet access.
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19
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Glucocorticoids and the Risk of Peptic Ulcer Bleeding: Case–Control Analysis Based on Swiss Claims Data. Drug Saf 2018; 41:725-730. [DOI: 10.1007/s40264-018-0645-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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20
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Gastrointestinal Motility, Mucosal Mast Cell, and Intestinal Histology in Rats: Effect of Prednisone. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4637621. [PMID: 29057260 PMCID: PMC5625752 DOI: 10.1155/2017/4637621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/20/2017] [Accepted: 08/13/2017] [Indexed: 12/20/2022]
Abstract
Our aim was to verify the effects of prednisone related to gastrointestinal motility, intestinal histology, and mucosal mast cells in rats. Two-month-old male Wistar rats were randomly assigned to control group (vehicle) animals receiving saline 0.9% (n = 7) or treated orally with 0.625 mg/kg/day of prednisone (n = 7) or 2.5 mg/kg/day of prednisone (n = 7) during 15 days. Mast cells and other histologic analyses were performed in order to correlate to gastric emptying, cecum arrival, and small intestine transit evaluated by Alternating Current Biosusceptometry. Results showed that prednisone in adult rats increased the frequency of gastric contractions, hastened gastric emptying, slowed small intestinal transit, and reduced mucosal mast cells. Histologically, the treatment with both doses of prednisone decreased villus height, whereas longitudinal and circular muscles and crypt depth were not affected. These findings indicate an impairment of intestinal absorption which may be linked to several GI dysfunctions and symptoms. The relationship between gastrointestinal motor disorders and cellular immunity needs to be clarified in experimental studies since prednisone is one of the most prescribed glucocorticoids worldwide.
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21
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Bignon E, Marazzi M, Besancenot V, Gattuso H, Drouot G, Morell C, Eriksson LA, Grandemange S, Dumont E, Monari A. Ibuprofen and ketoprofen potentiate UVA-induced cell death by a photosensitization process. Sci Rep 2017; 7:8885. [PMID: 28827702 PMCID: PMC5566383 DOI: 10.1038/s41598-017-09406-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/25/2017] [Indexed: 11/23/2022] Open
Abstract
Nonsteroidal 2-arylproprionic acids are widely used, over-the-counter, anti-inflammatory drugs. Photosensitivity is a commonly overlooked adverse effect of these drugs. Based on the combined use of cell viability assays and molecular modeling, we prove and rationalize the photochemical pathways triggering photosensitization for two drugs, ibuprofen and ketoprofen. As its parent compound benzophenone, ketoprofen produces singlet oxygen, upon triplet manifold population. However, ibuprofen and ketoprofen photodissociate and hence may generate two highly reactive radicals. The formation of metastable aggregates between the two drugs and B-DNA is also directly probed by molecular dynamics. Our approach characterizes the coupled influence of the drug's intrinsic photochemistry and the interaction pattern with DNA. The photosensitization activity of nonsteroidal 2-arylproprionic acids, being added to gels and creams for topical use, should be crucially analyzed and rationalized to enact the proper preventive measures.
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Affiliation(s)
- Emmanuelle Bignon
- Institut des Sciences Analytiques, UMR 5280, Université de Lyon1 (UCBL) CNRS, ENS Lyon, Lyon, France
- Université de Lyon, ENS de Lyon, CNRS, Université Lyon 1, Laboratoire de Chimie UMR 5182, F69342, Lyon, France
| | - Marco Marazzi
- Theory-Modeling-Simulation, Université de Lorraine - Nancy, SRSMC, Boulevard des Aiguillettes, Vandoeuvre-lès-Nancy, Nancy, France
- Theory-Modeling-Simulation, CNRS, SRSMC, Boulevard des Aiguillettes, Vandoeuvre-lès-Nancy, Nancy, France
| | - Vanessa Besancenot
- CRAN, UMR 7039 Université de Lorraine-Nancy, Vandoeuvre-lès-Nancy, Nancy, France
- CRAN, UMR 7039 CNRS, Vandoeuvre-lès-Nancy, Nancy, France
| | - Hugo Gattuso
- Theory-Modeling-Simulation, Université de Lorraine - Nancy, SRSMC, Boulevard des Aiguillettes, Vandoeuvre-lès-Nancy, Nancy, France
- Theory-Modeling-Simulation, CNRS, SRSMC, Boulevard des Aiguillettes, Vandoeuvre-lès-Nancy, Nancy, France
| | - Guillaume Drouot
- CRAN, UMR 7039 Université de Lorraine-Nancy, Vandoeuvre-lès-Nancy, Nancy, France
- CRAN, UMR 7039 CNRS, Vandoeuvre-lès-Nancy, Nancy, France
| | - Christophe Morell
- Institut des Sciences Analytiques, UMR 5280, Université de Lyon1 (UCBL) CNRS, ENS Lyon, Lyon, France
| | - Leif A Eriksson
- Department of Chemistry & Molecular Biology, University of Gothenburg, Medicinaregatan 9 c, 40530, Göteborg, Sweden
| | - Stephanie Grandemange
- CRAN, UMR 7039 Université de Lorraine-Nancy, Vandoeuvre-lès-Nancy, Nancy, France.
- CRAN, UMR 7039 CNRS, Vandoeuvre-lès-Nancy, Nancy, France.
| | - Elise Dumont
- Université de Lyon, ENS de Lyon, CNRS, Université Lyon 1, Laboratoire de Chimie UMR 5182, F69342, Lyon, France.
| | - Antonio Monari
- Theory-Modeling-Simulation, Université de Lorraine - Nancy, SRSMC, Boulevard des Aiguillettes, Vandoeuvre-lès-Nancy, Nancy, France.
- Theory-Modeling-Simulation, CNRS, SRSMC, Boulevard des Aiguillettes, Vandoeuvre-lès-Nancy, Nancy, France.
