Secondary prevention of upper gastrointestinal bleeding associated with maintenance acid-suppressing treatment in patients with peptic ulcer bleed

Prevalence of xenobiotic substances in first-trimester blood samples from Danish pregnant women: a cross-sectional study

OBJECTIVE

The aim of this study was to investigate the prevalence of xenobiotic substances, such as caffeine, nicotine and illicit drugs (eg, cannabis and cocaine), in blood samples from first-trimester Danish pregnant women unaware of the screening.

DESIGN

A cross-sectional study examined 436 anonymised residual blood samples obtained during 2014 as part of the nationwide prenatal first-trimester screening programme. The samples were analysed by ultra performance liquid chromatography with high-resolution time-of-flight mass spectrometry.

SETTING

An antenatal clinic in a Danish city with 62 000 inhabitants, where >95% of pregnant women joined the screening programme.

PRIMARY AND SECONDARY OUTCOME MEASURES

The prevalence and patterns of caffeine, nicotine, medication and illicit drug intake during the first trimester of pregnancy.

RESULTS

The prevalence of prescription and over-the-counter drug detection was 17.9%, including acetaminophen (8.9%) and antidepressants (3.0%), of which citalopram (0.9%) was the most frequent. The prevalence of illegal drugs, indicators of smoking (nicotine/cotinine) and caffeine was 0.9%, 9.9%, and 76.4%, respectively. Only 17.4% of women had no substance identified in their sample.

CONCLUSIONS

This study emphasises the need for further translational studies investigating lifestyle habits during pregnancy, as well as the underlying molecular mechanisms through which xenobiotic substances may affect placental function and fetal development.

The role of aspirin in the prevention of cardiovascular disease

Aspirin therapy is well-accepted as an agent for the secondary prevention of cardiovascular events and current guidelines also define a role for aspirin in primary prevention. In this review, we describe the seminal trials of aspirin use in the context of current guidelines, discuss factors that may influence the effectiveness of aspirin therapy for cardiovascular disease prevention, and briefly examine patterns of use. The body of evidence supports a role for aspirin in both secondary and primary prevention of cardiovascular events in selected population groups, but practice patterns may be suboptimal. As a simple and inexpensive prophylactic measure for cardiovascular disease, aspirin use should be carefully considered in all at-risk adult patients, and further measures, including patient education, are necessary to ensure its proper use.

Risk of complications after a peptic ulcer diagnosis: effectiveness of proton pump inhibitors

BACKGROUND

Few studies have evaluated the prevention of upper gastrointestinal complications (UGIC; bleeding or perforation) in patients with uncomplicated peptic ulcer (PU). We assessed the effect of proton pump inhibitors (PPI) in a non-randomized setting. To maximize exchangeability of exposed and unexposed groups we restricted the study to patients with a new diagnosis of PU, i.e., a clear indication. To minimize selection bias we mimicked an intention to treat approach by assessing the effect of PPI prescription after PU diagnosis.

METHODS

Within a population of subjects aged 40-84 years from The Health Improvement Network database, 1997-2006, we identified 3,850 patients with incident PU. Among them, we confirmed 74 first UGIC episodes during a mean follow-up of 4 years. Exposure was prescription coverage during the month following PU diagnosis. We performed a nested case-control analysis and compared UGIC cases with 400 controls matched for age, sex, year and duration of follow-up. Relative risks (RR) and 95 % confidence intervals (CI) were estimated.

RESULTS

The overall incidence of UGIC was 4.6 cases/1,000 person-years; it was highest during the months after PU diagnosis, increased with age, and it was higher in men and subjects with Helicobacter pylori infection, anemia, and alcohol use at PU diagnosis. The RR for UGIC associated with PPI prescriptions during the month after PU diagnosis was 0.56 (95 % CI 0.31-1.0). The RR for NSAIDs with and without a PPI was 1.72 (0.68-4.45) and 3.27 (0.85-12.67), respectively.

CONCLUSIONS

Findings suggest that prescription of PPIs after a PU diagnosis is associated with a reduced risk of UGIC.

Non-steroidal anti-inflammatory drugs and gastroprotection with proton pump inhibitors: a focus on ketoprofen/omeprazole

