A meta-analysis comparing the efficacy of omeprazole with H2-receptor antagonists for acute treatment of duodenal ulcer in Asian patients

Efficacy and safety of proton pump inhibitors and H2 receptor antagonists in the initial non‑eradication treatment of duodenal ulcer: A network meta‑analysis

The present network meta-analysis aimed to enhance the corresponding evidence with respect to the efficacy and safety of pharmaceuticals treatments. Frequentist network meta-analysis was used. Medical literature up to November 2022 was searched for randomized clinical trials assessing the efficacy and safety of these pharmaceuticals, either compared with each other or compared with placebo. With the exception of ranitidine (300 mg four times daily) and vonoprazan (20 mg once daily) having lower safety than placebo, the efficacy and safety of the remaining treatments were superior to placebo. Cimetidine (400 mg four times daily) and pantoprazole (40 mg once daily) were ranked first in terms of efficacy. The frequentist network meta-analysis shows that for cimetidine (except 400 mg once daily), famotidine, rabeprazole, ilaprazole, lansoprazole (except 7.5 mg once daily) and omeprazole (except 10 mg once daily or 30 mg once daily), the efficacy comparison between the different doses of each of the aforementioned pharmaceuticals did not indicate statistically significant differences. In conclusion, pantoprazole (40 mg once daily) was the best choice for the initial non-eradication treatment of patients with duodenal ulcer, and cimetidine (400 mg twice daily), omeprazole (20 mg once daily), lansoprazole (15 mg once daily), ilaprazole (5 mg once daily) and rabeprazole (10 mg once daily) could be used as the first choice. If the aforementioned pharmaceuticals cannot be prescribed, famotidine (40 mg twice daily) is recommended.

A Cross-Sectional Study on Single-Day Use of Proton Pump Inhibitors in Tertiary Care Hospitals of South India

Background: Proton pump inhibitors (PPIs) are the most potent antacids used in clinical practice with greater safety and efficacy. Limited data are available on the usage of PPIs in Indian health-care settings. Our aim was to understand the usage pattern and potential drug interactions with concurrently administered medications employing a single-day cross-sectional study design. Methods: A prospective observational cross-sectional study conducted on a single day, at two tertiary care teaching hospitals in South India. Inpatients of above 18 years of age were included. Case profiles were reviewed and data were collected in predesigned forms and analyzed. Drug interactions were identified using Micromedex and Medscape drug-interaction databases. Results: A total of 797 case profiles screened from both the centers; 714 were prescribed with PPIs. In intensive care units (ICUs), the use of PPIs was highest with 95% of cases getting these drugs. A PPI was seen in about 93% of patients, who had more than or equal to 4 drugs in their prescriptions. Pantoprazole was the mostly prescribed PPI in around 90% of the cases. Around 33% of the PPIs usage was through IV (intravenous) route, and 75% of that use was seen in wards. Around 134 drug interactions were identified, of which 10 were of major severity. Conclusions: Around 90% of inpatients were prescribed with PPIs. Pantoprazole is the most commonly prescribed PPI (90%). The IV administration was seen more in wards than ICUs, and 10 major drug interactions were observed in this single-day study. Careful monitoring is needed to avoid serious drug interactions involving PPIs, and training programs should sensitize the clinicians on the evidence-based use of PPIs.

Systematic toxicity mechanism analysis of proton pump inhibitors: an in silico study

