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Chen HL, Lei WY, Wang JH, Bair MJ, Chen CL. Proton pump inhibitor use and the risk for Parkinson's disease: A nationwide population-based study in Taiwan. Medicine (Baltimore) 2023; 102:e33711. [PMID: 37171333 PMCID: PMC10174385 DOI: 10.1097/md.0000000000033711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
Previous studies have shown that proton pump inhibitors (PPIs) are associated with an increased risk of dementia. However, little is known about the relationship between PPIs use and Parkinson's disease (PD). This study aimed to examine whether PPI use was associated with an increased risk of developing clinically verified PD. This used data from the Taiwan National Health Insurance Research Database for the period between 1999 and 2011, and patients with PPI use were compared with 1 to 1 propensity score-matched controls by age, sex, cohort entry year, and comorbidity. A multivariate analysis was performed using Cox proportional hazards models to estimate the association between PPI use and PD risk. Subgroup analyses according to sex, age, and comorbidities were also conducted. In total, 56,785 PPI users and 56,785 matched controls were enrolled in this study. In the PPI cohort, 366 patients developed PD during a median follow-up of 5.0 years. The incidence rate of PD was 1.48-fold higher in PPI users than in non-PPI users (90.0 vs 133.2 per 100,000 person-years), with an adjusted hazard ratio of 1.76 (95% confidence interval, 1.48-2.08). In the subgroup analysis, the adjusted risk of PD in the PPI and non-PPI cohorts increased in the subgroups regardless of age, sex, and comorbidities. The results of this retrospective, nationwide, population-based cohort study in Taiwan indicate that PPI use is associated with the risk of PD development. Further mechanistic studies on the effect of PPI on PD are needed.
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Affiliation(s)
- Huan-Lin Chen
- Division of Gastroenterology, Department of Internal Medicine, Taitung MacKay Memorial Hospital, Taitung, Taiwan
- Mackay Medical College, New Taipei, Taiwan
| | - Wei-Yi Lei
- Division of Gastroenterology, Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Ming-Jong Bair
- Division of Gastroenterology, Department of Internal Medicine, Taitung MacKay Memorial Hospital, Taitung, Taiwan
- Mackay Medical College, New Taipei, Taiwan
| | - Chien-Lin Chen
- Division of Gastroenterology, Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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Longo S, Altobelli E, Castellini C, Vernia F, Valvano M, Magistroni M, Mancusi A, Viscido A, Ashktorab H, Latella G. Non-steroidal anti-inflammatory drugs and acetylsalicylic acid increase the risk of complications of diverticular disease: a meta-analysis of case-control and cohort studies. Int J Colorectal Dis 2022; 37:521-529. [PMID: 35094111 DOI: 10.1007/s00384-021-04088-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The role of non-steroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid in the occurrence of diverticular bleeding (DB), complicated diverticulitis (CD), and acute diverticulitis (AD) is not yet defined. AIM Update a systematic review and meta-analyses of case-control and cohort studies to evaluate the association between NSAIDs or acetylsalicylic acid with DB, CD, or AD. METHODS The study included were identified through MEDLINE, Scopus, Web of Science, and Cochrane Library databases. Sizes were pooled across studies to obtain the overall effect size. A random-effects model was used to account for different sources of variation among studies. Odds ratio (OR) with 95% confidence interval (CI) was used as a measure of effect size. RESULTS Thirteen studies were included in the systematic review and meta-analysis. NSAIDs and acetylsalicylic acid use were associated with an increased risk of DB (OR: 6.90, 95% CI 3.86 to 12.35, P ˂ 0.00001, and OR 2.84, 95% CI 2.19 to 3.67, P < 0.00001, respectively). NSAIDs and acetylsalicylic acid use were also associated with increased risk of CD occurrence (OR 3.13, 95% CI 1.73 to 5.68, P = 0.0002, and OR 1.49, 95% CI 1.02 to 2.17, P = 0.04, respectively). The only study found about AD occurrence showed that NSAIDs use was not associated with AD and acetylsalicylic acid use had a low risk of AD. CONCLUSION NSAIDs and acetylsalicylic acid significantly increase the risk of DB and CD. Further studies are needed to clarify the role of NSAIDs and acetylsalicylic acid in AD. However, increasing evidence suggests caution in the use of such medications in patients with colonic diverticula.