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed agents for rheumatic disorders such as osteoarthritis (OA), rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Despite the known association between NSAID use and gastropathy, however, only around one-third of patients at risk of NSAID-induced gastrointestinal toxicity receive adequate gastroprotection, and as many as 44% of these patients are non-adherent. We review the co-prescription of proton pump inhibitors (PPIs) for the prevention of NSAID-induced gastropathy, with a particular focus on the first fixed-dose NSAID/PPI formulation: ketoprofen/omeprazole modified-release capsules. The ketoprofen/omeprazole fixed-dose combination is available in doses of 100 mg/20 mg, 150 mg/20 mg or 200 mg/20 mg as a single capsule for once-daily administration. Ketoprofen monotherapy has been shown to be generally equivalent to other NSAIDs when used in the treatment of OA. In RA, ketoprofen has demonstrated equivalent efficacy to diclofenac, indometacin, piroxicam, aceclofenac, phenylbutazone, naproxen and flurbiprofen. Studies comparing ketoprofen with ibuprofen and sulindac in patients with RA have, in general, favoured ketoprofen. Studies in AS have generally reported similar efficacy between ketoprofen and phenylbutazone and pirprofen. Prophylaxis with omeprazole is effective for the prevention of gastroduodenal ulcers, maintenance of remission and alleviation of dyspeptic symptoms in NSAID recipients. Omeprazole is well tolerated, and adverse events are generally gastrointestinal in nature. The fixed-dose combination of ketoprofen and omeprazole has demonstrated bioequivalence to the respective monotherapies. The incidence of digestive symptoms and the need for dose reduction was reported to be lower with the combination than with its components. Ketoprofen/omeprazole modified-release capsules are the first fixed-dose NSAID/PPI formulation to be approved. This formulation ensures compliance with the gastroprotective prophylaxis, as whenever the NSAID is taken, the PPI is co-administered. Additionally, the once-daily formulation has the potential to improve adherence to anti-inflammatory therapy.

Gastrointestinal and Cardiovascular Risk of Nonsteroidal Anti-inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) confer a gastrointestinal (GI) side effect profile and concerns regarding adverse cardiovascular effects have emerged associated with considerable morbidity and mortality. NSAIDs are highly effective in treating pain and inflammation, but it is well recognized that these agents are associated with substantial gastrointestinal toxicity. Cyclo-oxygenase-2 inhibitors may also reduce the risk for gastrointestinal events, although they may increase cardiovascular adverse events. The selection of an appropriate analgesic or anti-inflammatory agent with or without gastroprotective therapy should be individualized.

Evidence for endoscopic ulcers as meaningful surrogate endpoint for clinically significant upper gastrointestinal harm

BACKGROUND & AIMS

Surrogate endpoints are biomarkers intended to substitute for a clinical endpoint. Are endoscopic ulcers a useful surrogate endpoint for a biological progression to clinical endpoints of ulcer complications (perforation, ulcers, and bleeds), hospital admission, or death?

METHODS

Review of randomized trials, meta-analyses, clinical outcomes trials, and observational studies.

RESULTS

No large study examined both endoscopic and clinical endpoints. Endoscopic ulcers and clinically significant ulcer complications were affected in the same direction and to about the same extent in 4 distinct circumstances: (1) by risk factors-age, previous history of symptomatic ulcer or bleeding, Helicobacter pylori, aspirin; (2) in studies of antiulcer treatments with differing modes of action, especially in relation to nonsteroidal anti-inflammatory drug toxicity, and Helicobacter pylori infection; (3) in studies evaluating ulcer complications with Cox-2 selective drugs and nonsteroidal anti-inflammatory drugs; and (4) in studies of interventions in patients with high risk of recurrent ulcer bleed needing nonsteroidal anti-inflammatory drug therapy. All study designs showed consistent and reproducible effects on gastrointestinal ulcer complications paralleling endoscopy.

CONCLUSIONS

Consistent and plausible findings from disparate populations and designs make endoscopic ulcers a strong candidate for surrogacy, though direct progression from endoscopic ulcers to ulcer complications cannot be demonstrated. Large outcome studies are needed to establish the power of the surrogacy, absolute risk of clinical outcomes, and to identify the totality of risks and benefits of new pharmacologic therapies.

Management of NSAID-induced gastrointestinal toxicity: focus on proton pump inhibitors

The association between NSAIDs and the presence of upper gastrointestinal (GI) complications is well established. Evidence that acid aggravates NSAID-induced injury provides a rationale for minimizing such damage by acid suppression. Proton pump inhibitors (PPIs) appear to be very effective in treating NSAID-related dyspepsia, and also in healing gastric and duodenal ulcers in patients continuing to receive the NSAID. An analysis of data from comparative studies of PPIs versus ranitidine, misoprostol and sucralfate shows a therapeutic advantage in favour of the PPI. Several studies now confirm the efficacy of co-therapy with PPIs in the short- and long-term prevention of NSAID-induced upper GI injury. PPIs are more effective than histamine H(2)-receptor antagonists at standard dosages in reducing the risk of gastric and duodenal ulcer, and are superior to misoprostol in preventing duodenal but not gastric lesions. However, when balancing effectiveness and tolerance, PPIs may be considered the treatment of choice in the short- and long-term prevention of NSAID-related mucosal lesions. To date, there are only a few published articles dealing with the role of PPIs in the prevention of upper GI complications. Recent epidemiological and interventional studies provide some evidence that PPIs are of benefit. However, more controlled studies using clinical outcomes are needed to establish the best management strategy (PPIs combined with traditional NSAIDs or with cyclo-oxygenase-2 selective inhibitors) especially in patients with multiple risk factors, in patients using concomitant low-dose aspirin, corticosteroids or anticoagulants (high risk group), or in patients with a history of ulcer complications (very high risk group). Furthermore, it should be underlined that Helicobacter pylori infection positively interacts with the gastroprotective effect of PPIs; therefore, the true efficacy of these drugs in preventing NSAID-related ulcer complications should be reassessed without the confounding influence of this microorganism.

