Analysis of gastrointestinal prophylaxis in patients receiving dual antiplatelet therapy with aspirin and clopidogrel

Appropriateness of gastrointestinal prophylaxis use during hospitalization in patients with acute myocardial infarction: Analysis from the China Acute Myocardial Infarction Registry

BACKGROUND

The current status of gastrointestinal prophylaxis (GIP) usage and its effects on hospitalized acute myocardial infarction (AMI) patients is not clear. We investigate the appropriateness of GIP usage and its relationship with clinical events in China.

HYPOTHESIS

Appropriate use of GIP is not associated with increased adverse outcomes.

METHODS

From January 2013 to September 2014, a total of 24 001 consecutive patients from 108 hospitals with AMI in China Acute Myocardial Infarction (CAMI) registry were analyzed. The appropriateness of GIP was evaluated using the current American College of Cardiology Foundation/American Heart Association (ACCF/AHA) and European Society of Cardiology (ESC) guidelines. The primary endpoint was in-hospital gastrointestinal bleeding (GIB), while the secondary endpoints were in-hospital and 2-year follow-up net adverse cardiovascular and cerebrovascular events (NACCE). Multivariate logistic regression analysis and Cox proportional hazard models were used to assess the effect of appropriate GIP.

RESULTS

There were 16 413 (68.38%) AMI patients co-medicated with GIP. Among 108 involved hospitals, only 35 (32.4%) hospitals prescribed more than 50% appropriate GIP. Totally, 59.7% (14 340) AMI patients received inappropriate GIP. Inappropriate GIP use was independently associated with use of GPIIb/IIIa receptor inhibitor and primary percutaneous coronary intervention (PCI). Moreover, appropriate GIP use was associated with decreased GIB risk (OR: 0.692, 95% CI: 0.507-0.944, P = .0202) during hospitalization, while not with increased in-hospital and 2-year follow-up NACCE.

CONCLUSION

The use of GIP is prevalent in patients with AMI in China but only 40% of hospitalized patients received appropriate GIP. Appropriate prophylactic therapy was associated with decreased GIB risk during hospitalization.

NSAID, antiaggregant, and/or anticoagulant-related upper gastrointestinal bleeding: Is there any change in prophylaxis rate after a 10-year period?

BACKGROUND/AIMS

Using proton-pump inhibitor (PPI) is a protective option for patients who require long-term non-steroidal anti-inflammatory drugs (NSAIDs) and antiaggregants. In our previous study, the rate of PPI use in prophylaxis was found to be 2%. Here we aimed to investigate whether there is a change in PPI use in prophylaxis in a similar patient group after 10 years.

MATERIALS AND METHODS

The patients who followed up with upper gastrointestinal (GI) bleeding diagnosis between January 01, 2016 and December 31, 2017 were retrospectively evaluated. Patients who had malignancy or variceal hemorrhage were excluded. Ninety-six patients, who had taken NSAIDs, antiaggregants, or anticoagulants that were considered as the possible cause of bleeding, were included in the study. Risk groups for NSAID GI toxicity and PPI use rates in these patients were evaluated.

RESULTS

Twenty (21%) of all patients with upper GI bleeding were using PPI. According to the pre-bleeding risk factor assessment, 86% of the patients were found to have moderate to high risk for NSAID-related GI bleeding, and 81% of these patients were not using PPI. PPI prophylaxis was not provided to 15 (75%) of the 20 patients with previous history of peptic ulcer bleeding.

CONCLUSION

Despite many studies and recommendations on risk factors and prophylaxis for NSAID-related bleeding, prophylactic PPI use is still largely ignored by physicians. The rate of PPI use in the patient group of this study was found still quite insufficient.