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Affiliation(s)
- Salvatore Longo
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Emma Altobelli
- Epidemiology and Biostatistics Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Chiara Castellini
- Andrology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Filippo Vernia
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marco Valvano
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marco Magistroni
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Antonio Mancusi
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Angelo Viscido
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Hassan Ashktorab
- Department of Medicine, Gastroenterology Division and Cancer Center, Howard University, Washington, DC, USA
| | - Giovanni Latella
- Gastroenterology, Hepatology and Nutrition Division, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.
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Ágústsson AS, Ingason AB, Rumba E, Pálsson D, Reynisson IE, Hreinsson JP, Björnsson ES. Causes of gastrointestinal bleeding in oral anticoagulant users compared to non-users in a population-based study. Scand J Gastroenterol 2022; 57:239-245. [PMID: 34749581 DOI: 10.1080/00365521.2021.1998600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Causes of gastrointestinal bleeding (GIB) in patients on oral anticoagulants (OACs) are not well established. The aims of the study were to compare the causes of GIB in patients on OACs and those not on OAC therapy. METHODS A nationwide study of all GIB events in patients on OACs in Iceland from 2014-2019 was conducted. Bleeding events were obtained through ICD-10 codes and review of endoscopy databases, confirmed by review of medical records. For comparison, patients not on OACs from previous Icelandic population-based studies were used. RESULTS Among 752 GIB events in 12,005 patients on OACs, 273 (1.9%) had verified upper and 391 (2.7%) had verified lower GIB. For lower GIB, multivariate analysis showed that OAC users were more likely to have colonic polyps (OR 6.6, 95% CI: 2.4 - 17.8, p < .001) or colorectal cancer (OR 3.7, 95% CI: 2.0 - 7.0, p < .001) but less likely to have ischemic colitis (OR 0.11, 95% CI: 0.04 - 0.26, p < .001). For upper GIB, bleeding from mucosal erosions (OR 4.0 95% CI: 2.5 - 7.9, p < .001) and angiodysplasia (OR 3.6, 95%CI: 1.5 - 8.6, p = .003) were more common in OAC users. CONCLUSIONS A high proportion of GIB caused by colonic polyps and colorectal cancer among OAC patients indicates that OACs treatment may facilitate cancer diagnosis. The low proportion of ischemic colitis among those on OACs suggests that OACs provide a protective effect against ischemic colitis. OACs seem to increase the bleeding from angiodysplasia and mucosal erosive disease.
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Affiliation(s)
- Arnar S Ágústsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Arnar B Ingason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Edward Rumba
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Daníel Pálsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | | | - Jóhann P Hreinsson
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Einar S Björnsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
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Blanc F, Waechter C, Vogel T, Schorr B, Demuynck C, Hunyadi CM, Meyer M, Mutelica D, Bougaa N, Fafi-Kremer S, Calabrese L, Schmitt E, Imperiale D, Jehl C, Boussuge A, Suna C, Weill F, Matzinger A, Muller C, Karcher P, Kaltenbach G, Sauleau E. Therapeutic prevention of COVID-19 in elderly: a case-control study. GeroScience 2021; 43:2333-2343. [PMID: 34273049 PMCID: PMC8285285 DOI: 10.1007/s11357-021-00397-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/31/2021] [Indexed: 12/11/2022] Open
Abstract
COVID-19 is a particularly aggressive disease for the elderly as 86% of deaths related to COVID-19 occur in people over 65 years of age. Despite the urgent need for a preventive treatment, there are currently no serious leads, other than the vaccination. The aim of this retrospective case-control study is to find a pharmacological preventive treatment of COVID-19 in elderly patients. One-hundred-seventy-nine patients had been in contact with other COVID-19 patients at home or in hospital, of whom 89 had tested RT-PCR-positive (COVID-pos) for the virus and 90 had tested RT-PCR-negative (COVID-neg). Treatments within 15 days prior to RT-PCR (including antihypertensive drugs, antipsychotics, antibiotics, nonsteroidal anti-inflammatory drugs, proton pump inhibitors (PPIs), oral antidiabetics (OADs), corticosteroids, immunosuppressants), comorbidities, symptoms, laboratory values, and clinical outcome were all