Guidelines for prevention of NSAID-related ulcer complications

Guidelines for clinical practice are intended to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind, placebo-controlled studies are preferable, but compassionate use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. Only when data that will not withstand objective scrutiny are available is a recommendation identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject, without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only, acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. These guidelines were developed under the auspices of the American College of Gastroenterology by a committee of experts in the field, reviewed by its Practice Parameters Committee, and approved by the Board of Trustees. The recommendations of these guidelines are therefore considered valid at the time of production based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at an established time and indicated at publication to assure continued validity. Owing to the volume of new data on the subject of non-steroidal anti-inflammatory drug (NSAID)-related injury to the upper gastrointestinal tract, i.e., the advent of cyclooxygenase (COX)-2 inhibitors, new data on interactions between these agents, as well as traditional NSAIDs, with aspirin and H. pylori, it was elected by the Committee to confine these guidelines to upper gastrointestinal (GI) injury and to leave post-duodenal injury as the subject of a separate guideline.

Management of patients on nonsteroidal anti-inflammatory drugs: a clinical practice recommendation from the First International Working Party on Gastrointestinal and Cardiovascular Effects of Nonsteroidal Anti-inflammatory Drugs and Anti-platelet Agents

BACKGROUND

Prescribing nonsteroidal antiinflammatory drugs (NSAIDs) is challenging because physicians have to consider gastrointestinal (GI) and cardiovascular (CV) safety issues.

OBJECTIVE

The purpose of the study was to determine appropriate NSAID treatment strategies based on different combinations of GI and CV risks.

METHODS

The working party comprised a multidisciplinary international panel of 19 experts. Two hundred eighty-eight vignettes were evaluated for the appropriateness of each of six options: naproxen, non-naproxen nonselective NSAIDs, naproxen plus proton pump inhibitor (PPI)/misoprostol, non-naproxen nonselective NSAID plus PPI/misoprostol, cyclooxygenase-2 selective NSAID (coxib), or coxib plus PPI/misoprostol. Using a two-stage modified Delphi process, the panel anonymously ranked the appropriateness of each option from 1 (extremely inappropriate) to 9 (extremely appropriate). Vignettes were considered appropriate if > or = 80% of all panelists' scores were 7-9 and inappropriate if > or = 80% of all panelists' scores were 1-3.

RESULTS

The panel rated nonselective NSAIDs as appropriate when the patient had average GI risk (< 70 yr of age; no prior upper GI event; no corticosteroids, antithrombotic agents, anticoagulants). In patients with GI risk factors, cotherapy with a PPI/misoprostol was appropriate. Either a nonselective NSAID or a coxib was rated appropriate in patients with average CV risk; naproxen was preferred in patients with high CV risk. None of the options was considered appropriate in patients with multiple GI risk factors and high CV risk.

CONCLUSIONS

The initial choice of an NSAID (naproxen vs. others) relates to a patient's CV risk, and the need for therapy to decrease GI complications (PPI/misoprostol or coxibs) is determined by severity and number of GI risk factors.

Proton pump inhibitors reduce the long-term risk of recurrent upper gastrointestinal bleeding: an observational study

BACKGROUND

Between 3% and 40% of patients surviving an episode of upper gastrointestinal bleeding (UGIB) experience a recurrence within 1 year. Aim To characterize further the recurrence rate of UGIB and to investigate the role of long-term acid suppressive therapy in its secondary prevention.

METHODS

Recurrent cases of UGIB were identified among patients registered in The Health Improvement Network in the UK. A nested case-control analysis provided relative risk (RR) estimates of factors associated with recurrence.

RESULTS

Of 1287 patients included, 67 (5.2%) were identified with a recurrent UGIB episode, corresponding to a recurrence rate of 17.5 per 1000 person-years during a mean follow-up of 3 years. The greatest risk of recurrence was in patients prescribed the oral anticoagulant warfarin (RR: 5.38; 95% confidence interval: 2.02-14.36). Use of a single proton pump inhibitor (PPIs) was associated with a reduced risk of recurrence (RR: 0.51; 95% confidence interval: 0.26-0.99), even in patients taking warfarin, while current use of H(2)-receptor antagonists was not. After the first episode of UGIB, use of nonsteroidal anti-inflammatory drugs and aspirin was greatly reduced, preventing estimation of the risk associated with these drugs.

CONCLUSION

Long-term PPI therapy reduces the risk of UGIB recurrence.