The inappropriate use of proton pump inhibitors during admission and after discharge: a prospective cross-sectional study

Background Proton pump inhibitors are often inappropriately prescribed during hospital admission and after discharge. The inappropriate prescription may be associated with increased and unnecessary healthcare costs. Objective To determine the prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge at Thailand's largest national tertiary referral center. Setting Medicine wards at Siriraj Hospital (Bangkok, Thailand) during September 2016 to September 2017. Method This prospective observational cross-sectional study in hospitalized patients who were prescribed, or who were already taking proton pump inhibitors. Medical records were reviewed to determine whether proton pump inhibitors were prescribed at discharge and at the 1-month follow-up. Main outcome measure Prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge, indication of inappropriate prescription. Results Two hundred and sixty-five patients (mean age: 65.8 ± 18.3 years, 50.9% men) were included. Approximately half of patients had proton pump inhibitor treatment initiated in the hospital, and the other 50.6% started treatment earlier. Among all patients, 50.6% were inappropriately prescribed proton pump inhibitors, in which 79.1% resulted from invalid indications. Fifty-two percent and 47.3% of patients who were prescribed proton pump inhibitors at discharge and at the 1-month follow-up had no indications for them. Gastrointestinal ulcer prophylaxis in low-risk patients was the most commonly observed incorrect indication. Aspirin (p = 0.030) and corticosteroids (p = 0.038) were both found to be significantly associated with the inappropriate prescription of proton pump inhibitors. The estimated cost of inappropriate use among inpatients and outpatients was $118,659 and $214,663 per year, respectively. Conclusion Proton pump inhibitors are excessively and inappropriately prescribed during hospital admission and after discharge in Thailand. The cost of this overprescribing is excessive and needs to be controlled.

New clinical paradigms for treating and preventing antiplatelet gastrointestinal bleeding

PURPOSE OF REVIEW

To quantify antiplatelet-related gastrointestinal bleeding (GIB), characterize patients at greatest risk and summarize risk-management strategies emphasizing evolving knowledge in acute management of antiplatelet-related bleeding.

RECENT FINDINGS

New paradigms for acute management of antiplatelet-related GIB exist in the domains of resuscitation and the transfusion of blood products, strategic use of proton pump therapy and identification and eradication of Helicobacter pylori. This review will also highlight the importance of prompt resumption of cardiac aspirin and dual antiplatelet therapy following endoscopic hemostasis to minimize the risk of future cardiac events.

SUMMARY

This review will provide pragmatic strategies for the management of acute antiplatelet-related GIB. Emerging areas of clinical knowledge will be addressed and knowledge gaps requiring further research to inform clinical practice will be highlighted.

Comparison of prophylactic effect of UGIB and effects on platelet function between PPIs and H2RAs combined with DAPT: systematic review and meta-analysis

Objective

We compared prophylactic effects of proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H₂RAs) on upper gastrointestinal bleeding (UGIB) associated with dual antiplatelet therapy (DAPT) and explored this influence on platelet function.

Methods

Randomized controlled trials and cohort studies comparing PPIs with H₂RAs in adults receiving DAPT were collected from PubMed, EMBASE and Cochrane databases. Dichotomous data were pooled to obtain risk ratios (RRs) for UGIB, major adverse cardiovascular events (MACEs), poor responders to clopidogrel and rehospitalization, and continuous data were pooled to obtain mean differences (MDs) for P2Y₁₂ reaction units (PRUs), with 95% confidence intervals (CIs).

Results

Twelve clinical trials (n=3,301) met the inclusion criteria. Compared to H₂RAs, PPIs lessened UGIB (RR =0.16, 95% CI: 0.03–0.70), and there was no significant difference in the incidence of PRUs (MD =18.21 PRUs, 95% CI: −4.11–40.54), poor responders to clopidogrel (RR =1.21, 95% CI: 0.92–1.61), incidence of MACEs (RR =0.89, 95% CI: 0.45–1.75) or rehospitalization (RR =1.76, 95% CI: 0.79–3.92). Subgroup analysis confirmed fewer PRUs in the H₂RAs group compared to the omeprazole group (2 studies, n=189, MD =31.80 PRUs, 95% CI: 11.65–51.96). However, poor responder data for clopidogrel and MACEs might be unreliable because few studies of this kind were included.

Conclusion

Limited evidence indicates that PPIs were better than H₂RAs for prophylaxis of UGIB associated with DAPT and had no effect on platelet function. Further study is needed to confirm these observations.