collected. COVID-pos patients more frequently had a history of diabetes (P = .016) and alcoholism (P = .023), a lower leukocyte count (P = .014) and a higher mortality rate - 29.2% versus 14.4% - (P = .014) when compared to COVID-neg patients. Patients on PPIs were 2.3 times less likely (odds ratio [OR] = 0.4381, 95% confidence interval [CI] [0.2331, 0.8175], P = .0053) to develop COVID-19 infection, compared to those not on PPIs. No other treatment decreased or increased this risk. COVID-pos patients on antipsychotics (P = .0013) and OADs (P = .0153), particularly metformin (P = .0237), were less likely to die. Thus, patients on treatment with PPI were less likely to develop COVID-19 infection, and those on antipsychotics or metformin had a lower risk of mortality. However, prospective studies, including clinical trials, are needed to confirm or not these findings.
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Affiliation(s)
- Frederic Blanc
- ICube Laboratory, UMR 7357 and CNRS, University of Strasbourg, Strasbourg, France.
| | - Cedric Waechter
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Thomas Vogel
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Benoit Schorr
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Catherine Demuynck
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Catherine Martin Hunyadi
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Maxence Meyer
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Denata Mutelica
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Nadjiba Bougaa
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Samira Fafi-Kremer
- Virology Department, University Hospital of Strasbourg, Strasbourg, France
| | - Lidia Calabrese
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Elise Schmitt
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Delphine Imperiale
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Catherine Jehl
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Alexandre Boussuge
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Carmen Suna
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - François Weill
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Alexia Matzinger
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Candice Muller
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Patrick Karcher
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Georges Kaltenbach
- Pôle de Gériatrie, La Robertsau Geriatric Hospital, University Hospital of Strasbourg, Strasbourg, France
| | - Erik Sauleau
- ICube Laboratory, UMR 7357 and CNRS, University of Strasbourg, Strasbourg, France
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Zhang Y, Jin L, Zhang X, Bai R, Chen D, Ma Y, Zhai X. Emergency hospitalizations for adverse drug events in China: Clinical pharmacists' approach to assessment and categorization. Pharmacoepidemiol Drug Saf 2021; 30:636-643. [PMID: 33630347 DOI: 10.1002/pds.5215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 02/21/2021] [Indexed: 11/10/2022]
Abstract
PURPOSE Little is known about emergency hospitalizations owing to adverse drug events (ADEs) in Chinese populations. The aim of this study was to identify the types and characteristics of ADEs as well as estimate the length of hospital stay and ADE-related costs in a hospital emergency setting in China. METHODS This prospective study was conducted in the emergency department of our hospital from April 1, 2017 to December 31, 2019. ADEs of patients admitted to the emergency department were collected by a clinical pharmacist during daily pharmacy rounds. RESULTS Of 4020 cases admitted to the emergency department, 198 emergency ADE-related hospitalizations (4.93%) were noted, which were classified into certain (n = 0, 0%), probable (n = 122, 61.6%), and possible (n = 76, 38.4%). The ADE was serious in 93.9% of the 198 cases. Ten cases were fatal, and two cases were life-threatening. More than 80% of the emergency ADE-related hospitalization cases were of patients over 60 years. The pharmacological agents implicated in the hospitalizations were oral antiplatelet agents (20.7%), oral hypoglycemic agents (16.7%), insulin (11.1%), and antihypertensive agents (9.1%). The average length of ADE-related hospital stay was 10 (7.0-14.0) days. ADE-related costs ranged from $1684.68 to $4531.35 for each hospitalization. The length of ADE-related hospital stay and associated costs were statistically significant. Most ADEs (n = 146, 73.7%) were preventable. CONCLUSIONS Most emergency ADE-related hospitalizations in older adults resulted from lack of medication monitoring or inappropriate medication. Improved management of medicines by clinical pharmacists has the potential to reduce ADE-related hospitalizations in older adults in China.
