Intravenous proton pump inhibitors: an evidence-based review of their use in gastrointestinal disorders

Predictive Factors Associated with Inappropriate Intravenous Proton Pump Inhibitors Use in Hospitalized Patients: A Case-Control Study

Background and Objectives: Proton Pump Inhibitors (PPIs) are the most effective agents for treating acid-related gastrointestinal disorders. The prescription of an intravenous (IV) formulation of PPIs has increased dramatically. The aims of this study were to assess the appropriateness of IV PPI use and to define the risk factors and outcomes associated with its inappropriate use. Materials and Methods: A case-control retrospective study included all the hospitalized patients who received IV PPIs was conducted. Patient health records were reviewed, data were collected covering the period of the individual patients' admission to the hospital until discharge or death, and over the 3-month post-discharge period. The appropriateness of the IV PPI use and the resulting clinical outcomes were analyzed. Results: Overall, 540 patients were analyzed. Among them, 130/540 (24%) had inappropriate PPI use in terms of indication, dosage, and duration of treatment vs. 410 patients who had appropriate indications. Two parameters were associated with inappropriate use: congestive heart failure (OR 1.77; p = 0.02) and prescription of IV PPIs by surgeons vs. internists (OR 1.53; p = 0.05). Conclusions: Inappropriate IV PPI use is still common in daily clinical practice. Significant predictors of inappropriate use were the presence of congestive heart failure, elderly age, current use of anticoagulants and antithromotics, and the cases managed by surgeons, naturally due to suspected upper gastrointestinal bleedings.

A Randomized Controlled Trial of Fibrin Glue to Prevent Bleeding After Gastric Endoscopic Submucosal Dissection

INTRODUCTION

This study evaluated the efficacy of fibrin glue for preventing postendoscopic submucosal dissection (ESD) bleeding in high-risk patients for bleeding (expected iatrogenic ulcer size ≥40 mm or receiving antithrombotic therapy).

METHODS

A multicenter, open-label, randomized controlled trial was performed at 4 tertiary medical centers in South Korea between July 1, 2020, and June 22, 2022. Patients with gastric neoplasm and a high risk of post-ESD bleeding were enrolled and allocated at 1:1 to a control group (standard ESD) or a fibrin glue group (fibrin glue applied to iatrogenic ulcers after standard ESD). The primary outcome was overall bleeding events within 4 weeks. The secondary outcomes were acute bleeding (within 48 hours post-ESD) and delayed bleeding (48 hours to 4 weeks post-ESD).

RESULTS

In total, 254 patients were randomized, and 247 patients were included in the modified intention-to-treat population (125 patients in the fibrin glue group and 122 patients in the control group). Overall bleeding events occurred in 12.0% (15/125) of the fibrin glue group and 13.1% (16/122) of the control group ( P = 0.791). Acute bleeding events were significantly less common in the fibrin glue group than in the control group (1/125 vs 7/122, P = 0.034). Delayed bleeding events occurred in 11.2% (14/125) in the fibrin glue group and 7.3% (9/122) in the control group ( P = 0.301).

DISCUSSION

This trial failed to show a preventive effect of fibrin glue on overall post-ESD bleeding in high-risk patients. However, the secondary outcomes suggest a potential sealing effect of fibrin glue during the acute period.

Effect of proton pump inhibitors and H2 antagonists on gastric wall uptake in myocardial perfusion scan with 99mTc-sestamibi

BACKGROUND

Proton pump inhibitors (PPIs) have been speculated to cause gastric wall uptake (GWU) in MPI scans. However, the uptake mechanism and prevention methods are less studied. In this prospective trial we aimed to evaluate the impact of gastroprotective medications on GWU and its solutions.

METHODS

351 consecutive patients, scheduled for 2-day rest/stress 99mTc-MIBI scan, were distributed into 5 groups. 3-7 days following the baseline rest scan, the stress scan was acquired after intervention in the trial group, consisting of patients with history of PPI intake, randomly assigned to 3 subgroups: discontinuing PPIs(A), replacement with H2 blockers (B), and continuing PPIs (C). Patients receiving H2 blockers, continued it as before (D) and the remaining patients were the control group (E). GWU was graded compared to the myocardial uptake.