Long-Term Safety of a Coordinated Delivery Tablet of Enteric-Coated Aspirin 325 mg and Immediate-Release Omeprazole 40 mg for Secondary Cardiovascular Disease Prevention in Patients at GI Risk

Introduction

In two, 6‐month, randomized, double‐blind Phase 3 trials, PA32540 (enteric‐coated aspirin 325 mg and immediate‐release omeprazole 40 mg) compared to aspirin alone was associated with fewer endoscopic gastric and duodenal ulcers in patients requiring aspirin therapy for secondary cardiovascular disease (CVD) prevention who were at risk for upper gastrointestinal (UGI) events.

Aims

In this 12‐month, open‐label, multicenter Phase 3 study, we evaluated the long‐term cardiovascular and gastrointestinal safety of PA32540 in subjects who were taking aspirin 325 mg daily for ≥3 months for secondary CVD prevention and were at risk for aspirin‐associated UGI events. Enrolled subjects received PA32540 once daily for up to 12 months and were assessed at baseline, month 1, month 6, and month 12.

Results

The overall safety population consisted of 379 subjects, and 290 subjects (76%) were on PA32540 for ≥348 days (12‐month completers). Adverse events (AEs) caused study withdrawal in 13.5% of subjects, most commonly gastroesophageal reflux disease (1.1%). Treatment‐emergent AEs occurred in 76% of the safety population (11% treatment‐related) and 73% of 12‐month completers (8% treatment‐related). The most common treatment‐related AE was dyspepsia (2%). One subject had a gastric ulcer observed on for‐cause endoscopy. There were five cases of adjudicated nonfatal myocardial infarction, one nonfatal stroke, and one cardiovascular death, but none considered treatment‐related.

Conclusions

Long‐term treatment with PA32540 once daily for up to 12 months in subjects at risk for aspirin‐associated UGI events is not associated with any new or unexpected safety events.

Audit of IV pantoprazole: pattern of administration and compliance with guideline in a teaching hospital

BACKGROUND

Drug use evaluation is a performance improvement method that evaluates medication-use processes. Medication studies are especially important for drugs with narrow therapeutic index, specific indication, high costs as well as for drugs with widespread use. Intravenous pantoprazole always ranked among the top 5 costly drugs in Amir-al-Momenin Hospital. Considering the fact that widespread and inappropriate use of this drug is considered as a concern in hospitals all over the world rather than being a regional problem, we decided to establish a guideline for intravenous (IV) pantoprazole in our hospital and evaluated the pattern of its administration both before and after establishing the guideline.

METHODS

This is an experimental study (clinical trial) performed at the Amir-al-Momenin Hospital, on 400 randomly selected patients receiving IV pantoprazole (bolus or infusion) during a 6-month period (3 months before and 3 months after establishing guideline). We used predesigned data collection forms to collect related information. We used SPSS Ver. 18 for statistical analysis.

RESULTS

Our results showed that the established guideline could significantly reduce the rate (P = 0.00) and cost (301,289,000 Rials or 8608 USD in 3 months study period after establishing guideline) of IV pantoprazole administration, but failed to rectify indications and dosage of its administration at the same rate. Stress ulcer prophylaxis was the most frequent approved indication for IV pantoprazole administration in our study population. We also observed that the rate of commitment to the guideline decreased by the time passed from its establishment.

CONCLUSION

We concluded that although establishing guideline was successful in reducing the overall rate of IV pantoprazole administration and its related costs, different contributing factors halted its effect on correcting the prescribed dosage and indications, especially as the time gaps from guideline establishment. This fact magnifies the importance of continuous educations of prescribers about the importance of evidence based practice and need for and implementing a powerful executive supervisory in our hospital.

CYP2C19*2 and Other Allelic Variants Affecting Platelet Response to Clopidogrel Tested by Thrombelastography in Patients with Acute Coronary Syndrome

Background:

To investigate the contributions of CYP2C19 polymorphisms to the various clopidogrel responses tested by thrombelastography (TEG) in Chinese patients with the acute coronary syndrome (ACS).

Methods:

Patients were screened prospectively with ACS diagnose and were treated with clopidogrel and aspirin dual antiplatelet therapy. CYP2C19 loss of function (LOF) and gain of function (GOF) genotype, adenosine 5′-diphosphate (ADP)-channel platelet inhibition rate (PIR) tested by TEG and the occurrence of 3-month major adverse cardiovascular events and ischemic events were assessed in 116 patients.