Combination of a cyclo-oxygenase-2 inhibitor and a proton-pump inhibitor for prevention of recurrent ulcer bleeding in patients at very high risk: a double-blind, randomised trial

BACKGROUND

Guidelines on pain management recommend that patients at risk of ulcers receive either a cyclo-oxygenase (COX 2) inhibitor or a non-steroidal anti-inflammatory drug (NSAID) with a proton-pump inhibitor (PPI). These two treatments have similar effectiveness, but they are insufficient for protection of patients at very high risk for ulcer bleeding. We aimed to test the hypothesis that in patients with previous ulcer bleeding induced by non-selective NSAIDs, combined treatment with the COX 2 inhibitor celecoxib and the PPI esomeprazole would be better than celecoxib alone for prevention of recurrent ulcer bleeding.

METHODS

441 consecutively presenting patients who were taking non-selective NSAIDs for arthritis were recruited to our single-centre, prospective, randomised, double-blind trial after admission to hospital with upper-gastrointestinal bleeding. Patients were enrolled after their ulcers had healed and a histological test for Helicobacter pylori was negative. All patients were given 200 mg celecoxib twice daily. 137 patients were randomly assigned to receive 20 mg esomeprazole twice daily (combined-treatment group), and 136 to receive a placebo (control group) for 12 months. The primary endpoint was recurrent ulcer bleeding during treatment or within 1 month of the end of treatment. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00365313.

FINDINGS

Combination treatment was more effective than celecoxib alone for prevention of ulcer bleeding in patients at high risk. The 13-month cumulative incidence of the primary endpoint was 0% in the combined-treatment group and 12 (8.9%) in the controls (95% CI difference, 4.1 to 13.7; p=0.0004). The median follow-up was 13 months (range 0.4-13.0). Discontinuation of treatment and the incidence of adverse events were similar in the two treatment groups.

INTERPRETATION

Patients at very high risk for recurrent ulcer bleeding who need anti-inflammatory analgesics should receive combination treatment with a COX 2 inhibitor and a PPI. Our findings should encourage guideline committees to review their recommendations for patients at very high risk of recurrent ulcer bleeding.

Complicated and uncomplicated peptic ulcers in a Danish county 1993-2002: a population-based cohort study

Peptic ulcer epidemiology changes as the proportion of Helicobacter pylori infected people decreases, use of nonsteroidal anti-inflammatory drugs (NSAID) increases, and the proportion of elderly persons increases.

OBJECTIVES

To describe incidence and prognosis of uncomplicated and complicated peptic ulcer patients in Funen County 1993-2002.

METHODS

Data on endoscopies, gastric and duodenal operations, and related peptic ulcer diagnoses were extracted from four population-based databases covering a period from 1974 to 2002. All citizens of Funen County (population 470,000) who between 1993 and 2002 had a peptic ulcer diagnosed for the first time were identified.

RESULTS

Between 1993 and 2002 the incidence of uncomplicated duodenal ulcer decreased from 0.55/1,000 person-years (95% CI 0.49-0.62) to 0.37 (0.31-0.43), uncomplicated gastric ulcer decreased from 0.56 (0.49-0.63) to 0.40 (0.34-0.46), and perforated ulcer decreased from 0.14 (0.11-0.18) to 0.08 (0.06-0.11). The incidence of bleeding peptic ulcer was stable with 0.55 (0.49-0.62) in 1993 and 0.57 (0.51-0.64) in 2002. The proportion of possible NSAID-related incident peptic ulcers increased from 320/827 (39%) in 1993 to 363/686 (53%) in 2002 (p < 0.01). A total of 3,233 patients with incident complicated peptic ulcer (9,927 person-years) and 4,421 patients with incident uncomplicated peptic ulcer (17,773 person-years) was followed for up to 10 yr. The first month following newly diagnosed complicated ulcer the standardized mortality rate was 37.1 (33.4-41.1) during the next 11 months it was 5.1 (4.6-5.6), and in the following years it was 2.6 (2.4-2.8). The corresponding figures for incident uncomplicated peptic ulcer was 11.6 (9.6-13.9), 4.0 (3.6-4.4), and 2.5 (2.3-2.7).

CONCLUSION

During the period, incidence of peptic ulcers decreased and an increasing proportion was related to NSAID. Mortality is high.

Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding

BACKGROUND

Concurrent therapy with a proton-pump inhibitor is a standard treatment for patients receiving aspirin who are at risk for ulcer. Current U.S. guidelines also recommend clopidrogel for patients who have major gastrointestinal intolerance of aspirin. We compared clopidogrel with aspirin plus esomeprazole for the prevention of recurrent bleeding from ulcers in high-risk patients.

METHODS

We studied patients who took aspirin to prevent vascular diseases and who presented with ulcer bleeding. After the ulcers had healed, we randomly assigned patients who were negative for Helicobacter pylori to receive either 75 mg of clopidogrel daily plus esomeprazole placebo twice daily or 80 mg of aspirin daily plus 20 mg of esomeprazole twice daily for 12 months. The end point was recurrent ulcer bleeding.