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Affiliation(s)
- Yuyi Zhang
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Li Jin
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaogang Zhang
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rong Bai
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Danxia Chen
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yabin Ma
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaobo Zhai
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Fernando SM, Mok G, Castellucci LA, Dowlatshahi D, Rochwerg B, McIsaac DI, Carrier M, Wells PS, Bagshaw SM, Fergusson DA, Tanuseputro P, Kyeremanteng K. Impact of Anticoagulation on Mortality and Resource Utilization Among Critically Ill Patients With Major Bleeding. Crit Care Med 2020; 48:515-524. [PMID: 32205598 DOI: 10.1097/ccm.0000000000004206] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Patients with major bleeding are commonly admitted to the ICU. A growing number are on either oral or parenteral anticoagulation, but the impact of anticoagulation on patient outcomes is unknown. We sought to examine this association between anticoagulation therapy and mortality, as well as the independent effects of warfarin compared to direct oral anticoagulants. DESIGN Analysis of a prospectively collected registry (2011-2017) of consecutive ICU patients admitted with major bleeding (as defined by International Society on Thrombosis and Haemostasis clinical criteria). SETTING Two hospitals within a single tertiary care level hospital system. PATIENTS We analyzed 1,598 patients identified with major bleeding, of which 245 (15.3%) had been using anticoagulation at the time of ICU admission. Of patients on anticoagulation, 149 were using warfarin, and 60 were using a direct oral anticoagulant. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model. Patients with anticoagulation-associated major bleeding had higher in-hospital mortality (adjusted odds ratio, 1.49; 95% CI, 1.16-1.92). Among survivors, anticoagulation use was associated with longer median hospital length of stay, and higher mean costs. No differences in hospital mortality were seen between warfarin- and direct oral anticoagulant-associated major bleeding. Patients with warfarin-associated major bleeding had longer median length of stay (11 vs 6 d; p = 0.02), and higher total costs than patients with direct oral anticoagulant-associated major bleeding. CONCLUSIONS Among ICU patients admitted with major bleeding, pre-admission anticoagulation use was associated with increased hospital mortality, prolonged length of stay, and higher costs among survivors. As compared to direct oral anticoagulants, patients with warfarin-associated major bleeding had increased length of stay and costs. These findings have important implications in the care of ICU patients with major bleeding.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Garrick Mok
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Daniel I McIsaac
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Dean A Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Oakland K, Desborough MJ, Murphy MF, Schachter M, Jairath V. Rebleeding and Mortality After Lower Gastrointestinal Bleeding in Patients Taking Antiplatelets or Anticoagulants. Clin Gastroenterol Hepatol 2019; 17:1276-1284.e3. [PMID: 29277620 DOI: 10.1016/j.cgh.2017.12.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/27/2017] [Accepted: 12/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients who develop lower gastrointestinal bleeding (LGIB) while receiving anticoagulants or anti-platelets have increased severity of bleeding and risk of rebleeding. We compared outcomes of patients receiving antiplatelets, anticoagulants, or direct oral anticoagulants (DOACs) who develop LGIB, as well as the effects of withholding these drugs on their course of bleeding. METHODS We performed a retrospective study of 2528 consecutive adult patients with LGIB at 143 hospitals in the United Kingdom, from September through December 2015; 917 were taking anticoagulant or antiplatelet drugs and 1218 were taking neither (unexposed). We collected data on demographic features of patients, interventions or medications, outcomes, laboratory test results, and patient readmission until patient death, discharge, or 28 days after admission (whichever came first). Rebleeding was defined as additional transfusion requirements and/or a decrease in hematocrit ≥20% after 24 hrs of clinical stability. Multivariate regression was used to examine the relationship between drug class on presentation with LGIB and rebleeding, mortality, and cardiovascular events. Rates of rebleeding and cardiovascular complications in patients who had these drugs withheld were also analyzed. RESULTS Patients receiving antiplatelets, but not those receiving warfarin (n = 232) or DOACs (n = 102), had a higher