Results:

High on-treatment platelet reactivity (HTPR) prevalence defined by PIR <30% by TEG in ADP-channel was 32.76% (38/116). With respect to the normal wild type, CYP2C19*2, and *3 LOF alleles, and *17 GOF alleles, patients were classified into three metabolism phenotypes: 41.38% were extensive metabolizers (EMs), 56.90% were intermediate metabolizers (IMs), and 1.72% were poor metabolizers (PMs). Of the enrolled patients, 31.47%, 5.17%, and 0.43%, respectively, were carriers of *2, *3, and *17 alleles. The HTPR incidence differed significantly according to CYP2C19 genotypes, accounting for 18.75%, 41.54%, and 100.00% in EMs, IMs, and PMs, respectively. Eighteen (17.24%) ischemic events occurred during the 3-month follow-up, and there was a significant difference in ischemic events between HTPR group and nonhigh on-treatment platelet reactivity group.

Conclusions:

Genetic CYP2C19 polymorphisms are relative to the inferior, the antiplatelet activity after clopidogrel admission and may increase the incidence of ischemic events in patients with ACS.

Inappropriate Use of Proton Pump Inhibitors in Elderly Patients Discharged from Acute Care Hospitals

BACKGROUND

Proton-pump inhibitors (PPI) are extensively prescribed in older patients. However, little information is available on factors associated to PPI prescribing patterns among older patients discharged from hospital.

OBJECTIVE

To evaluate the appropriateness and clinical correlates of PPI prescription at discharge in a population of 1081 older patients discharged from acute care Italian hospitals.

DESIGN

We used data from the CRiteria to Assess Appropriate Medication Use among Elderly Complex Patients (CRIME) study, a multicenter observational study. The appropriateness of PPI prescriptions was defined according to the Italian Medicines Agency (AIFA) rules. Correlates of overprescribing (i.e prescribing without recognized AIFA indications) and underprescribing (i.e. not prescribing despite the presence of recognized AIFA indications) were investigated by logistic regression analysis.

RESULTS

Overprescribing was observed in 30% of patients receiving PPIs at discharge. Underprescribing was observed in 11% of patients not receiving PPIs at discharge. Overprescribing of PPIs at discharge was negatively associated with age (OR=0.88, 95%CI=0.85-0.91), depression (OR=0.58, 95%CI=0.35-0.96), use of aspirin (OR=0.03, 95%CI=0.02-0.06) and systemic corticosteroids (OR=0.02, 95%CI=0.01-0.04). The negative association with number of medications (OR=0.95, 95%CI=0.88-1.03) and overall comorbidities (OR=0.92, 95%CI=0.83-1.02) was nearly significant. Conversely, older age (OR=1.09, 95%CI=1.04-1.14), use of aspirin (OR=24.0, 95%CI=11.5-49.8) and systemic corticosteroids (OR=19.3, 95%CI=11.5-49.8) and overall comorbidities (OR=1.22, 95%CI=1.04-1.42) were independent correlates of underprescribing.

CONCLUSION

Overprescribing of PPIs is more frequent in younger patients with lower burden of depression, whilst underprescribing is characterized by older age and greater burden of comorbidity and polypharmacy. Hospitalization should be considered as a clue to identify inappropriate use of PPIs and improve appropriateness of prescribing.

Current Strategies to Reduce Gastrointestinal Bleeding Risk Associated with Antiplatelet Agents

Antiplatelet agents remain the cornerstone in the primary and secondary therapeutic intervention for cardiovascular disease. Some patients may be subjected to a year or more of dual antiplatelet therapy to reduce the risk of subsequent cardiovascular events. Patients on antiplatelet therapy have an increased risk of gastrointestinal bleeding; however, not all patients benefit from concomitant acid suppressive therapy. This review will provide an overview of the pharmacology of antiplatelet agents and outline patient risk profiles that ought to be considered when considering prophylactic therapy to reduce gastrointestinal toxicity. In addition, we discuss the current risk-reduction strategies intended to mitigate against the potential for related gastroduodenal injury.