Proton pump inhibitors (PPIs) are extensively used for the treatment of gastric acid-related disorders. PPIs appear to be well tolerated and almost have no short-term side effects. However, the clinical adverse reactions of long-term PPI usage are increasingly reported in recent years. So far, there is no study that elucidates the side effect mechanisms of PPIs comprehensively and systematically. In this study, a well-defined small molecule perturbed microarray data set of 344 compounds and 1695 samples was analyzed. With this high-throughput data set, a new index (Identity, I) was designed to identify PPI-specific differentially expressed genes. Results indicated that (1) up-regulated genes, such as RETSAT, CYP1A1, CYP1A2, and UGT, enhanced vitamin A's metabolism processes in the cellular retinol metabolism pathway; and that (2) down-regulated genes, such as C1QA, C1QC, C4BPA, C4BPB, CFI, and SERPING1, enriched in the complement and coagulation cascades pathway. In addition, strong association was observed between these PPI-specific differentially expressed genes and the reported side effects of PPIs by the gene-disease association network analysis. One potential toxicity mechanism of PPIs as suggested from this systematic PPI-specific gene expression analysis is that PPIs are enriched in acidic organelles where they are activated and inhibit V-ATPases and acid hydrolases, and consequently block the pathways of antigen presentation, the synthesis and secretion of cytokines, and complement component proteins and coagulation factors. The strategies developed in this work could be extended to studies on other drugs.

Efficacy of turmeric in the treatment of digestive disorders: a systematic review and meta-analysis protocol

BACKGROUND

Digestive disorders pose significant burdens to millions of people worldwide in terms of morbidity, mortality and healthcare costs. Turmeric has been traditionally used for conditions associated with the digestive system, and its therapeutic benefits were also confirmed in clinical studies. However, rigorous systematic review on this topic is severely limited. Our study aims to systematically review the therapeutic and adverse effects of turmeric and its compounds on digestive disorders, including dyspepsia, peptic ulcer, irritable bowel disease, Crohn's disease, ulcerative colitis, and gastroesophageal reflux disease.

METHODS/DESIGN

This study will include both randomized controlled trials and non-randomized controlled trials assessing the efficacy and safety of turmeric or its compounds in comparison to a placebo or any other active interventions for digestive disorders without any restrictions on participant age or language of publication. The primary outcome is the proportion of patients that have experienced treatment success. Secondary outcomes are the prevalence of an individual symptom of digestive disorders, the proportion of patients who experienced relapse, the number of physician visits/hospitalization due to digestive disorders, health-related quality of life and the proportion of patients who experienced adverse events. Relevant studies will be identified through MEDLINE, EMBASE, AMED, Dissertations & Theses Database and the Cochrane Central Register of Control Trials from their inception to August 31, 2013. In addition, grey literature such as information published on drug regulatory agencies websites and abstracts/proceedings from conferences will also be reviewed. A calibration exercise will be conducted in a process of study screening, whereby two reviewers will independently screen titles and abstracts from the literature search. Any conflicts will be resolved through a subsequent team discussion. The same process will be adopted in data abstraction and methodological quality appraisal by the Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale. We will describe study and patient characteristics, risk of bias/methodological quality results, and outcomes of the included studies. If we have sufficient data and homogeneity, a random effects meta-analysis will be performed.

DISCUSSION

Our results will help patients and healthcare practitioners to make informed decisions when considering turmeric as an alternative therapy for digestive disorders.

TRIAL REGISTRATION

PROSPERO registry number: CRD42013005739.

Inhibition of lysosomal enzyme activities by proton pump inhibitors

BACKGROUND

Proton pump inhibitors (PPIs) are pro-drugs requiring an acidic pH for activation. The specificity of PPI toward the proton pump is mainly due to the extremely low pH at the parietal cell canalicular membrane where the pump is located. Reactivity of PPIs was also observed in moderately acidic environments like the renal collecting duct. But no PPI effect on lysosomal enzymes has been observed possibly because the previous studies were performed with liver tissue, where PPIs are metabolized.

METHODS

The reactivity of PPIs (omeprazole, lansoprazole and pantoprazole) with a cysteine-containing peptide was analyzed by mass spectrometry, and the impact of PPIs on lysosomal enzymes was evaluated in cultured cells and mice. The effect of PPIs on the immune system was examined with a mouse tumor immunotherapy model.

RESULTS

Incubation of a cysteine-containing peptide with PPIs at pH5 led to the conversion of most of the peptide into PPI-peptide adducts. Dose dependent inhibition of lysosomal enzyme activities by PPIs was observed in cultured cells and mouse spleen. Further, PPI counteracted the tumor immunotherapy in a mouse model.