RESULTS

In the rest phase, all groups had significantly higher GWU compared to the control group. In the stress phase, group A had less GWU than group B (P-value < 0.05) and both of them had significantly less GWU compared to group C (P-value < 0.001). There was no significant difference between PPI discontinuation periods of 3-5 days versus 5-7 days. There was a significant association between duration of oral PPI intake, but not IV PPIs, and GWU. GWU was significantly lower with oral compared to IV PPI administration.

CONCLUSION

PPIs significantly increase GWU and discontinuing them for at least 3-5 days significantly reduces GWU. H2 antagonists are a good alternative in patients who cannot tolerate dyspepsia symptoms.

Therapeutic efficacy of proton transport inhibitors alone or in combination with cisplatin in triple negative and hormone sensitive breast cancer models

Triple negative breast cancers (TNBCs) are very aggressive and have a poor prognosis due to lack of efficacious therapies. The only effective treatment is chemotherapy that however is frequently hindered by the occurrence of drug resistance. We approached this problem in vitro and in vivo on a triple negative and a hormone sensitive breast cancer cell lines: 4T1 and TS/A. A main defense mechanism of tumors is the extrusion of intracellular protons derived from the metabolic shift to glycolysis, and necessary to maintain an intracellular pH compatible with life. The resulting acidic extracellular milieu bursts the malignant behavior of tumors and impairs chemotherapy. Therefore, we investigated the efficacy of combined therapies that associate cisplatin (Cis) with proton exchanger inhibitors, such as esomeprazole (ESO) and 5-(N-ethyl-N-isopropyl)amiloride (EIPA). Our results demonstrate that in the 4T1 triple negative model the combined therapy Cis plus EIPA is significantly more effective than the other treatments. Instead, in the TS/A tumor the best therapeutic result is obtained with ESO alone. Remarkably, in both 4T1 and TS/A tumors these treatments correlate with increase of CD8+  T lymphocytes and dendritic cells, and a dramatic reduction of M2 macrophages and other suppressor myeloid cells (MDSC) in the tumor infiltrates.

A novel knock-in mouse model of cryopyrin-associated periodic syndromes with development of amyloidosis: Therapeutic efficacy of proton pump inhibitors

BACKGROUND

Cryopyrin-associated periodic syndromes (CAPS) are a group of autoinflammatory diseases linked to gain-of-function mutations in the NOD-like receptor family, pyrin domain containing 3 (NLRP3) gene, which cause uncontrolled IL-1β secretion. Proton pump inhibitors (PPIs), which are commonly used as inhibitors of gastric acid production, also have anti-inflammatory properties, protect mice from sepsis, and prevent IL-1β secretion by monocytes from patients with CAPS.

OBJECTIVE

We sought to develop a novel Nlrp3 knock-in (KI) mouse model of CAPS to study amyloidosis, a severe CAPS complication, and test novel therapeutic approaches.

METHODS

We generated KI mice by engineering the N475K mutation, which is associated with the CAPS phenotype, into the mouse Nlrp3 gene. KI and wild-type mice received PPIs or PBS intraperitoneally and were analyzed for survival, inflammation, cytokine secretion, and amyloidosis development.

RESULTS

Mutant Nlrp3 KI mice displayed features that recapitulate the immunologic and clinical phenotype of CAPS. They showed systemic inflammation with high levels of serum proinflammatory cytokines, inflammatory infiltrates in various organs, and amyloid deposits in the spleen, liver, and kidneys. Toll-like receptor stimulated macrophages from KI mice secreted high levels of IL-1β, IL-18, and IL-1α but low amounts of IL-1 receptor antagonist. Treatment of KI mice with PPIs had a clear clinical effect, showing a reduction in inflammatory manifestations, regression of amyloid deposits, and normalization of proinflammatory and anti-inflammatory cytokine production by macrophages.

CONCLUSION

Nlrp3 KI mice displayed a CAPS phenotype with many characteristics of autoinflammation, including amyloidosis. The therapeutic effectiveness of PPIs associated with a lack of toxicity indicates that these drugs could represent relevant adjuvants to the anti-IL-1 drugs in patients with CAPS and other IL-1-driven diseases.

Rising Events and Improved Outcomes of Gastrointestinal Bleed With Shock in USA: A 12-year National Analysis

OBJECTIVE

Limited information is available based on single-center studies on trends of incidence and outcomes in gastrointestinal (GI) bleed with shock.