RESULTS

We enrolled 320 patients (161 patients assigned to receive clopidogrel and 159 to receive aspirin plus esomeprazole). Recurrent ulcer bleeding occurred in 13 patients receiving clopidogrel and 1 receiving aspirin plus esomeprazole. The cumulative incidence of recurrent bleeding during the 12-month period was 8.6 percent (95 percent confidence interval, 4.1 to 13.1 percent) among patients who received clopidogrel and 0.7 percent (95 percent confidence interval, 0 to 2.0 percent) among those who received aspirin plus esomeprazole (difference, 7.9 percentage points; 95 percent confidence interval for the difference, 3.4 to 12.4; P=0.001).

CONCLUSIONS

Among patients with a history of aspirin-induced ulcer bleeding whose ulcers had healed before they received the study treatment, aspirin plus esomeprazole was superior to clopidogrel in the prevention of recurrent ulcer bleeding. Our finding does not support the current recommendation that patients with major gastrointestinal intolerance of aspirin be given clopidogrel.

Celecoxib versus diclofenac and omeprazole in reducing the risk of recurrent ulcer bleeding in patients with arthritis

BACKGROUND

Current guidelines recommend that patients at risk for ulcer disease who require treatment for arthritis receive nonsteroidal antiinflammatory drugs (NSAIDs) that are selective for cyclooxygenase-2 or the combination of a nonselective NSAID with a proton-pump inhibitor. We assessed whether celecoxib would be similar to diclofenac plus omeprazole in reducing the risk of recurrent ulcer bleeding in patients at high risk for bleeding.

METHODS

We studied patients who used NSAIDs for arthritis and who presented with ulcer bleeding. After their ulcers had healed, we randomly assigned patients who were negative for Helicobacter pylori to receive either 200 mg of celecoxib twice daily plus daily placebo or 75 mg of diclofenac twice daily plus 20 mg of omeprazole daily for six months. The end point was recurrent ulcer bleeding.

RESULTS

In the intention-to-treat analysis, which included 287 patients (144 receiving celecoxib and 143 receiving diclofenac plus omeprazole), recurrent ulcer bleeding occurred in 7 patients receiving celecoxib and 9 receiving diclofenac plus omeprazole. The probability of recurrent bleeding during the six-month period was 4.9 percent (95 percent confidence interval, 3.1 to 6.7) for patients who received celecoxib and 6.4 percent (95 percent confidence interval, 4.3 to 8.4) for patients who received diclofenac plus omeprazole (difference, -1.5 percentage points; 95 percent confidence interval for the difference, -6.8 to 3.8). Renal adverse events, including hypertension, peripheral edema, and renal failure, occurred in 24.3 percent of the patients receiving celecoxib and 30.8 percent of those receiving diclofenac plus omeprazole.

CONCLUSIONS

Among patients with a recent history of ulcer bleeding, treatment with celecoxib was as effective as treatment with diclofenac plus omeprazole, with respect to the prevention of recurrent bleeding. Renal toxic effects are common in high-risk patients receiving celecoxib or diclofenac plus omeprazole.

A prospective study of the effects of female and male caffeine consumption on the reproductive endpoints of IVF and gamete intra-Fallopian transfer

BACKGROUND

This study evaluated the timing and amount of caffeine intake by women and men undergoing IVF and gamete intra-Fallopian transfer (GIFT) on oocyte retrieval, sperm parameters, fertilization, multiple gestations, miscarriage, and live births.

METHODS

A prospective study of 221 couples was conducted in Southern California between 1993 and 1998. "Usual" caffeine intake during lifetime and 1 year prior to attempt, caffeine intake during the week of the initial clinic visit, as well as intake during the week of the procedure, was evaluated from beverages (coffee, soda, tea) and chocolates.

RESULTS

Not achieving a live birth was significantly associated with "usual" female caffeine consumption [adjusted odds ratios (95% confidence intervals): 3.1 (1.1, 9.7) and 3.9 (1.3, 11.6) for intake of >2-50 and 50 mg/day, compared with 0-2 mg/day] and consumption during the week of the initial visit [2.9 (1.1, 7.5) and 3.8 (1.4, 10.7)] female compared with 0-2 mg/day, although caffeine use was low. Infant gestational age decreased by 3.8 (-6.9, -0.7) or 3.5 (-6.7, -0.3) weeks for women who consumed >50 mg/day of caffeine "usually" or during the week of the initial visit. The odds of having multiple gestations increased by 2.2 (1.1, 4.4) and 3.0 (1.2, 7.4) for men who increased their "usual" intake or intake during the week of the initial visit by an extra 100 mg/day. Caffeine intake was not significantly associated with other outcomes.