risk of in-hospital rebleeding (monotherapy hazard ratio [HR], 3.57; 95% CI, 1.13-11.28; n = 504 and dual antiplatelet therapy hazard ratio, 5.3; 95% CI, 1.56-18.54; n = 79) compared with the unexposed group. This risk was not lower in patients who received antiplatelets and had the drug withheld for fewer than 5 days, compared to those who continued the drug throughout admission (HR, 0.98; 95% CI, 0.45-2.17) No differences were observed in risk-adjusted mortality or readmission with further bleeding for patients receiving antiplatelets, DOACs, or warfarin. Cardiovascular events were too few to allow meaningful comparison. CONCLUSIONS In patients with LGIB, antiplatelet drugs, but not warfarin or DOACs, are associated with an increased risk of rebleeding. Withholding antiplatelets during admission does not lead to reduction in rebleeding.
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Affiliation(s)
- Kathryn Oakland
- NHS Blood and Transplant, Oxford, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
| | - Michael J Desborough
- NHS Blood and Transplant, Oxford, United Kingdom; Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Mike Schachter
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Vipul Jairath
- Division of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Department of Medicine, Division of Gastroenterology, University Hospital, Ontario, Canada
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8
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Oakland K. Changing epidemiology and etiology of upper and lower gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101610. [PMID: 31785737 DOI: 10.1016/j.bpg.2019.04.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 04/15/2019] [Indexed: 01/31/2023]
Abstract
Upper gastrointestinal bleeding (UGIB) develops in the oesophagus, stomach or duodenum and has an incidence of 47/100,000. Lower GIB (LGIB) develops in the small bowel, colon or anorectum and has an incidence of 33/100,000. Where the incidence of UGIB has fallen, driven by helicobacter pylori eradication and the use of proton pump inhibitors, the incidence of LGIB may be increasing. Interventions such as early endoscopy, risk assessment and national guidelines have improved clinical outcomes but have had limited impact on the economic burden of GIB. Previously LGIB was thought to be less severe than UGIB, but contemporary data suggest that patients with LGIB tend to have a longer length of hospital stay and may be at higher risk of death or re-bleeding.
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Affiliation(s)
- Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare UK, 242 Marylebone Road, London, NW16JL, United Kingdom.
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9
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Senel T, Ates I, Demir BF, Arikan MF, Karaahmetoglu S, Altiparmak E, Yilmaz N. The diagnostic and prognostic value of platelet indices in gastrointestinal bleeding. Am J Emerg Med 2019; 37:657-663. [DOI: 10.1016/j.ajem.2018.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/08/2018] [Accepted: 07/02/2018] [Indexed: 01/28/2023] Open
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Abstract
OBJECTIVE To determine the incidence of diverticular bleeding (DB) and examine the time trend of the incidence. Furthermore to study prognosis with regard to therapy and rebleeding. METHODS A retrospective, population-based study of patients with DB in a National University Hospital from 2006 to 2016. Patients were identified in an electronically stored colonoscopy database. Definite diverticular bleeding was defined as active bleeding, a nonbleeding visible vessel or adherent clot. Presumptive diverticular bleeding was defined as acute painless rectal bleeding leading to hospitalization with visible diverticula but no evidence of bleeding and no other colonic lesions or bleeding sites identified on endoscopy. A 30-day re-bleeding was determined after discharge. RESULTS A total of 3683 colonoscopy reports were reviewed, including 345 patients (males 51%) with presumptive 95% (n = 327) or definitive 5% (n = 18) diverticular bleeding. Overall 96% were treated conservatively, 3% endoscopically and 0.3% surgically. Only 5.8% of patients had a 30-day rebleed. After exclusion, 315 patients were included in the incidence calculations. The mean cumulative incidence of diverticular bleeding was 14/100,000 inhabitants per year. A time trend analysis of the incidence of DB revealed no significant change in incidence during the study period. CONCLUSIONS The mean incidence of colonic diverticular bleeding was found to be approximately 14 cases per 100,000 inhabitants and year. The incidence does not seem to have changed in the past decade. The vast majority of patients with diverticular bleeding did not require endoscopic therapy and could be managed with conservative treatment.