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22
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Comparative Evaluation of Premedication with Ketorolac and Prednisolone on Postendodontic Pain: A Double-blind Randomized Controlled Trial. J Endod 2017; 43:667-673. [DOI: 10.1016/j.joen.2016.12.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 12/08/2016] [Accepted: 12/11/2016] [Indexed: 11/20/2022]
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23
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Lee U, Choi YJ, Choi GJ, Kang H. Intravenous lidocaine for effective pain relief after bimaxillary surgery. Clin Oral Investig 2017; 21:2645-2652. [PMID: 28168381 DOI: 10.1007/s00784-017-2066-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 01/27/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of this prospective, randomized, double-blind, placebo-controlled study was to evaluate the analgesic effect of intravenous lidocaine on postoperative pain in bimaxillary surgery. MATERIALS AND METHODS Between July 2015 and November 2015, 52 consecutive patients that underwent bimaxillary surgery were recruited to the present study. The patients were randomly divided into two groups: group L (1.5 mg/kg bolus and 2 mg/kg/h continuous infusion during the operation) and group C (normal saline). To measure pain intensity, a visual analog scale (VAS) was used at 2, 4, 8, 12, 24, and 48 h after surgery. Rescue ketorolac use was measured in the first 4, 4-8, 8-24, and 24-48 h after surgery. Total ketorolac consumption (the sum of rescue and eight-hourly fixed schedule ketorolac injection), WBC count, neutrophil count, and postoperative swelling were recorded. RESULTS There were no significant differences between the two groups with respect to demographics. VAS pain scores were significantly lower in group L compared with group C up to 8 h after surgery. Rescue ketorolac use up to 8 h after surgery and total ketorolac consumption were significantly lower in group L than in group C. Postoperative WBC and neutrophil counts were significantly decreased in group L. Compared with group C, the amount of calibrated postoperative swelling was lower in group L. CONCLUSIONS Systemic lidocaine infusion during bimaxillary surgery reduces postoperative pain, analgesic consumption, and facial swelling. CLINICAL RELEVANCE Systemic lidocaine is simple, economic, and a safe procedure reducing pain and soft tissue swelling after bimaxillary surgery.
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Affiliation(s)
- Uilyong Lee
- Department of Oral and Maxillofacial Surgery, Chung-Ang University College of Medicine, 84 Heukseok-ro, Dongjak-gu, Seoul, 06911, Republic of Korea
| | - Young-Jun Choi
- Department of Oral and Maxillofacial Surgery, Chung-Ang University College of Medicine, 84 Heukseok-ro, Dongjak-gu, Seoul, 06911, Republic of Korea
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, 84 Heukseok-ro, Dongjak-gu, Seoul, 06911, Republic of Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, 84 Heukseok-ro, Dongjak-gu, Seoul, 06911, Republic of Korea.
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Caplan A, Fett N, Rosenbach M, Werth VP, Micheletti RG. Prevention and management of glucocorticoid-induced side effects: A comprehensive review. J Am Acad Dermatol 2017; 76:11-16. [DOI: 10.1016/j.jaad.2016.02.1239] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 01/29/2016] [Accepted: 02/01/2016] [Indexed: 01/04/2023]
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Scarpignato C, Gatta L, Zullo A, Blandizzi C. Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression. BMC Med 2016; 14:179. [PMID: 27825371 PMCID: PMC5101793 DOI: 10.1186/s12916-016-0718-z] [Citation(s) in RCA: 247] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/14/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications. METHODS The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence. RESULTS Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile. CONCLUSIONS Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .
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Affiliation(s)
- Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy.
| | - Luigi Gatta
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy
- Gastroenterology & Endoscopy Unit, Versilia Hospital, Azienda USL Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Angelo Zullo
- Division of Gastroenterology & Digestive Endoscopy, Nuovo Regina Elena Hospital, Rome, Italy
| | - Corrado Blandizzi
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
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Souvignet J, Asfari H, Lardon J, Del Tedesco E, Declerck G, Bousquet C. MedDRA® automated term groupings using OntoADR: evaluation with upper gastrointestinal bleedings. Expert Opin Drug Saf 2016; 15:1153-61. [PMID: 27348725 DOI: 10.1080/14740338.2016.1206075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To propose a method to build customized sets of MedDRA terms for the description of a medical condition. We illustrate this method with upper gastrointestinal bleedings (UGIB). RESEARCH DESIGN AND METHODS We created a broad list of MedDRA terms related to UGIB and defined a gold standard with the help of experts. MedDRA terms were formally described in a semantic resource named OntoADR. We report the use of two semantic queries that automatically select candidate terms for UGIB. Query 1 is a combination of two SNOMED CT concepts describing both morphology 'Hemorrhage' and finding site 'Upper digestive tract structure'. Query 2 complements Query 1 by taking into account MedDRA terms associated to SNOMED CT concepts describing clinical manifestations 'Melena' or 'Hematemesis'. RESULTS We compared terms in queries and our gold standard achieving a recall of 71.0% and a precision of 81.4% for query 1 (F1 score 0.76); and a recall of 96.7% and a precision of 77.0% for query 2 (F1 score 0.86). CONCLUSIONS Our results demonstrate the feasibility of applying knowledge engineering techniques for building customized sets of MedDRA terms. Additional work is necessary to improve precision and recall, and confirm the interest of the proposed strategy.
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Affiliation(s)
- Julien Souvignet
- a INSERM, U1142, LIMICS, F-75006, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1142, LIMICS, F-75006, Paris, France; Université Paris 13, Sorbonne Paris Cité, LIMICS, (UMR_S 1142) , F-93430 , Villetaneuse , France.,b Department of Public Health and medical informatics , CHU University of Saint Etienne , Saint-Etienne , France
| | - Hadyl Asfari
- a INSERM, U1142, LIMICS, F-75006, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1142, LIMICS, F-75006, Paris, France; Université Paris 13, Sorbonne Paris Cité, LIMICS, (UMR_S 1142) , F-93430 , Villetaneuse , France.,b Department of Public Health and medical informatics , CHU University of Saint Etienne , Saint-Etienne , France
| | - Jérémy Lardon
- a INSERM, U1142, LIMICS, F-75006, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1142, LIMICS, F-75006, Paris, France; Université Paris 13, Sorbonne Paris Cité, LIMICS, (UMR_S 1142) , F-93430 , Villetaneuse , France.,b Department of Public Health and medical informatics , CHU University of Saint Etienne , Saint-Etienne , France
| | - Emilie Del Tedesco
- c Gastroenterology Department , CHU of Saint-Etienne , Saint-Etienne , France
| | - Gunnar Declerck
- d Sorbonne universités, Université de technologie de Compiègne, EA 2223 Costech (Connaissance, Organisation et Systèmes Techniques), Centre Pierre Guillaumat , Compiègne CEDEX , France
| | - Cédric Bousquet
- a INSERM, U1142, LIMICS, F-75006, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1142, LIMICS, F-75006, Paris, France; Université Paris 13, Sorbonne Paris Cité, LIMICS, (UMR_S 1142) , F-93430 , Villetaneuse , France.,b Department of Public Health and medical informatics , CHU University of Saint Etienne , Saint-Etienne , France
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Rajitha P, Gopinath D, Biswas R, Sabitha M, Jayakumar R. Chitosan nanoparticles in drug therapy of infectious and inflammatory diseases. Expert Opin Drug Deliv 2016; 13:1177-94. [PMID: 27087148 DOI: 10.1080/17425247.2016.1178232] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Chitosan, a polymer from the chitin family has diverse pharmaceutical and bio-medical utility because of its easy widespread availability, non-toxicity, biocompatibility, biodegradability, rich functionalities and high drug-loading capacity. Recent pharmaceutical research has examined the use of chitosan-based systems for drug delivery applications in various diseases. The availability of functional groups permits the conjugation of specific ligands and thus helps to target loaded drugs to the site of infection/inflammation. Slow biodegradation of chitosan permits controlled and sustained release of loaded moieties; reduces the dosing frequency and is useful for improving patient compliance in infectious drug therapy. The muco-adhesion offered by chitosan makes it an attractive candidate for anti-inflammatory drug delivery, where rapid clearance of the active moiety due to the increased tissue permeability is the major problem. The pH-dependent swelling and drug release properties of chitosan present a means of passive targeting of active drug moieties to inflammatory sites. AREAS COVERED Development of chitosan-based nanoparticulate systems for drug delivery applications is reviewed. The current state of chitosan-based nanosystems; with particular emphasis on drug therapy in inflammatory and infectious diseases is also covered. EXPERT OPINION The authors believe that chitosan-based nanosystems, due to the special and specific advantages, will have a promising role in the management of infectious and inflammatory diseases.