CONCLUSIONS

Our data support the hypothesis that many of the PPI adverse effects are caused by systematically compromised immunity, a result of PPI inhibition of the lysosomal enzymes. This novel mechanism complements the existing mechanisms in explaining the increased incidence of tumorigenesis and infectious diseases among PPI users and underlie the ongoing concern about the overuse of PPIs in adult and pediatric populations.

Mutation of the gastric hydrogen-potassium ATPase alpha subunit causes iron-deficiency anemia in mice

Iron is an essential component of heme and hemoglobin, and therefore restriction of iron availability directly limits erythropoiesis. In the present study, we report a defect in iron absorption that results in iron-deficiency anemia, as revealed by an N-ethyl-N-nitrosourea-induced mouse phenotype called sublytic. Homozygous sublytic mice develop hypochromic microcytic anemia with reduced osmotic fragility of RBCs. The sublytic phenotype stems from impaired gastrointestinal iron absorption caused by a point mutation of the gastric hydrogen-potassium ATPase α subunit encoded by Atp4a, which results in achlorhydria. The anemia of sublytic homozygotes can be corrected by feeding with a high-iron diet or by parenteral injection of iron dextran; rescue can also be achieved by providing acidified drinking water to sublytic homozygotes. These findings establish the necessity of the gastric proton pump for iron absorption and effective erythropoiesis.

Adverse effects of long-term proton pump inhibitor therapy

Proton pump inhibitors have an excellent safety profile and have become one of the most commonly prescribed class of drugs in primary and specialty care. Long-term, sometimes lifetime, use is becoming increasingly common, often without appropriate indications. This paper is a detailed review of the current evidence on this important topic, focusing on the potential adverse effects of long-term proton pump inhibitor use that have generated the greatest concern: B12 deficiency; iron deficiency; hypomagnesemia; increased susceptibility to pneumonia, enteric infections, and fractures; hypergastrinemia and cancer; drug interactions; and birth defects. We explain the pathophysiological mechanisms that may underlie each of these relationships, review the existing evidence, and discuss implications for clinical management. The benefits of proton pump inhibitor use outweigh its risks in most patients. Elderly, malnourished, immune-compromised, chronically ill, and osteoporotic patients theoretically could be at increased risk from long-term therapy.

Adverse effects of proton pump inhibitors

Proton pump inhibitors (PPI) are very effective drugs used largely in acid related disorders. During the last years concern have been raised regarding their overutilisation in benign condition, such as gastroesophageal reflux disease. The debate focussed also on the risk of adverse events related to long term use of PPI. Apart of the case of Helicobacter Pylori (H. Pylori) positive patients, in whose long term acid suppression lead to the development of corpus predominant atrophic gastritis, precursor of cancer; the other assumed adverse events, have never been demonstrated in prospective studies. The attention should move towards the appropriate prescription of PPI, rather than the fear adverse effects of PPI. In fact, in clinical practise, PPI are often prescribed in patients without a specific acid related disease and continued long term based on their safety profile. This review focus on the main adverse events related to long term PPI use.

Proton pump inhibitors in cirrhosis: Tradition or evidence based practice?

Proton Pump Inhibitors (PPI) are very effective in inhibiting acid secretion and are extensively used in many acid related diseases. They are also often used in patients with cirrhosis sometimes in the absence of a specific acid related disease, with the aim of preventing peptic complications in patients with variceal or hypertensive gastropathic bleeding receiving multidrug treatment. Contradicting reports support their use in cirrhosis and evidence of their efficacy in this condition is poor. Moreover there are convincing papers suggesting that acid secretion is reduced in patients with liver cirrhosis. With regard to Helicobacter pylori (H pylori) infection, its prevalence in patients with cirrhosis is largely variable among different studies, and it seems that H pylori eradication does not prevent gastro-duodenal ulcer formation and bleeding. With regard to the prevention and treatment of oesophageal complications after banding or sclerotherapy of oesophageal varices, there is little evidence for a protective role of PPI. Moreover, due to liver metabolism of PPI, the dose of most available PPIs should be reduced in cirrhotics. In conclusion, the use of this class of drugs seems more habit related than evidence-based eventually leading to an increase in health costs.