METHODS

We analyzed data from 2002 to 2013 National Inpatient Sample. Using ICD-9 codes we identified 6.4 million hospital discharges of GI bleed from National Inpatient Sample database. Events were analyzed based on type of GI bleed, in-hospital mortality, hemodynamic status, and use of blood products.

RESULTS

GI bleed with shock results in higher hospital mortality (20.77% with shock vs. 2.6% without shock). Between 2002 and 2013, there has been an increase in the percentage of upper and lower GI bleed with shock (1.35% to 4.92% and 1.49% to 3.06%) along with a reduction in mortality in both upper GI bleed with shock (26.9% to 13.8%) and lower GI bleed with shock (54.7% to 19.7%). Consistent with the rise in GI bleed with shock was an increase in blood product utilization. Packed red blood cell (pRBC) transfusion was associated with reduction in mortality in both nonvariceal upper GI bleed with shock (18.3% without pRBC vs. 13.9% receiving pRBC) and lower GI bleed with shock (36.05% without pRBC vs. 22.13% receiving pRBC), but did not affect mortality in variceal upper GI bleed with shock (31.79% vs. 32.22%).

CONCLUSIONS

GI bleed with shock carries a higher mortality and have been steadily increasing from 2002 to 2013. pRBC transfusion was associated in improved mortality in GI bleed with shock except variceal bleed.

Proton pump inhibitors protect mice from acute systemic inflammation and induce long-term cross-tolerance

Incidence of sepsis is increasing, representing a tremendous burden for health-care systems. Death in acute sepsis is attributed to hyperinflammatory responses, but the underlying mechanisms are still unclear. We report here that proton pump inhibitors (PPIs), which block gastric acid secretion, selectively inhibited tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) secretion by Toll-like receptor (TLR)-activated human monocytes in vitro, in the absence of toxic effects. Remarkably, the oversecretion of IL-1β that represents a hallmark of monocytes from patients affected by cryopyrin-associated periodic syndrome is also blocked. Based on these propaedeutic experiments, we tested the effects of high doses of PPIs in vivo in the mouse model of endotoxic shock. Our data show that a single administration of PPI protected mice from death (60% survival versus 5% of untreated mice) and decreased TNF-α and IL-1β systemic production. PPIs were efficacious even when administered after lipopolysaccharide (LPS) injection. PPI-treated mice that survived developed a long-term cross-tolerance, becoming resistant to LPS- and zymosan-induced sepsis. In vitro, their macrophages displayed impaired TNF-α and IL-1β to different TLR ligands. PPIs also prevented sodium thioglycollate-induced peritoneal inflammation, indicating their efficacy also in a non-infectious setting independent of TLR stimulation. Lack of toxicity and therapeutic effectiveness make PPIs promising new drugs against sepsis and other severe inflammatory conditions.

Hospital-Based HTA and Know4Go at MEDICI in London, Ontario, Canada

The majority of healthcare in Canada is universally provided and publicly funded through the provincial government.

[Medication errors with concentrated potassium intravenous solutions: Data of the literature, context and prevention]

Accidental direct intravenous injection of a concentrated solution of potassium often leads to patient death. In France, recommendations of healthcare agencies to prevent such accidents cover only preparation and intravenous infusion conditions. Accidents continue to occur in French hospitals. These facts demonstrate that these recommendations are insufficient and ineffective to prevent such deaths, especially those occurring during a catheter flushing. This article reviews the measures able to reduce the number of accidents. Countries which removed concentrated ampoules from ward stocks observed a decrease of the number of accidental deaths. This withdrawal, recommended by the World Health Organization, is now part of standards in studies aimed at determining the safety of care in hospitals. However, removal alone is insufficient to eliminate the risk. The combination with other measures should be considered. These measures are the provision of a combination of diluted intravenous ready to use solutions, the promotion of the oral route with tablets and oral solutions for potassium replenishment and to make available products with safeguards to prevent single shot intravenous injection. Studies aimed at determining the consequences on preventing concentrated potassium accidents of a widespread distribution of isotonic sodium chloride pre-filled ready-to-use syringes for catheter flushing should be performed.