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Affiliation(s)
- G D Olafsson
- a Faculty of Medicine , University of Iceland , Reykjavik , Iceland
| | - J P Hreinsson
- b Division of Gastroenterology and Hepatology, Department of Internal Medicine , The National University Hospital of Iceland , Reykjavik , Iceland
| | - E S Björnsson
- a Faculty of Medicine , University of Iceland , Reykjavik , Iceland.,b Division of Gastroenterology and Hepatology, Department of Internal Medicine , The National University Hospital of Iceland , Reykjavik , Iceland
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Vodusek Z, Feuerstadt P, Brandt LJ. Review article: the pharmacological causes of colon ischaemia. Aliment Pharmacol Ther 2019; 49:51-63. [PMID: 30467871 DOI: 10.1111/apt.15052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/05/2018] [Accepted: 10/18/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Colon ischaemia is the most common ischaemic disorder of the gastrointestinal system, can affect any segment of the colon, and may present with a range of symptoms. Diagnosis can be challenging due to symptom overlap with other conditions, varied aetiology, and often rapid and self-resolving course. AIM To review comprehensively the literature regarding the pharmacological aetiologies of colonic ischaemia to enhance the understanding of the various mechanisms of disease, presentations, distribution, and outcomes. METHODS A PubMed search for "colon ischaemia" and "ischaemic colitis" alone as well as in combination with various known pharmacologic causes was performed. Only the highest quality and relevant literature was included in this review. The quality of the literature for each association was rated by the authors and a consensus was made when discrepancies were encountered. Only associations that were deemed "moderate" or "strong" were included. RESULTS The literature considering pharmacologically associated colonic ischaemia is diverse, lacks codification and is characterised by numerous case reports and case series. Constipation-inducing drugs, digoxin, hormonal therapies, illicit drugs, immunomodulators, laxatives, and NSAIDs were strongly associated with colonic ischaemia. Antimicrobials, appetite suppressants, chemotherapies, decongestants, diuretics, ergot alkaloids, serotonin agents, statins, and vasopressor agents were moderately associated. CONCLUSIONS Patients presenting with abdominal pain, diarrhoea, or bloody stool need to be evaluated for the possibility of this condition and treated accordingly. Timely diagnosis is necessary to improve patient outcomes. This review aims to increase awareness among clinicians regarding the presentation of pharmacologically induced colonic ischaemia.