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Affiliation(s)
- P Rajitha
- a Amrita School of Pharmacy, Amrita Institute of Medical Sciences and Research Centre , Amrita Vishwa Vidyapeetham University , Kochi , India
| | - Divya Gopinath
- a Amrita School of Pharmacy, Amrita Institute of Medical Sciences and Research Centre , Amrita Vishwa Vidyapeetham University , Kochi , India
| | - Raja Biswas
- b Amrita Centre for Nanosciences and Molecular Medicine, Amrita Institute of Medical Sciences and Research Centre , Amrita Vishwa Vidyapeetham University , Kochi , India
| | - M Sabitha
- a Amrita School of Pharmacy, Amrita Institute of Medical Sciences and Research Centre , Amrita Vishwa Vidyapeetham University , Kochi , India
| | - R Jayakumar
- b Amrita Centre for Nanosciences and Molecular Medicine, Amrita Institute of Medical Sciences and Research Centre , Amrita Vishwa Vidyapeetham University , Kochi , India
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Tseng CL, Chen YT, Huang CJ, Luo JC, Peng YL, Huang DF, Hou MC, Lin HC, Lee FY. Short-term use of glucocorticoids and risk of peptic ulcer bleeding: a nationwide population-based case-crossover study. Aliment Pharmacol Ther 2015; 42:599-606. [PMID: 26096497 DOI: 10.1111/apt.13298] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 04/08/2015] [Accepted: 06/08/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Controversy exists regarding glucocorticoids therapy and the risk of peptic ulcer bleeding (PUB). AIM The present study was undertaken to determine whether short-term use of glucocorticoids is associated with the occurrence of peptic ulcer bleeding. METHODS The records of adult patients hospitalised for newly diagnosed peptic ulcer bleeding from 2000 to 2012 were retrieved from the Taiwan National Health Insurance Research Database, a nationwide population-based registry system. The association between systemic glucocorticoids usage and peptic ulcer bleeding was determined with a conditional logistic regression model comparing cases and controls during time windows of 7, 14 and 28 days using a case-crossover design. RESULTS Of the 8894 enrolled patients, the adjusted self-matched odds ratios for peptic ulcer bleeding after exposure to the glucocorticoids were 1.37 (95% CI: 1.12-1.68, P = 0.003) for the 7-day window, 1.66 (95% CI: 1.38-2.00, P < 0.001) for the 14-day window and 1.84 (95% CI: 1.57-2.16, P < 0.001) for the 28-day window. Moderate to high, but not low dose glucocorticoids (methylprednisolone <4 mg/day or its equivalence) were associated with an increased risk of peptic ulcer bleeding. Concomitant use of a nonselective nonsteroidal anti-inflammatory drug (NSAID) or aspirin further elevated the risk. However, it does not eliminate the effect of underlying diseases flare-up that may have placed the patients at risk for peptic ulcer bleeding in this kind of study design. CONCLUSIONS Short-term (7-28 days) exposure to glucocorticoids is significantly associated with peptic ulcer bleeding; this risk seems dose-dependent and is higher when nonselective NSAIDs or aspirin are used concurrently.
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Affiliation(s)
- C-L Tseng
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Y-T Chen
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, Taipei City Hospital Heping Fuyou Branch, Taipei, Taiwan
| | - C-J Huang
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - J-C Luo
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Y-L Peng
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - D-F Huang
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - M-C Hou
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, Endoscopic Center for Diagnosis and Therapy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - H-C Lin
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - F-Y Lee
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Furuya-Kanamori L, Stone JC, Clark J, McKenzie SJ, Yakob L, Paterson DL, Riley TV, Doi SAR, Clements AC. Comorbidities, Exposure to Medications, and the Risk of Community-Acquired Clostridium difficile Infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2015; 36:132-41. [PMID: 25632995 DOI: 10.1017/ice.2014.39] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) has been extensively described in healthcare settings; however, risk factors associated with community-acquired (CA) CDI remain uncertain. This study aimed to synthesize the current evidence for an association between commonly prescribed medications and comorbidities with CA-CDI. METHODS A systematic search was conducted in 5 electronic databases for epidemiologic studies that examined the association between the presence of comorbidities and exposure to medications with the risk of CA-CDI. Pooled odds ratios were estimated using 3 meta-analytic methods. Subgroup analyses by location of studies and by life stages were conducted. RESULTS Twelve publications (n=56,776 patients) met inclusion criteria. Antimicrobial (odds ratio, 6.18; 95% CI, 3.80-10.04) and corticosteroid (1.81; 1.15-2.84) exposure were associated with increased risk of CA-CDI. Among the comorbidities, inflammatory bowel disease (odds ratio, 3.72; 95% CI, 1.52-9.12), renal failure (2.64; 1.23-5.68), hematologic cancer (1.75; 1.02-5.68), and diabetes mellitus (1.15; 1.05-1.27) were associated with CA-CDI. By location, antimicrobial exposure was associated with a higher risk of CA-CDI in the United States, whereas proton-pump inhibitor exposure was associated with a higher risk in Europe. By life stages, the risk of CA-CDI associated with antimicrobial exposure greatly increased in adults older than 65 years. CONCLUSIONS Antimicrobial exposure was the strongest risk factor associated with CA-CDI. Further studies are required to investigate the risk of CA-CDI associated with medications commonly prescribed in the community. Patients with diarrhea who have inflammatory bowel disease, renal failure, hematologic cancer, or diabetes are appropriate populations for interventional studies of screening.