Role of Medical Therapy for Nonvariceal Upper Gastrointestinal Bleeding

Nonvariceal upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality worldwide. Mortality from UGIB has remained 5-10% over the past decade. This article presents current evidence-based recommendations for the medical management of UGIB. Preendoscopic management includes initial resuscitation, risk stratification, appropriate use of blood products, and consideration of nasogastric tube insertion, erythromycin, and proton pump inhibitor therapy. The use of postendoscopic intravenous proton pump inhibitors is strongly recommended for certain patient populations. Postendoscopic management also includes the diagnosis and treatment of Helicobacter pylori, appropriate use of proton pump inhibitors and iron replacement therapy.

Optimal initiation of Helicobacter pylori eradication in patients with peptic ulcer bleeding

AIM: To evaluate when Helicobacter pylori (H. pylori) eradication therapy (ET) should be started in patients with peptic ulcer bleeding (PUB).

METHODS: Clinical data concerning adults hospitalized with PUB were retrospectively collected and analyzed. Age, sex, type and stage of peptic ulcer, whether endoscopic therapy was performed or not, methods of H. pylori detection, duration of hospitalization, and specialty of the attending physician were investigated. Factors influencing the confirmation of H. pylori infection prior to discharge were determined using multiple logistic regression analysis. The H. pylori eradication rates of patients who received ET during hospitalization and those who commenced ET as outpatients were compared.

RESULTS: A total of 232 patients with PUB were evaluated for H. pylori infection by histology and/or rapid urease testing. Of these patients, 53.7% (127/232) had confirmed results of H. pylori infection prior to discharge. In multivariate analysis, duration of hospitalization and ulcer stage were factors independently influencing whether H. pylori infection was confirmed before or after discharge. Among the patients discharged before confirmation of H. pylori infection, 13.3% (14/105) were lost to follow-up. Among the patients found to be H. pylori-positive after discharge, 41.4% (12/29) did not receive ET. There was no significant difference in the H. pylori eradication rate between patients who received ET during hospitalization and those who commenced ET as outpatients [intention-to-treat: 68.8% (53/77) vs 60% (12/20), P = 0.594; per-protocol: 82.8% (53/64) vs 80% (12/15), P = 0.723].

CONCLUSION: Because many patients with PUB who were discharged before H. pylori infection status was confirmed lost an opportunity to receive ET, we should confirm H. pylori infection and start ET prior to discharge.

Perils and pitfalls of long-term effects of proton pump inhibitors

This review summarizes the literature regarding long-term adverse effects of proton pump inhibitors (PPIs). A PubMed search (1966 to February 2013) for English language studies was conducted using key terms PPI: omeprazole, esomeprazole, pantoprazole, lansoprazole, dexlansoprazole, rabeprazole, pneumonia, Clostridium difficile, osteoporosis, risk of fractures, thrombocytopenia, rhabdomyolysis, anemia, iron deficiency, hypomagnesemia, vitamin B₁₂ and nephritis. The risk of pneumonia was increased 27-39% in short-term use of PPIs in three meta-analyses. C. difficile infections were also associated with the use of PPIs (odds ratio: 2.15; 95% CI: 1.81-2.55; p < 0.00001). This effect appears to be dose related. The US FDA has recently issued a warning regarding fractures and the impaired magnesium absorption associated with the use of PPI. Thrombocytopenia, iron deficiency, vitamin B12 deficiency, rhabdomyolysis and acute interstitial nephritis have also been reported with the use of PPIs. There is mounting evidence that PPIs are associated with serious adverse effects. Practitioners should be vigilant and counsel patients accordingly.

Pharmacists' interventions on intravenous to oral conversion for potassium

BACKGROUND

Guidelines recommend use of the oral route whenever possible to treat or prevent hypokalemia. Although a myriad of papers have been published regarding intravenous to oral (IV to PO) therapy conversion programs and about clinical pharmacy services provided in hospitals, little is known on the role of hospital pharmacists in promoting the oral route for potassium administration.

OBJECTIVE

The aim of this work was to describe the frequency of interventions related to IV to PO potassium therapy conversions performed by hospital pharmacists. Setting French hospitals recording pharmacist's interventions on the website tool of the French Society of Clinical Pharmacy.

METHODS

From the pharmacist's interventions (PI) dataset recorded we extracted all interventions related to potassium IV to PO conversion. We assessed the acceptance rate of these PI by prescribers. Additional free text information in the dataset was analysed.

MAIN OUTCOME MEASURES

IV to PO potassium therapy conversions related to potassium chloride.