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Affiliation(s)
- Ziga Vodusek
- Frank H. Netter, MD. School of Medicine, Quinnipiac University, North Haven, Connecticut
| | - Paul Feuerstadt
- Gastroenterology Center of Connecticut, Yale University School of Medicine, Hamden, Connecticut
| | - Lawrence J Brandt
- Division of Gastroenterology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Hreinsson JP, Sigurdardottir R, Lund SH, Bjornsson ES. The SHA 2PE score: a new score for lower gastrointestinal bleeding that predicts low-risk of hospital-based intervention. Scand J Gastroenterol 2018; 53:1484-1489. [PMID: 30457020 DOI: 10.1080/00365521.2018.1532019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Lower gastrointestinal bleeding (LGIB) risk scores have mainly focused on identifying high-risk patients. A risk score aimed at predicting which patients will not require hospital-based intervention may reduce unnecessary hospital admissions. The aim of the current study was to develop such a risk score. MATERIAL AND METHODS A retrospective, population-based study that included patients presenting to the emergency room (ER) with LGIB from 2010 to 2013. Hospital-based intervention was defined as blood transfusion, endoscopic hemostasis, arterial embolization or surgery. The study cohort was split into train (70%) and test (30%) data. Train data were used to produce a multiple logistic regression model and a risk score that was validated on the test data. RESULTS Overall, 581 patients presented 625 times to the ER, mean age 61 (±22), males 49%. Of train data patients, 72% did not require hospital-based intervention. Independent predictors of low-risk patients (did not require hospital-based intervention) were systolic pressure ≥100mmHg (Odds ratio [OR] 4.9), hemoglobin >12g/dL (OR 103), hemoglobin 10.5-12.0g/dL (OR 19), no antiplatelets (OR 3.7), no anticoagulants (OR 2.2), pulse ≤100 (OR 2.9), and visible bleeding in the ER (OR 3.8). When validating the score on the test data, only 2% were wrongly predicted to be low-risk, the negative predictive value was 96% and the area under curve was 0.83. CONCLUSIONS A new risk score has been developed for LGIB that may help identify low-risk patients in the ER that can be managed in an outpatient setting, thereby lowering unnecessary hospital admissions.
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Affiliation(s)
- Johann P Hreinsson
- a Department of Internal Medicine, Section of Gastroenterology and Hepatology , Landspitali - The National University Hospital , Reykjavik , Iceland.,b Faculty of Medicine , University of Iceland , Reykjavik , Iceland
| | - Ragna Sigurdardottir
- a Department of Internal Medicine, Section of Gastroenterology and Hepatology , Landspitali - The National University Hospital , Reykjavik , Iceland.,b Faculty of Medicine , University of Iceland , Reykjavik , Iceland
| | - Sigrun H Lund
- c Centre of Public Health Sciences , University of Iceland , Reykjavik , Iceland
| | - Einar S Bjornsson
- a Department of Internal Medicine, Section of Gastroenterology and Hepatology , Landspitali - The National University Hospital , Reykjavik , Iceland.,b Faculty of Medicine , University of Iceland , Reykjavik , Iceland
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Hálfdánarson ÓÖ, Pottegård A, Björnsson ES, Lund SH, Ogmundsdottir MH, Steingrímsson E, Ogmundsdottir HM, Zoega H. Proton-pump inhibitors among adults: a nationwide drug-utilization study. Therap Adv Gastroenterol 2018; 11:1756284818777943. [PMID: 29872455 PMCID: PMC5977421 DOI: 10.1177/1756284818777943] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/25/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The use of proton-pump inhibitors (PPIs) has grown worldwide, and there are concerns about increased unsubstantiated long-term use. The aim of the study was to describe the real-world use of PPIs over the past decade in an entire national population. METHODS This was a nationwide population-based drug-utilization study. Patterns of outpatient PPI use among adults in Iceland between 2003 and 2015 were investigated, including annual incidence and prevalence, duration of use, and dose of tablet used (lower versus higher), as well as the proportion of PPI use attributable to gastroprotection. RESULTS We observed 1,372,790 prescription fills over the entire study period, of which 95% were for higher-dose PPIs. Annual incidence remained stable across time (3.3-4.1 per 100 persons per year), while the annual prevalence increased from 8.5 per 100 persons to 15.5 per 100 persons. Prevalence increased with patient age and was higher among women than men. Duration of treatment increased with patients' age (36% of users over 80 years remained on treatment after 1 year compared with 13% of users aged 19-39 years), and was longer among those initiating on a higher dose compared with a lower dose. The proportion of PPI users concurrently using nonsteroidal anti-inflammatory drugs decreased over the study period, while the proportion concurrently using acetylsalicylic acid, oral anticoagulants, or platelet inhibitors increased. CONCLUSIONS In this nationwide study, a considerable increase in overall outpatient use of PPIs over a 13-year period was observed, particularly among older adults. Patients were increasingly treated for longer durations than recommended by clinical guidelines and mainly with higher doses.