CONCLUSIONS

This is the first IVF/GIFT study to report any effect of caffeine on live births, gestational age, and multiple gestations. If these findings are replicated, caffeine use should be minimized prior to and while undergoing IVF/GIFT.

Contraindicated NSAIDs are frequently prescribed to elderly patients with peptic ulcer disease

AIMS

To establish the frequency with which NSAIDs were prescribed to elderly patients after admission to hospital for serious gastrointestinal complications and to study which factors are determinants of the prescription of these contraindicated drugs.

METHODS

A retrospective cohort study of patients from The Rotterdam Elderly Study, a prospective population-based cohort study of people older than 55 years of age was carried out. Elderly patients with a hospital admission for serious gastrointestinal complications were followed until prescription of an NSAID, death, removal to another area or end of the study period, whichever came first. The following baseline determinants for receiving a contraindicated prescription were studied: gender, age, presence of rheumatoid arthritis or osteoarthritis, presence of cardiovascular risk factors, number of GP visits, number of visits to a medical specialist, cognitive function and the prescriber being a GP or a medical specialist.

RESULTS

Prescriptions of an NSAID after discharge from hospital, were identified in 73 patients (73%). Fifty-one percent were prescribed aspirin of whom the large majority used it as an antithrombotic agent, and 49% were prescribed a nonaspirin NSAID after discharge from hospital. Twenty percent of the patients used more than one NSAID on one or more occasions after discharge. For patients who were prescribed NSAIDs before admission as well as after discharge, the proportion of contraindicated prescriptions with concomitant use of antiulcer drugs rose significantly from 0.19 before discharge to 0.60 after discharge for aspirin and from 0.11 to 0.61 for nonaspirin NSAIDs. In the multivariate analysis the only remaining factor with prognostic influence on prescription of NSAIDs was a history of NSAID use before cohort enrollment. A history of rheumatoid arthritis or osteoarthritis was not associated with NSAID prescription after discharge.

CONCLUSIONS

Contraindicated NSAIDs are prescribed to a great extent in elderly patients, despite their greater vulnerability for life-threatening gastrointestinal blood loss. It is remarkable that a history of rheumatoid arthritis or osteoarthritis is no significant determinant for receiving a contraindicated prescription, which suggests that these drugs are mainly prescribed for uncomplicated arthralgia.

[The BIFAP project: database for pharmaco-epidemiological research in primary care]

OBJECTIVES

To create a data base (BIFAP) with information provided by primary care doctors from the National Health System who use a computer at work, to evaluate its validity as a source of pharmaco-epidemiological information and to use it for the study of the efficacy and safety of medicines.

JUSTIFICATION

Some data bases, such as the British GPRD, have shown great efficiency in pharmaco-epidemiological research and in analysis of alarm signals in pharmacovigilance: primary care doctors are in a very good position to obtain clinical information from their patients. It is recommended that the impact of medicines on various populations is evaluated, including of course those medicines most used in Spain.

PILOT PHASE

January 2000-end of 2003. 300-500 doctors took part: a) monitoring of certain recommendations on recording; b) dispatch every 2 or 3 months to the Spanish Medicines Agency (AEM) of anonymous information with its origin encrypted (basic demographic details, morbidity, prescriptions, other data of epidemiological relevance), which are analysed by computer to check whether they meet adequate recording standards; c) despatch to the AEM of copies of anonymous clinical reports from small samples of patients (for BIFAP validation studies).

FEASIBILITY AND PERSPECTIVES

If BIFAP were viable, a standardised procedure for its use and protocols to support it as a research tool would be put in place.

Epidemiology of NSAID-related gastroduodenal mucosal injury

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the agents most frequently used against musculoskeletal and rheumatic disorders throughout the world. The gastroduodenal adverse effects include dyspepsia without endoscopically proven damage, asymptomatic endoscopic lesions of submucosal haemorrhage, erosions and ulcers, and-most important-ulcer complications. Established risk factors for NSAID-associated ulcer complications include patient-specific factors such as advanced age, female gender, a history of peptic ulcer, and drug-specific factors such as the use of non-selective NSAIDs (type, dose, duration, multiple use) and concomitant anticoagulant drugs or corticosteroids. Probable risk factors comprise Helicobacter pylori infection and heavy consumption of alcohol, whereas use of selective serotonin re-uptake inhibitors, smoking and a number of other factors have also been proposed to contribute. Knowledge of absolute risk estimates is important for clinical decision making. The aim of this chapter is to summarize the epidemiological data related to the broad spectrum of iatrogenic gastroduodenal mucosal injury.