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Affiliation(s)
- Luis Furuya-Kanamori
- 1Research School of Population Health,Australian National University,Canberra,Australia
| | - Jennifer C Stone
- 2School of Population Health,University of Queensland,Herston,Australia
| | | | | | - Laith Yakob
- 4Department of Disease Control,London School of Hygiene & Tropical Medicine,London,UK
| | - David L Paterson
- 5University of Queensland,UQ Centre for Clinical Research,Herston,Australia
| | - Thomas V Riley
- 6Microbiology & Immunology,University of Western Australia, andDepartment of Microbiology PathWest Laboratory Medicine,Queen Elizabeth II Medical Centre,Nedlands,Australia
| | - Suhail A R Doi
- 2School of Population Health,University of Queensland,Herston,Australia
| | - Archie C Clements
- 1Research School of Population Health,Australian National University,Canberra,Australia
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Insight into the role of mTOR and metabolism in T cells reveals new potential approaches to preventing graft rejection. Curr Opin Organ Transplant 2015; 19:363-71. [PMID: 24991977 DOI: 10.1097/mot.0000000000000098] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW In this review, we discuss the recent advances with regard to the mammalian target of rapamycin (mTOR) signaling pathway and focus on how this pathway modulates immune responses. Overall, these insights provide important clues in terms of strategically integrating mTOR and metabolic inhibitors into transplantation rejection protocols. RECENT FINDINGS mTOR is regulated by environmental cues and activates diverse downstream pathways to guide cell growth and fate. What has emerged from recent studies is that mechanistically mTOR directs T cell differentiation and function in part by regulating metabolic programs. Such findings not only inform us with regard to the metabolic demands of effector and memory T cells but also elucidate metabolic pathways that might be targeted to selectively regulate immune responses. SUMMARY Initial studies focused on the ability of the mTOR inhibitor rapamycin to suppress immune responses by inhibiting T cell proliferation. Since then, both pharmacologic and genetic studies have revealed a central role for mTOR in regulating T cell activation, differentiation, and function independent of proliferation. Specifically, it has become clear that mTOR plays an important role in regulating the metabolic machinery necessary for effector, regulatory, and memory T cell generation. As such, direct inhibition of metabolism may emerge as a potent and selective means of preventing graft rejection. This review will discuss new insights regarding the ability of downstream signaling pathways, including mTOR-dependent metabolic pathways in regulating T cell responses. Finally, we will discuss these new insights in the context of developing novel immunoregulatory regimens for transplantation.
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Masclee GMC, Valkhoff VE, Coloma PM, de Ridder M, Romio S, Schuemie MJ, Herings R, Gini R, Mazzaglia G, Picelli G, Scotti L, Pedersen L, Kuipers EJ, van der Lei J, Sturkenboom MCJM. Risk of upper gastrointestinal bleeding from different drug combinations. Gastroenterology 2014; 147:784-792.e9; quiz e13-4. [PMID: 24937265 DOI: 10.1053/j.gastro.2014.06.007] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 05/22/2014] [Accepted: 06/11/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND & AIMS Concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin increases the risk of upper gastrointestinal bleeding (UGIB). Guidelines suggest avoiding certain drug combinations, yet little is known about the magnitude of their interactions. We estimated the risk of UGIB during concomitant use of nonselective (ns)NSAIDs, cyclooxygenase -2 selective inhibitors (COX-2 inhibitors), and low-dose aspirin with other drugs. METHODS We performed a case series analysis of data from 114,835 patients with UGIB (930,888 person-years of follow-up) identified from 7 population-based health care databases (approximately 20 million subjects). Each patient served as his or her own control. Drug exposure was determined based on prescriptions of nsNSAIDs, COX-2 inhibitors, or low-dose aspirin, alone and in combination with other drugs that affect the risk of UGIB. We measured relative risk (incidence rate ratio [IRR] during drug exposure vs nonexposure) and excess risk due to concomitant drug exposure (relative excess risk due to interaction [RERI]). RESULTS Monotherapy with nsNSAIDs increased the risk of diagnosis of UGIB (IRR, 4.3) to a greater extent than monotherapy with COX-2 inhibitors (IRR, 2.9) or low-dose aspirin (IRR, 3.1). Combination therapy generally increased the risk of UGIB; concomitant nsNSAID and corticosteroid therapies increased the IRR to the greatest extent (12.8) and also produced the greatest excess risk (RERI, 5.5). Concomitant use of nsNSAIDs and aldosterone antagonists produced an IRR for UGIB of 11.0 (RERI, 4.5). Excess risk from concomitant use of nsNSAIDs with selective serotonin reuptake inhibitors (SSRIs) was 1.6, whereas that from use of COX-2 inhibitors with SSRIs was 1.9 and that for use of low-dose aspirin with SSRIs was 0.5. Excess risk of concomitant use of nsNSAIDs with anticoagulants was 2.4, of COX-2 inhibitors with anticoagulants was 0.1, and of low-dose aspirin with anticoagulants was 1.9. CONCLUSIONS Based on a case series analysis, concomitant use of nsNSAIDs, COX-2 inhibitors, or low-dose aspirin with SSRIs significantly increases the risk of UGIB. Concomitant use of nsNSAIDs or low-dose aspirin, but not COX-2 inhibitors, with corticosteroids, aldosterone antagonists, or anticoagulants produces significant excess risk of UGIB.
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Affiliation(s)
- Gwen M C Masclee
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Vera E Valkhoff
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Preciosa M Coloma
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maria de Ridder
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Silvana Romio
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Martijn J Schuemie
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ron Herings
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands; PHARMO Institute, Utrecht, The Netherlands
| | - Rosa Gini
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands; Agenzi Regionali di Sanità della Toscana, Florence, Italy
| | | | - Gino Picelli
- Pedianet, Societá Servizi Telematici SRL, Padova, Italy
| | | | - Lars Pedersen
- Clinical Epidemiology, Aarhus University Hospital, Århus Sygehus, Aarhus, Denmark
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Miriam C J M Sturkenboom
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Oda K, Ishimoto H, Yamada S, Kushima H, Ishii H, Imanaga T, Harada T, Ishimatsu Y, Matsumoto N, Naito K, Yatera K, Nakazato M, Kadota JI, Watanabe K, Kohno S, Mukae H. Autopsy analyses in acute exacerbation of idiopathic pulmonary fibrosis. Respir Res 2014; 15:109. [PMID: 25176016 PMCID: PMC4243719 DOI: 10.1186/s12931-014-0109-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/26/2014] [Indexed: 11/18/2022] Open
Abstract
Background Acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is associated with high mortality. However, few studies have so far reviewed analyses of autopsy findings in patients with AE-IPF. Methods We retrospectively reviewed 52 consecutive patients with AE-IPF who underwent autopsies at five university hospitals and one municipal hospital between 1999 and 2013. The following variables were abstracted from the medical records: demographic and clinical data, autopsy findings and complications during the clinical course until death. Results The median age at autopsy was 71 years (range 47–86 years), and the subjects included 38 (73.1%) males. High-dose corticosteroid therapy was initiated in 45 (86.5%) patients after AE-IPF. The underling fibrotic lesion was classified as having the usual interstitial pneumonia (UIP) pattern in all cases. Furthermore, 41 (78.8%) patients had diffuse alveolar damage (DAD), 15 (28.8%) exhibited pulmonary hemorrhage, nine (17.3%) developed pulmonary thromboembolism and six (11.5%) were diagnosed with lung carcinoma. In addition, six (11.5%) patients developed pneumothorax prior to death and 26 (53.1%) developed diabetes that required insulin treatment after the administration of high-dose corticosteroid therapy. In addition, 15 (28.8%) patients presented with bronchopneumonia during their clinical course and/or until death, including fungal (seven, 13.5%), cytomegalovirus (six, 11.5%) and bacterial (five, 9.6%) infections. Conclusions The pathological findings in patients with AE-IPF represent not only DAD, but also a variety of pathological conditions. Therefore, making a diagnosis of AE-IPF is often difficult, and the use of cautious diagnostic approaches is required for appropriate treatment.