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Affiliation(s)
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Einar S. Björnsson
- Department of Internal Medicine, The National University Hospital of Iceland, Reykjavik, Iceland, and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Sigrún H. Lund
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Margret H. Ogmundsdottir
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Eiríkur Steingrímsson
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Helga M. Ogmundsdottir
- Cancer Research Laboratory, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Helga Zoega
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland, and Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
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Elwood PC, Morgan G, Galante J, Chia JWK, Dolwani S, Graziano JM, Kelson M, Lanas A, Longley M, Phillips CJ, Pickering J, Roberts SE, Soon SS, Steward W, Morris D, Weightman AL. Systematic Review and Meta-Analysis of Randomised Trials to Ascertain Fatal Gastrointestinal Bleeding Events Attributable to Preventive Low-Dose Aspirin: No Evidence of Increased Risk. PLoS One 2016; 11:e0166166. [PMID: 27846246 PMCID: PMC5113022 DOI: 10.1371/journal.pone.0166166] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/19/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Aspirin has been shown to lower the incidence and the mortality of vascular disease and cancer but its wider adoption appears to be seriously impeded by concerns about gastrointestinal (GI) bleeding. Unlike heart attacks, stroke and cancer, GI bleeding is an acute event, usually followed by complete recovery. We propose therefore that a more appropriate evaluation of the risk-benefit balance would be based on fatal adverse events, rather than on the incidence of bleeding. We therefore present a literature search and meta-analysis to ascertain fatal events attributable to low-dose aspirin. METHODS In a systematic literature review we identified reports of randomised controlled trials of aspirin in which both total GI bleeding events and bleeds that led to death had been reported. Principal investigators of studies in which fatal events had not been adequately described were contacted via email and asked for further details. A meta-analyses was then performed to estimate the risk of fatal gastrointestinal bleeding attributable to low-dose aspirin. RESULTS Eleven randomised trials were identified in the literature search. In these the relative risk (RR) of 'major' incident GI bleeding in subjects who had been randomised to low-dose aspirin was 1.55 (95% CI 1.33, 1.83), and the risk of a bleed attributable to aspirin being fatal was 0.45 (95% CI 0.25, 0.80). In all the subjects randomised to aspirin, compared with those randomised not to receive aspirin, there was no significant increase in the risk of a fatal bleed (RR 0.77; 95% CI 0.41, 1.43). CONCLUSIONS The majority of the adverse events caused by aspirin are GI bleeds, and there appears to be no valid evidence that the overall frequency of fatal GI bleeds is increased by aspirin. The substantive risk for prophylactic aspirin is therefore cerebral haemorrhage which can be fatal or severely disabling, with an estimated risk of one death and one disabling stroke for every 1,000 people taking aspirin for ten years. These adverse effects of aspirin should be weighed against the reductions in vascular disease and cancer.
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Affiliation(s)
- Peter C. Elwood
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | - Gareth Morgan
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Hywel Dda University Health Board, Llanelli, United Kingdom
| | - Julieta Galante
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - John W. K. Chia
- Division of Medical Oncology, National Cancer Centre, Singapore, Singapore
| | - Sunil Dolwani
- Institute of Cancer & Genetics Cardiff University, Cardiff, United Kingdom
| | | | - Mark Kelson
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | - Angel Lanas
- University Clinic Hospital, University of Zaragoza, IIS Aragón, CIBEReshd, Zaragoza, Spain
| | - Marcus Longley
- Welsh Institute for Health and Social Care, University of South Wales, Cardiff, United Kingdom
| | - Ceri J. Phillips
- Swansea Centre for Health Economics, Swansea University, Swansea, United Kingdom
| | - Janet Pickering
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | | | - Swee S. Soon
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Will Steward
- Department of Cancer Studies, University of Leicester, Leicester, United Kingdom
| | - Delyth Morris
- University Library Services, Cardiff University, Cardiff, United Kingdom
| | - Alison L. Weightman
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Specialist Unit for Review Evidence (SURE), Cardiff University, Cardiff, United Kingdom
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