Nonsteroidal anti-inflammatory drugs, low-dose aspirin, and potential ways of reducing the risk of complications

Use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with an annual incidence of 1-2% of gastrointestinal (GI) complications, which may be fatal in some cases. Low-dose aspirin is also associated with an increased risk of upper GI bleeding, but the increase is about three times lower than that found with common NSAIDs. Misoprostol (600-800 microg/day) reduces the incidence of complications in non-aspirin NSAID users. Co-therapy with antisecretory drugs (proton pump inhibitors, PPIs) also reduces the risk of GI bleeding in high-risk patients taking NSAIDs and/or low-dose aspirin. Another way of reducing the incidence of GI complications is to use the highly selective cyclo-oxygenase 2 (COX-2) inhibitors. The GI safety of nitric oxide NSAIDs (NO-NSAIDs) has been demonstrated extensively in experimental conditions and preliminary clinical studies. Epidemiological studies have also shown that nitric oxide donor drugs reduce the risk of upper GI bleeding, which might be important in patients receiving low-dose aspirin.

Role of acid suppressants in prophylaxis of NSAID damage

Gastric acid contributes to the pathogenesis of non-steroidal anti-inflammatory drug (NSAID)-induced ulceration via several mechanisms, including conversion of superficial to deeper injury, impairment of haemostasis, and interference with ulcer healing. The suppression of acid secretion has been shown to reduce the severity of NSAID-induced mucosal damage in experimental models and clinical studies. Current evidence indicates that proton pump inhibitors (PPIs) are the preferred treatment for the healing of gastric ulcers when NSAIDs cannot be discontinued. PPIs are superior to standard-dose H(2)-receptor antagonists and equivalent to low-dose misoprostol in preventing NSAID-induced gastric ulcers. Whether there is any significant advantage of PPIs over higher doses of H(2)-receptor antagonists or misoprostol is unknown. The efficacy of PPIs is enhanced in the presence of H. Pylori infection. Omeprazole has been shown to be effective for the secondary prevention of ulcer bleeding in H. pylori -infected NSAID users. The efficacy of PPIs for the prevention of ulcer complications in H. pylori-negative NSAID users remains uncertain.

Preventing recurrent upper gastrointestinal bleeding in patients with Helicobacter pylori infection who are taking low-dose aspirin or naproxen

BACKGROUND

Many patients who have had upper gastrointestinal bleeding continue to take low-dose aspirin for cardiovascular prophylaxis or other non-steroidal antiinflammatory drugs (NSAIDs) for musculoskeletal pain. It is uncertain whether infection with Helicobacter pylori is a risk factor for bleeding in such patients.

METHODS

We studied patients with a history of upper gastrointestinal bleeding who were infected with H. pylori and who were taking low-dose aspirin or other NSAIDs. We evaluated whether eradication of the infection or omeprazole treatment was more effective in preventing recurrent bleeding. We recruited patients who presented with upper gastrointestinal bleeding that was confirmed by endoscopy. Their ulcers were healed by daily treatment with 20 mg of omeprazole for eight weeks or longer. Then, those who had been taking aspirin were given 80 mg of aspirin daily, and those who had been taking other NSAIDs were given 500 mg of naproxen twice daily for six months. The patients in each group were then randomly assigned separately to receive 20 mg of omeprazole daily for six months or one week of eradication therapy, consisting of 120 mg of bismuth subcitrate, 500 mg of tetracycline, and 400 mg of metronidazole, all given four times daily, followed by placebo for six months.

RESULTS

We enrolled 400 patients (250 of whom were taking aspirin and 150 of whom were taking other NSAIDs). Among those taking aspirin, the probability of recurrent bleeding during the six-month period was 1.9 percent for patients who received eradication therapy and 0.9 percent for patients who received omeprazole (absolute difference, 1.0 percent; 95 percent confidence interval for the difference, -1.9 to 3.9 percent). Among users of other NSAIDs, the probability of recurrent bleeding was 18.8 percent for patients receiving eradication therapy and 4.4 percent for those treated with omeprazole (absolute difference, 14.4 percent; 95 percent confidence interval for the difference, 4.4 to 24.4 percent; P=0.005).

CONCLUSIONS

Among patients with H. pylori infection and a history of upper gastrointestinal bleeding who are taking low-dose aspirin, the eradication of H. pylori is equivalent to treatment with omeprazole in preventing recurrent bleeding. Omeprazole is superior to the eradication of H. pylori in preventing recurrent bleeding in patients who are taking other NSAIDs.

Prospects for changing the burden of nonsteroidal anti-inflammatory drug toxicity

Traditional nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of clinically important upper gastrointestinal ulcers and bleeds about fourfold. Other risk factors for these events include advanced age, higher NSAID dose, prior ulcer or bleed, use of anticoagulants, use of corticosteroids, and poor general health. Among NSAID users with more than one risk factor, the incidence of serious ulcer complications may be as high as 4% to 8% per year. NSAIDs may also increase blood pressure and have adverse effects on renal function. NSAID-associated toxicity may be decreased by (1) trying less toxic alternative drugs; (2) using NSAIDs less frequently or at a lower dose; (3) use of cotherapy, such as misoprostol or proton pump inhibitors, to prevent complications; (4) or use of the more selective cyclooxygenase-2 inhibitors. More research is needed to determine which of these strategies or combination of strategies is optimal in terms of patient safety and cost.