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Owen C, Panesar P, Marks DJB, Banks M. The dangers of proton pump inhibitor therapy. Br J Hosp Med (Lond) 2014; 75:C108-12. [DOI: 10.12968/hmed.2014.75.sup7.c108] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
| | | | - Daniel JB Marks
- Specialty Registrar in Clinical Pharmacology and Therapeutics
| | - Matthew Banks
- Consultant Gastroenterologist, University College London Hospital NHS Foundation Trust, London NW1 2BU
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Abstract
OBJECTIVE To assess whether corticosteroids are associated with increased risk of gastrointestinal bleeding or perforation. DESIGN Systematic review and meta-analysis of randomised, double-blind, controlled trials comparing a corticosteroid to placebo for any medical condition or in healthy participants. Studies with steroids given either locally, as a single dose, or in crossover studies were excluded. DATA SOURCES Literature search using MEDLINE, EMBASE and Cochrane Database of Systematic Reviews between 1983 and 22 May 2013. OUTCOME MEASURE Outcome measures were the occurrence of gastrointestinal bleeding or perforation. Predefined subgroup analyses were carried out for disease severity, use of non-steroidal anti-inflammatory drugs (NSAIDs) or gastroprotective drugs, and history of peptic ulcer. RESULTS 159 studies (N=33 253) were included. In total, 804 (2.4%) patients had a gastrointestinal bleeding or perforation (2.9% and 2.0% for corticosteroids and placebo). Corticosteroids increased the risk of gastrointestinal bleeding or perforation by 40% (OR 1.43, 95% CI 1.22 to 1.66). The risk was increased for hospitalised patients (OR 1.42, 95% CI 1.22 to 1.66). For patients in ambulatory care, the increased risk was not statistically significant (OR 1.63, 95% CI 0.42 to 6.34). Only 11 gastrointestinal bleeds or perforations occurred among 8651 patients in ambulatory care (0.13%). Increased risk was still present in subgroup analyses (studies with NSAID use excluded; OR 1.44, 95% CI 1.20 to 1.71, peptic ulcer as an exclusion criterion excluded; OR 1.47, 95% CI 1.21 to 1.78, and use of gastroprotective drugs excluded; OR 1.42, 95% CI 1.21 to 1.67). CONCLUSIONS Corticosteroid use was associated with increased risk of gastrointestinal bleeding and perforation. The increased risk was statistically significant for hospitalised patients only. For patients in ambulatory care, the total occurrence of bleeding or perforation was very low, and the increased risk was not statistically significant.
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Affiliation(s)
- Sigrid Narum
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
- Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Tone Westergren
- Department of Pharmacology, Regional Medicines Information & Pharmacovigilance Centre (RELIS), Oslo University Hospital, Oslo, Norway
| | - Marianne Klemp
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
- Department of Pharmacology, University of Oslo, Oslo, Norway
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Masclee GMC, Sturkenboom MCJM, Kuipers EJ. A Benefit–Risk Assessment of the Use of Proton Pump Inhibitors in the Elderly. Drugs Aging 2014; 31:263-82. [DOI: 10.1007/s40266-014-0166-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Hansebout RR, Hansebout CR. Local cooling for traumatic spinal cord injury: outcomes in 20 patients and review of the literature. J Neurosurg Spine 2014; 20:550-61. [PMID: 24628130 DOI: 10.3171/2014.2.spine13318] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECT In this prospective study, the authors offered protocol-selected patients a combination of parenteral steroids, decompression surgery, and localized cooling to preserve viable spinal cord tissue and enhance functional recovery. METHODS After acquiring informed consent, the authors offered this regimen with localized deep cord cooling (dural temperature 6°C) to 20 patients with a neurologically complete spinal cord injury to begin within 8 hours of injury. After decompression, the cord was locally cooled through the intact dura using a suspended extradural saddle at the site of injury for up to 4 hours, during which time spinal fusion was performed. Sensation and motor function were evaluated directly after the injury and again over a year later. The patients were evaluated using the 2011 amendment to the American Spinal Injury Association (ASIA) Impairment Scale. RESULTS Eighty percent of the 20 patients (12 with cervical and 4 thoracic injuries) with an initial neurologically complete cord injury had some recovery of sensory or motor function. All patients initially had ASIA Grade A impairment. Of 14 patients with quadriplegia, 5 remained ASIA Grade A, 5 improved to ASIA Grade B, 3 to ASIA Grade C, and 1 to ASIA Grade D. The remaining 6 patients had suffered a thoracic spinal cord injury, and of these 2 remained ASIA Grade A, 1 recovered to ASIA Grade B, 2 to ASIA Grade C, and 1 ASIA Grade D. All considered, of 20 patients, 35% remained ASIA Grade A, 30% improved to ASIA Grade B, and 25% to ASIA Grade C. Impairment in 2 (10%) of 20 patients improved to ASIA Grade D. The mean improvement in neurological level of injury in all patients was 1.05, the mean improvement in motor level was 1.7, and the mean improvement in sensory level was 2.8. Two patients recovered the ability to walk, 2 could extend their legs, 5 could sense bladder fullness, and 3 had partial ability to void voluntarily. Four males recovered subnormal ability to have voluntary erection sufficient for limited sexual activity. CONCLUSIONS The authors present here results of 20 patients with neurologically complete spinal cord injury treated with a combination of surgical decompression, glucocorticoid administration, and regional hypothermia. These patients experienced a better recovery than might have been expected had traditional forms of treatment been used. The benefit of steroid treatment for cord injury has been debated in the last decade, but the authors feel that research into the effects of cord cooling should be expanded. Given that the optimal neuroprotective temperature after acute trauma has not yet been defined, and may well be below that which is considered safely approachable through systemic cooling, methods that allow for the early attainment of such a temperature locally should be further explored. The results are encouraging enough to suggest the undertaking of controlled clinical trials of treatment using localized spinal cord cooling, where such treatment can be instituted within hours following injury.