External validation of a measurement tool to assess systematic reviews (AMSTAR)

BACKGROUND

Thousands of systematic reviews have been conducted in all areas of health care. However, the methodological quality of these reviews is variable and should routinely be appraised. AMSTAR is a measurement tool to assess systematic reviews.

METHODOLOGY

AMSTAR was used to appraise 42 reviews focusing on therapies to treat gastro-esophageal reflux disease, peptic ulcer disease, and other acid-related diseases. Two assessors applied the AMSTAR to each review. Two other assessors, plus a clinician and/or methodologist applied a global assessment to each review independently.

CONCLUSIONS

The sample of 42 reviews covered a wide range of methodological quality. The overall scores on AMSTAR ranged from 0 to 10 (out of a maximum of 11) with a mean of 4.6 (95% CI: 3.7 to 5.6) and median 4.0 (range 2.0 to 6.0). The inter-observer agreement of the individual items ranged from moderate to almost perfect agreement. Nine items scored a kappa of >0.75 (95% CI: 0.55 to 0.96). The reliability of the total AMSTAR score was excellent: kappa 0.84 (95% CI: 0.67 to 1.00) and Pearson's R 0.96 (95% CI: 0.92 to 0.98). The overall scores for the global assessment ranged from 2 to 7 (out of a maximum score of 7) with a mean of 4.43 (95% CI: 3.6 to 5.3) and median 4.0 (range 2.25 to 5.75). The agreement was lower with a kappa of 0.63 (95% CI: 0.40 to 0.88). Construct validity was shown by AMSTAR convergence with the results of the global assessment: Pearson's R 0.72 (95% CI: 0.53 to 0.84). For the AMSTAR total score, the limits of agreement were -0.19+/-1.38. This translates to a minimum detectable difference between reviews of 0.64 'AMSTAR points'. Further validation of AMSTAR is needed to assess its validity, reliability and perceived utility by appraisers and end users of reviews across a broader range of systematic reviews.

Optimising acid inhibition treatment

Acid inhibition is safe and useful in several clinical settings. Proton pump inhibitors are more effective than H2-receptor antagonists in virtually all cases. Proton pump inhibitors should be used in: the eradication of Helicobacter pylori; the treatment of non-H. pylori-related peptic ulcer healing; for the prevention and treatment of non-steroidal anti-inflammatory drug-induced upper digestive lesions; for bleeding peptic lesions; and, especially, in the short-term and long-term control of gastro-oesophageal reflux disease. The timing, the dosing and the specific drugs should be adapted to the particular patient, clinical situation and local factors. For instance, in a patient with active bleeding from a duodenal ulcer, intravenous constant infusion should be the preferred treatment. When seeking oral 'potent' acid inhibition (refractory gastro-oesophageal reflux disease, and perhaps Barrett's oesophagus), available data suggest that the pharmacological and clinical profiles of esomeprazole are slightly better.

What is potent acid inhibition, and how can it be achieved?

The clinical response to antisecretory treatment correlates directly with the degree of inhibition of acid secretion achieved. Acid inhibition able to maintain the intragastric pH at a value greater than 4 for at least 16 h/day seems to heal even the most refractory acid-related diseases. It has also been shown that the degree of inhibition of acid secretion in response to antisecretory treatment depends on the genetic characteristics of the patient and on the presence of Helicobacter pylori infection. A possible definition of potent (or profound) acid inhibition is, therefore, the achievement of the aforementioned level of control of acid secretion regardless of patient characteristics or of the presence of H. pylori infection. Antisecretory drugs differ in their ability to reach potent acid inhibition. As far as the comparative efficacy of different drugs for inhibiting acid secretion is concerned, proton pump inhibitors are more efficient in inhibiting gastric acid secretion than histamine (H2) receptor antagonists. Among the different proton pump inhibitors, esomeprazole 40 mg/day exhibits greater antisecretory potency than the others at standard doses. Rabeprazole 20 mg/day and lansoprazole 30 mg/day exhibit a more rapid onset of action than omeprazole 20 mg/day or pantoprazole 40 mg/day.