Nitrovasodilators, low-dose aspirin, other nonsteroidal antiinflammatory drugs, and the risk of upper gastrointestinal bleeding

BACKGROUND The relation between medications that release nitric oxide, such as nitroglycerin and other nitrovasodilators, and upper gastrointestinal bleeding is uncertain. In animals, these medications reduce the gastric damage induced by nonsteroidal antiinflammatory drugs. Nitric oxide, however, inhibits platelet aggregation and may contribute to bleeding from an ulcer.

METHODS

We performed a case-control study to determine the risk of bleeding in patients taking nitrovasodilators, low-dose aspirin, or other nonsteroidal antiinflammatory drugs. The case group was made up of 1122 consecutive patients admitted to one of four hospitals with bleeding from a peptic lesion. The 2231 control subjects were 1109 patients hospitalized for other reasons and 1122 outpatients from the same geographic area.

RESULTS

In the week before admission, 520 (46.3 percent) of the patients with bleeding had taken a nonsteroidal antiinflammatory drug other than low-dose aspirin, 120 (10.7 percent) had taken low-dose aspirin (< or = 300 mg per day), 60 (5.3 percent) a nitrovasodilator, and 135 (12.0 percent) an antisecretory agent such as a histamine H2-receptor antagonist or a proton-pump inhibitor. In multivariate models that adjusted for age, sex, and clinical risk factors, the use of a nonsteroidal antiinflammatory drug other than low-dose aspirin was independently associated with an increased risk of bleeding from a peptic ulcer (odds ratio, 7.4; 95 percent confidence interval, 4.5 to 12.0), as was the use of low-dose aspirin alone (odds ratio, 2.4; 95 percent confidence interval, 1.8 to 3.3). The use of a nitrovasodilator was associated with a decreased risk of bleeding (odds ratio, 0.6; 95 percent confidence interval, 0.4 to 0.9), as was antisecretory therapy (odds ratio, 0.6; 95 percent confidence interval, 0.4 to 0.8). In patients taking any type of nonsteroidai antiinflammatory drug, the use of a nitrovasodilator or antisecretory therapy was independently associated with a decreased risk of bleeding.

CONCLUSIONS

The use of nitrovasodilator drugs is independently associated with a decreased risk of upper gastrointestinal bleeding.

Nonsteroidal anti-inflammatory drug gastropathy

By inhibiting prostaglandin synthesis, nonsteroidal anti-inflammatory drugs (NSAIDs) compromise gastroduodenal defense mechanism including blood flow and mucus/bicarbonate secretion. This has led to NSAIDs being the most widely reported drug cause of adverse events. While NSAIDs also cause dyspepsia, inhibition of prostaglandin synthesis may reduce this from even higher levels that would otherwise prevail and mask ulcer-related dyspepsia, making anticipatory management difficult. On average, the risk of ulcer complications increases 4-fold, resulting in 1.25 additional hospitalizations per 100 patient-years according to one estimate. Older patients, those with a past history, and those taking anticoagulants or corticosteroids are at higher risk. Risk is dose dependent and is lower with ibuprofen at low doses than with other NSAIDs. It is unlikely that Helicobacter pylori increases the risk, and under some circumstances it may be protective. Selective inhibitors of the inducible cyclooxygenase 2 spare gastric mucosal prostaglandin synthesis and do not damage the gastric mucosa. Their place in therapy, compared with use of misoprostol or proton pump inhibitors, is currently emerging. Future competitors may include nitric oxide-donating, zwitterionic, or R-enantiomer NSAIDs.

Management of gastroduodenal ulcers caused by non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are a major cause of morbidity and mortality, probably resulting in the death of 1200 patients per annum in the UK. The main mechanism of toxicity involves an inhibition of prostaglandin synthesis that results in mucosal erosion as a result of the abrogation of defence mechanisms. However, acid peptic attack can deepen this initial injury. Thus, logical treatments include prostaglandin analogues as 'replacement therapy', acid suppression, enteric coating to avoid topical effects and the use of safer NSAIDs, including those that have little or no effect on gastric mucosal prostaglandin synthesis. There is less logic to the strategy of Helicobacter pylori (H. pylori) eradication, and the status of this approach is controversial. Overall, proton pump inhibitors have the best profile of efficacy and side-effects for the healing and prevention of NSAID-associated ulcers. Misoprostol is also effective and appears to be superior to proton pump inhibitors for superficial erosive injury. Early indications are that selective inhibitors of the inducible cyclooxygenase-2 enzyme have little or no effect in causing ulcers. Growing experience with these agents will probably revolutionize the management of patients with arthritic conditions. However, the increasing use of low-dose aspirin for cardiovascular prophylaxis means that gastroenterologists will have to continue to grapple with the problems of NSAID-associated ulcers for some time to come.