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Affiliation(s)
- Robert R Hansebout
- Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada; and
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Han JB, Keller EE, Grothe RM. Postoperative gastrointestinal bleeding in orthognathic surgery patients: its estimated prevalence and possible association to known risk factors. J Oral Maxillofac Surg 2014; 72:2043-51. [PMID: 24997023 DOI: 10.1016/j.joms.2014.02.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 02/22/2014] [Accepted: 02/25/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE To assess the prevalence of gastrointestinal (GI) bleeding in patients after orthognathic surgery and its relation to known risk factors. PATIENT AND METHODS With institutional review board approval, a single-center case series was conducted with data collected retrospectively from orthognathic surgical patients' medical records from 1990 to 2010. All patients were treated by 1 primary surgeon, were limited to 21 years or younger at the time of surgery, and had no coagulopathy. The authors' hypothesis was that patients concurrently exposed to mechanical ventilation and dual anti-inflammatory drugs in the postoperative period would be at a greater risk for clinically significant GI bleeding according to the American Society of Health-System Pharmacists guideline compared with those exposed to fewer risk factors. Its prevalence and relation to known risk factors were analyzed. RESULTS In total 498 orthognathic cases consisting of 220 male patients (median age, 17 yr; age range, 3 to 21 yr) and 262 female patients (median age, 17 yr; age range, 10 to 21 yr) were reviewed. Of 17 patients admitted to intensive care unit level of care postoperatively, 4 patients were exposed to concomitant administration of ketorolac and steroids while being mechanically ventilated. Two of these 4 patients developed esophagogastroduodenoscopy-confirmed upper GI bleeding (UGIB). There was no incidence of UGIB in patients not exposed to all 3 risk factors concurrently. CONCLUSIONS Postoperative GI bleeding complication is rare in orthognathic surgical patients, with an estimated prevalence of 0.4%. Based on these observations, orthognathic surgical patients who require mechanical ventilation and are receiving anti-inflammatory medications may have an increased risk of GI bleeding. In the absence of active bleeding from the surgical site, persistent decrease in hemoglobin concentration should alert one to consider the possibility of UGIB.
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Affiliation(s)
- James B Han
- Resident, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.
| | - Eugene E Keller
- Consultant, Division of Oral and Maxillofacial Surgery, Department of Surgery; Professor of Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | - Rayna M Grothe
- Chair, Pediatric Gastroenterology, Pediatric and Adolescent Medicine; Assistant Professor of Pediatrics, Mayo Clinic College of Medicine, Rochester, MN
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Sancho L, Téllez L, Cuño JL, Aicart M, López-Sanromán A. [Corticosteroids and gastroprotection]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:49-50. [PMID: 24309483 DOI: 10.1016/j.gastrohep.2013.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 02/18/2013] [Indexed: 06/02/2023]
Affiliation(s)
- Lorena Sancho
- Servicio de Aparato Digestivo, Hospital Universitario Río Hortega, Valladolid, España.
| | - Luis Téllez
- Servicio de Aparato Digestivo, Hospital Ramón y Cajal, Valladolid, España
| | - José Luis Cuño
- Servicio de Aparato Digestivo, Hospital Ramón y Cajal, Valladolid, España
| | - Marta Aicart
- Servicio de Aparato Digestivo, Hospital Ramón y Cajal, Valladolid, España
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Lanas A, Boers M, Nuevo J. Gastrointestinal events in at-risk patients starting non-steroidal anti-inflammatory drugs (NSAIDs) for rheumatic diseases: the EVIDENCE study of European routine practice. Ann Rheum Dis 2013; 74:675-81. [PMID: 24351518 DOI: 10.1136/annrheumdis-2013-204155] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Data concerning rates of gastrointestinal (GI) events in non-steroidal anti-inflammatory drug (NSAID) users derive mainly from clinical trials. The EVIDENCE study quantified the incidence of symptomatic uncomplicated and/or complicated GI events in at-risk European patients treated with NSAIDs in real-life practice. METHODS This non-interventional study assessed 4144 adults with at least one GI risk factor who recently initiated NSAID therapy for osteoarthritis (85%), rheumatoid arthritis (11%), ankylosing spondylitis (3%) or a combination (1%). Patient characteristics and medical history were collected from medical records. GI events (upper and lower) were recorded at in-clinic visits during 6 months' follow-up. RESULTS Mean time on index NSAID at enrolment was 33 days. The incidence (per 100 person-years) was 18.5 per 100 person-years for uncomplicated GI events and 0.7 per 100 person-years for complicated GI events. Upper GI events were far more common (12%) than lower GI events (1%) during study follow-up (median 182 days (range 61-320)). Other reported rates for cardiovascular, anaemia or non-GI events were much less frequent. A minority (28%) of patients had ongoing proton pump inhibitor use at enrolment, with strong variation by practice and country. CONCLUSIONS EVIDENCE is the largest prospective study of the real-life management of European patients treated with NSAIDs for rheumatic diseases and at increased GI risk. It shows that GI events from the upper GI tract are far more common than those from the lower GI tract. It also shows adherence to guidelines for gastroprotection is generally low. CLINICALTRIALSGOV IDENTIFIER NCT01176682.