Reappraisal of non-invasive management strategies for uninvestigated dyspepsia: a cost-minimization analysis

BACKGROUND

The benefits of the Helicobacter pylori test-and-treat strategy are attributable largely to the cure of peptic ulcer disease while limiting the use of endoscopy.

AIM

To reappraise the test-and-treat strategy and empirical proton pump inhibitor therapy for the management of uninvestigated dyspepsia in the light of the decreasing prevalence of H. pylori infection, peptic ulcer disease and peptic ulcer disease attributable to H. pylori.

METHODS

Using a decision analytical model, we estimated the cost per patient with uninvestigated dyspepsia managed with the test-and-treat strategy ($25/test; H.pylori treatment, $200) or proton pump inhibitor ($90/month). Endoscopy ($550) guided therapy for persistent or recurrent symptoms.

RESULTS

In the base case (25%H. pylori prevalence, 20% likelihood of peptic ulcer disease, 75% of ulcers due to H.pylori), the cost per patient is $545 with the test-and-treat strategy and $529 with proton pump inhibitor, and both strategies yield similar clinical outcomes at 1 year. H. pylori prevalence, the likelihood of peptic ulcer disease and the proportion of ulcers due to H.pylori are important determinants of the least costly strategy. At an H. pylori prevalence below 20%, proton pump inhibitor is consistently less costly than the test-and-treat strategy.

CONCLUSIONS

As the H. pylori prevalence, the likelihood of peptic ulcer disease and the proportion of ulcers due to H. pylori decrease, empirical proton pump inhibitor becomes less costly than the test-and-treat strategy for the management of uninvestigated dyspepsia. Given the modest cost differential between the strategies, the test-and-treat strategy may be favoured if patients without peptic ulcer disease derive long-term benefit from H.pylori eradication.

Is upper gastrointestinal radiography a cost-effective alternative to a Helicobacter pylori "test and treat" strategy for patients with suspected peptic ulcer disease?

OBJECTIVE

Current clinical consensus supports an initial Helicobacter pylori (HP) "test and treat" approach when compared to immediate endoscopy for patients with suspected peptic ulcer disease. Alternative diagnostic approaches that incorporate upper GI radiography (UGI) have not been previously evaluated. We sought to determine the cost effectiveness of UGI compared to a HP test and treat strategy, incorporating recent data addressing the reduced prevalence of HP, lower cost of diagnostic interventions, and reduced attribution of PUD to HP.

METHODS

Using decision analysis, three diagnostic and treatment strategies were evaluated: 1) Test and Treat--initial HP serology, treat patients who test positive with HP eradication and antiulcer therapy; 2) Initial UGI series--treat all patients with documented ulcer disease with HP eradication and antiulcer therapy; and 3) Initial UGI series, HP serology if ulcer present--treat ulcer and HP based on diagnostic test results.

RESULTS

The estimated cost per ulcer cured for each strategy were as follows: test and treat, $3,025; initial UGI, $3,690; and UGI with serology, $3,790. The estimated cost per patient treatment were: test and treat, $498; initial UGI, $610; and UGI with serology, $620. When UGI reimbursement was decreased to less than $50, the UGI strategies yielded a lower cost per patient treated than the test and treat strategy.

CONCLUSION

At the current level of reimbursement, UGI should not be considered a cost-effective alternative to the HP test and treat strategy for the initial evaluation of patients with suspected peptic ulcer disease.

Evaluation of Nigerian traditional medicines: II. Effects of some Nigerian folk remedies on peptic ulcer

Antiulcer activity of four medicinal plants, Diodia sarmentosa (whole plant), Cassia nigricans (leaves), Ficus exasperata (leaves) and Synclisia scabrida (leaves), which are commonly used by the Nigerian traditional healers for the treatment of peptic ulcer were investigated. Acute toxicity tests were also carried out. The results revealed that the four extracts possess significant anti-ulcerogenic properties in a dose-dependent way. They protected rats from aspirin-induced ulcerogenesis, delayed intestinal transit, increased the pH, and decreased both the volume and acidity of gastric secretion. These results correlate with local use of the plants.

Meta-analyses to evaluate analgesic interventions: a systematic qualitative review of their methodology

A systematic search of the literature was performed to identify the maximum possible number of meta-analyses that evaluated analgesic interventions. Seventy-four reports were identified and retrieved and the scientific quality of 80 separate meta-analyses was assessed under blind conditions by 2 judges using Oxman and Guyatt's index. Most of the meta-analyses evaluated pharmacological interventions for chronic pain conditions and two-thirds were published since 1990. Ninety percent of the meta-analyses had methodological flaws that could limit their validity. The main deficiencies were lack of information on methods to retrieve and to assess the validity of primary studies and lack of data on the design of the primary studies. Meta-analyses of low quality produced significantly more positive conclusions. For several topics, different meta-analyses evaluating the same intervention produced conflicting results. The need to resolve these contradictions is highlighted.

Omeprazole. An update of its pharmacology and therapeutic use in acid-related disorders

Omeprazole, a gastric acid pump inhibitor, dose-dependently controls gastric acid secretion: the drug has greater antisecretory activity than histamine H2-receptor antagonists. Omeprazole 20 to 40 mg/day is more effective than histamine H2-receptor antagonists in the short term treatment of duodenal ulcer, gastric ulcer and reflux oesophagitis. Available data suggest that omeprazole 10 to 40 mg/day is also more effective than ranitidine in the maintenance therapy of duodenal ulcer and reflux oesophagitis. The drug is also effective in patients with duodenal ulcer, gastric ulcer or reflux oesophagitis poorly responsive to histamine H2-receptor antagonists. The efficacy of omeprazole 20 mg/day appears to be similar to that of lansoprazole 30 mg/day in the short term treatment of duodenal ulcer, gastric ulcer and reflux oesophagitis. However, most available studies have been reported in abstract form only, and 2 of 3 studies in patients with duodenal ulcer have shown greater healing rates at 2 (but not 4) weeks with lansoprazole. Helicobacter pylori eradication decreases duodenal ulcer relapse rates and appears to be associated with improved duodenal ulcer healing rates. Evidence also suggests that H. pylori eradication is associated with reduced gastric ulcer relapse rates. Omeprazole monotherapy may suppress but does not eradicate H. pylori infection. Eradication rates with omeprazole 20 or 40 mg twice daily plus amoxicillin usually up to 2 g/day (3 g/day in a few studies) for 2 weeks appear to be similar to those of standard triple therapy (bismuth salt plus metronidazole, plus tetracycline or amoxicillin) or omeprazole plus clarithromycin, although eradication rates vary widely. Omeprazole plus amoxicillin appears to be better tolerated than triple therapy and represents a first-line treatment alternative in patients with H. pylori-associated peptic ulcer disease. Omeprazole plus amoxicillin plus metronidazole appears to be more effective than omeprazole plus amoxicillin in patients with metronidazole-sensitive H. pylori infection. Omeprazole remains a treatment of choice in patients with Zollinger-Ellison syndrome. The dosages should be adjusted according to individual response. However, relatively low dosages of 10 to 40 mg/day may be sufficient in some patients. The drug has also shown promise in the treatment of children with severe reflux oesophagitis, in patients with reflux oesophagitis and coexisting systemic sclerosis, and in the prevention of aspiration pneumonia. Evidence suggests that omeprazole is more effective than ranitidine in patients with nonsteroidal anti-inflammatory drug (NSAID)-induced gastric damage who continue to take NSAIDs, especially in patients with large gastric ulcers; however, completion of ongoing studies is required to verify this.(ABSTRACT TRUNCATED AT 400 WORDS)