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Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Clinic Hospital, University of Zaragoza, Zaragoza, Spain
| | - Maarten Boers
- Departments of Epidemiology and Biostatistics and Rheumatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Javier Nuevo
- Observational Research Centre, Global Medicines Development, AstraZeneca, Madrid, Spain
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Masclee GMC, Valkhoff VE, van Soest EM, Schade R, Mazzaglia G, Molokhia M, Trifirò G, Goldstein JL, Hernández-Díaz S, Kuipers EJ, Sturkenboom MCJM. Cyclo-oxygenase-2 inhibitors or nonselective NSAIDs plus gastroprotective agents: what to prescribe in daily clinical practice? Aliment Pharmacol Ther 2013; 38:178-89. [PMID: 23710837 PMCID: PMC3687334 DOI: 10.1111/apt.12348] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 04/03/2013] [Accepted: 05/06/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Two strategies for prevention of upper gastrointestinal (UGI) events for nonselective nonsteroidal anti-inflammatory drug (nsNSAID) users are replacement of the nsNSAID by a cyclo-oxygenase-2-selective inhibitor (coxib) or co-prescription of a gastroprotective agent (GPA). AIM To identify whether and in whom either of these strategies should be preferred in daily practice. METHODS A nested case-control study was conducted using three European primary care databases. We selected a cohort including all naive nsNSAID+GPA (≥80% GPA adherence) and coxib users (without GPA use) aged ≥50 years. Cases with an UGI event (i.e. symptomatic UGI ulcer or bleeding) were matched to cohort members without an UGI event on age, sex and number of individual UGI risk factors (i.e. UGI event history, age ≥65 years, concomitant use of anticoagulants, antiplatelets, or glucocorticoids) and calendar time. Conditional logistic regression analysis was used to calculate odds ratios (ORs) with 95% CI, while adjusting for potential confounders. RESULTS Within the NSAID cohort (n = 617,220), 398 UGI cases were identified. The risk of UGI events was equivalent for coxib and nsNSAID+GPA (≥80% adherence) users (OR: 1.02; 95%CI: 0.77-1.37). In concurrent glucocorticoid users, the risk of UGI events was significantly elevated for nsNSAID+GPA (≥80% adherence) compared with coxib users (OR: 9.01; 95%CI: 1.61-50.50). CONCLUSIONS The risk of UGI events was similar in nsNSAID+GPA (≥80% adherence) and coxibs users. In patients concurrently using glucocorticoids, a significant increase in the risk of UGI events for nsNSAID+GPA users was observed and coxibs should be preferred.
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Affiliation(s)
- Gwen MC Masclee
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, The Netherlands.
,Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Vera E Valkhoff
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, The Netherlands.
,Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Eva M van Soest
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - René Schade
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Mariam Molokhia
- Primary Care & Public Health Sciences, Kings College London, London, United Kingdom
| | - Gianluca Trifirò
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, The Netherlands.
,Department of Clinical and Experimental Medicine and Pharmacology, University of Messina, Italy
| | - Jay L Goldstein
- Department of Medicine, Division of Gastroenterology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
,Department of Internal Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Miriam C J M Sturkenboom
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, The Netherlands.
,Department of Epidemiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Daniel BS, Murrell DF, Borradori L. Bullous pemphigoid: therapeutic algorithm and practical management. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2013.794693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bianciotto M, Chiappini E, Raffaldi I, Gabiano C, Tovo PA, Sollai S, de Martino M, Mannelli F, Tipo V, Da Cas R, Traversa G, Menniti-Ippolito F. Drug use and upper gastrointestinal complications in children: a case-control study. Arch Dis Child 2013; 98:218-21. [PMID: 23264432 PMCID: PMC3582087 DOI: 10.1136/archdischild-2012-302100] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the risk of upper gastrointestinal complications (UGIC) associated with drug use in the paediatric population. METHODS This study is part of a large Italian prospective multicentre study. The study population included children hospitalised for acute conditions through the emergency departments of eight clinical centres. Patients admitted for UGIC (defined as endoscopically confirmed gastroduodenal lesions or clinically defined haematemesis or melena) comprised the case series; children hospitalised for neurological disorders formed the control group. Information on drug and vaccine exposure was collected through parental interview during the children's hospitalisation. Logistic regression was used to estimate ORs for the occurrence of UGIC associated with drug use adjusted for age, clinical centre and concomitant use of any drug. RESULTS 486 children hospitalised for UGIC and 1930 for neurological disorders were enrolled between November 1999 and November 2010. Drug use was higher in cases than in controls (73% vs 54%; p<0.001). UGICs were associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) (adjusted OR 2.9, 95% CI 2.1 to 4.0), oral steroids (adjusted OR 2.9, 95% CI 1.7 to 4.8) and antibiotics (adjusted OR 2.3, 95% CI 1.8 to 3.1). The duration of use of these drug categories was short (range 1-8 days). Paracetamol showed a lower risk (adjusted OR 2.0, 95% CI 1.5 to 2.6) compared to ibuprofen (adjusted OR 3.7, 95% CI 2.3 to 5.9), although with partially overlapping CIs. CONCLUSIONS NSAIDs, oral steroids and antibiotics, even when administered for a short period, were associated with an increased risk of UGIC.
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Affiliation(s)
| | | | | | | | | | - Sara Sollai
- Anna Meyer Children's University Hospital, Florence, Italy
| | | | | | | | - Roberto Da Cas
- National Centre for Epidemiology, Italian National Institute of Health, Rome, Italy
| | - Giuseppe Traversa
- National Centre for Epidemiology, Italian National Institute of Health, Rome, Italy
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Koomanan N, Ko Y, Yong WP, Ng R, Wong YP, Lim SW, Salim A, Chan A. Clinical Impact of Drug–Drug Interaction Between Aspirin and Prednisolone at a Cancer Center. Clin Ther 2012. [DOI: 10.1016/j.clinthera.2012.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Han J, Keller E, Grothe R. Poster 35: Postoperative Stress-Induced Gastrointestinal Bleeding in Healthy Adolescent Patients Following Orthognathic Surgery. J Oral Maxillofac Surg 2012. [DOI: 10.1016/j.joms.2012.06.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lamchahab FE, Reffas W, Bouattar T, Abdellaoui EK, Ouzeddoun N, Bayahia R, Aouni A, El Fassi Fihri T, Senouci K, Ait Ourhroui M, Hassam B. [Evaluation of the prescription of long-term systemic steroid-therapy associated measures]. ANNALES PHARMACEUTIQUES FRANÇAISES 2012; 70:292-7. [PMID: 23020920 DOI: 10.1016/j.pharma.2012.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Revised: 07/08/2012] [Accepted: 07/14/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION To prevent the occurrence of corticosteroid's side effects, adjuvant measures are prescribed in a very different way depending on the practitioner's experience. The aim of this study was to assess the physicians' practices regarding the prescription of long-term corticosteroid therapy. METHODS In May 2010, we realized a cross-sectional study among physicians in Ibn Sina University Hospital in Rabat. With a data collection form, we assessed the principal indications for prescribing steroids and the frequency of prescription of measures sometimes associated with systemic corticosteroid. RESULTS Fifty-nine out of eighty physicians completed the data collection form (response rate: 69.4%). Calcium-vitamin D supplementation was recommended by most of the physicians. Half of them were prescribing biphosphonate therapy. Most of them propose a low-sodium, a low-fat and a low-carbohydrate dietary regimen. Regular physical exercise was recommended by 35% of physicians. Gastric protection was indicating by 54.4% of practicians and potassium supplementation by 42.1% of them. Finally, the recommendation for influenza vaccination, hydrocortisone prescription and Synacthen(®) test, varied between physicians. CONCLUSION The prescription of adjuvant measures with a long-term corticosteroid therapy was very heterogeneous. There is no consensus regarding most of the measures.
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Affiliation(s)
- F E Lamchahab
- Service de dermatologie vénérologie, faculté de médecine et de pharmacie, université Mohamed V, CHU Ibn Sina, Rabat, Maroc.
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Huang KW, Luo JC, Leu HB, Lin HC, Lee FY, Chan WL, Lin SJ, Chen JW, Chang FY. Chronic obstructive pulmonary disease: an independent risk factor for peptic ulcer bleeding: a nationwide population-based study. Aliment Pharmacol Ther 2012; 35:796-802. [PMID: 22348540 DOI: 10.1111/j.1365-2036.2012.05028.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 01/18/2012] [Accepted: 01/26/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Peptic ulcer bleeding remains a major healthcare problem despite decreasing prevalence of peptic ulcer disease. The role of chronic obstructive pulmonary disease (COPD) in the risk of peptic ulcer bleeding has not yet been established. AIM To determine if COPD patients have a higher risk of peptic ulcer bleeding than the general population and to identify the risk factors of peptic ulcer bleeding in COPD patients. METHODS From Taiwan's National Health Insurance research database, 62,876 patients, including 32,682 COPD and 30,194 age-gender-matched non-COPD controls, were recruited. Cox proportional hazard regression was performed to evaluate independent risk factors for ulcer bleeding in all patients and to identify risk factors in COPD patients. RESULTS During the 8-year follow-up, COPD patients had a significant higher rate of peptic ulcer bleeding than the control group (P < 0.001, by log-rank test). By Cox proportional hazard regression analysis, COPD [hazard ratio (HR) 1.93, 95% CI 1.73-2.17] was an independent risk factor after adjusting for age, gender, underlying comorbidities and ulcerogenic medication. Age > 65 years, male, comorbidities of hypertension, diabetes, heart failure, history of peptic ulcer disease, and chronic renal disease and use of nonsteroidal anti-inflammatory drugs were risk factors of ulcer bleeding in COPD patients. CONCLUSION Patients with chronic obstructive pulmonary disease have a higher risk of peptic ulcer bleeding after adjustments for possible confounding factors like underlying comorbidities and ulcerogenic medication.
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Affiliation(s)
- K-W Huang
- Department of Medicine, National Yang-Ming University, School of Medicine, Taipei, Taiwan
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Ruiz-Irastorza G, Espinosa G, Frutos MA, Jiménez Alonso J, Praga M, Pallarés L, Rivera F, Robles Marhuenda Á, Segarra A, Quereda C. [Diagnosis and treatment of lupus nephritis]. Rev Clin Esp 2012; 212:147.e1-30. [PMID: 22361331 DOI: 10.1016/j.rce.2012.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- G Ruiz-Irastorza
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, Hospital Universitario Cruces, UPV/EHU, Barakaldo, Bizkaia, España.
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Munson JC, Wahl PM, Daniel G, Kimmel SE, Hennessy S. Factors associated with the initiation of proton pump inhibitors in corticosteroid users. Pharmacoepidemiol Drug Saf 2012; 21:366-74. [PMID: 22278844 DOI: 10.1002/pds.2350] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 10/13/2011] [Accepted: 11/12/2011] [Indexed: 11/08/2022]
Abstract
PURPOSE Proton pump inhibitors (PPIs) and corticosteroids are commonly prescribed drugs; however, each has been associated with fracture and community-acquired pneumonia. How physicians select patients for co-therapy may have implications for potential additive or synergistic toxicities. METHODS We conducted a retrospective cohort study of 13 749 incident corticosteroid users with no prior PPI exposure using the HealthCore Integrated Research Database(SM) . We used logistic regression to evaluate the association between PPI initiation in the first 30 days of steroid therapy and corticosteroid dose, clinical risk factors including comorbid diseases, and medication use including prescription nonsteroidal anti-inflammatory drugs (NSAIDs). RESULTS A new PPI prescription within 30 days of starting corticosteroids was filled by 1050 patients (7.6%). PPI use was associated with the number of baseline comorbid conditions (OR = 1.21 for each additional condition, 95%CI = 1.13-1.28), recent hospitalization (OR = 4.71, 95%CI = 4.02-5.52), prednisone dose higher than 40 mg/day (OR = 1.87, 95%CI = 1.45-2.41), history of gastroesophageal reflux or gastric ulcer disease (OR = 1.54, 95%CI = 1.24-1.91), renal insufficiency (OR = 2.06, 95%CI = 1.73-2.46), and liver disease (OR = 1.82, 95%CI = 1.45-2.28). The concomitant use of prescription NSAIDs was also associated with PPI use (OR = 1.89, 95%CI = 1.32-2.70); however, the total use of PPIs in this group was low (6.3%, 95%CI = 4.4-8.2%). CONCLUSIONS Overall, PPI therapy among corticosteroid users was uncommon, even among those with risk factors for gastrointestinal toxicity. PPI use was significantly more common among patients who had recently been hospitalized, had a greater burden of comorbid illness, or were receiving high daily doses of corticosteroids.
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Affiliation(s)
- Jeffrey C Munson
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA.
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Rofecoxib and clinically significant upper and lower gastrointestinal events revisited based on documents from recent litigation. Am J Med Sci 2012; 342:356-64. [PMID: 21986300 DOI: 10.1097/maj.0b013e3182113658] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION On the basis of published data, it is widely believed and cited that rofecoxib use is associated with approximately a 50% reduction in significant gastrointestinal (GI) complications such as bleeding. METHODS Data made available as part of litigation, including the Vioxx Gastrointestinal Outcomes Research trial and an Alzheimer's study, allow a reassessment of the reported benefits of rofecoxib in terms of a significant reduction in complicated GI events and in lower GI bleeding. RESULTS During the review process of the Vioxx Gastrointestinal Outcomes Research study, it was suggested that rofecoxib might have little benefit, with regard to GI toxicity, for patients with rheumatoid arthritis not treated with corticosteroids. Reanalysis of the original Merck data set showed 9 complicated confirmed events in the rofecoxib group compared with 10 in the naproxen group among corticosteroid nonusers and 7 versus 27 among corticosteroid users so that the difference between rofecoxib and naproxen in the occurrence of confirmed complicated perforations, ulcers or bleeds seemed to be entirely because of the effects within corticosteroid users. The claim that serious lower GI events were 54% lower with the use of the selective cyclooxygenase-2 inhibitor rofecoxib was stated to be based on an assessment blinded to treatment allocation. In fact, the choice did not represent the original blinded analysis that showed a nonsignificant difference, but rather was based on an assessment after treatment allocation was disclosed. CONCLUSION Examination and reanalysis of unpublished data regarding rofecoxib has failed to confirm a safety advantage of rofecoxib over traditional nonsteroidal anti-inflammatory drugs in terms of complicated upper or lower GI events.
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