RESULTS

From January 2007 to December 2010, 87 hospitals recorded 1,868 PIs concerning IV to PO therapy conversion. Among these, 16 (<1 %) concerned potassium chloride. They were recorded by four hospitals (4.6 %) with respectively 12, 2, 1 and 1 PIs. Six PIs were accepted by physicians and the prescriptions were modified.

CONCLUSION

PIs to promote the administration of potassium by the oral route are extremely rare. Our results and scarce previously published data reveal that this field of practice remains almost unexplored. These findings highlight an important gap in the field of intravenous to oral therapy programs. This situation must be regarded as unsatisfactory and should lead to setting up more education and research programs.

Acute therapy with intravenous omeprazole on caustic esophageal injury: a prospective case series

The ingestion of caustic substances may result in significant esophageal injury. There is no standard treatment protocol for esophageal injury and most patients are treated with a proton pump inhibitor or H2 antagonist. However, there is no clinical study evaluating the efficacy of omeprazole for caustic esophageal injury. A prospective study of 13 adult patients (>18 years of age) who were admitted to our hospital for caustic ingestion between May 2010 and June 2010 was conducted. Mucosal damage was graded using a modified endoscopic classification described by Zargar et al. Patients were treated with a proton pump inhibitor and maintained without oral intake until their condition was considered stable. Patients received omeprazole 80 mg in bolus IV, followed by continuous infusion of 8 mg/hour for 72 hours. A control endoscopy was performed 72 hours after admission. There was significant difference regarding endoscopic healing between the before and after omeprazole infusion (P = 0.004). There was no hospital mortality at the follow-up. Omeprazole may effectively be used in the acute phase treatment of caustic esophagus injuries.

Managing acute upper gastrointestinal bleeding in the acute assessment unit

AAUs should develop and review protocols and local guidelines for the multidisciplinary team management of upper GI bleeding, for example with respect to: Early and appropriate resuscitation. Use of the tools for assessing severity. Timing of endoscopy, including recognising low-risk patients who could be discharged for outpatient investigation. Postendoscopy drug treatment, including appropriate and limited use of iv PPIs and Helicobacter pylori eradication therapy. Follow up, including referral for repeat endoscopy and/or urea breath testing. Regular review and audit of local guidance of the management of UGIB should become an integral part of an acute trust's clinical governance programme.

Inhibitory effects of intravenous lansoprazole 30 mg and pantoprazole 40 mg twice daily on intragastric acidity in healthy Chinese volunteers: a randomized, open-labeled, two-way crossover study

BACKGROUND

Until now there has been no study that directly compares the effect of lansoprazole and pantoprazole administered intravenously on intragastric acidity. The aim of this study is to compare the effect of lansoprazole (30 mg) and pantoprazole (40 mg) administered intravenously on gastric acidity.

MATERIAL/METHODS

Helicobacter pylori-negative healthy volunteers were recruited in this open-label, randomized, two-way crossover, single centre study. Lansoprazole at 30 mg or pantoprazole at 40 mg was intravenously administered twice daily for 5 consecutive days with at least a 14-day washout interval. Twenty-four-hour intragastric pH was continuously monitored on days 1 and 5 of each dosing period.

RESULTS

Twenty-five volunteers completed the 2 dosing periods. The mean intragastric pH values were higher in subjects treated with lansoprazole than those with pantoprazole on both day 1 (6.41 ± 0.14 vs. 5.49 ± 0.13, P=0.0003) and day 5 (7.09 ± 0.07 vs. 6.64 ± 0.07, P=0.0002). Significantly higher percentages of time with intragastric pH >4 and pH >6 were found in the subjects treated with lansoprazole than those with pantoprazole on day 1 (pH >4, 87.12 ± 4.55% vs. 62.28 ± 4.15%, P=0.0012; pH >6, 62.12 ± 4.12% vs. 47.25 ± 3.76%, P=0.0216) and pH >6 on day 5 (76.79 ± 3.77% vs. 58.20 ± 3.77%, P=0.0025).

CONCLUSIONS

Intravenous lansoprazole produces a longer and more potent inhibitory effect on intragastric acidity than does intravenous pantoprazole.

Diagnosis and management of nonvariceal upper gastrointestinal bleeding

Nonvariceal upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality worldwide. Despite the improvements in the management of this condition in western countries, mortality rates have remained at 5-10% over the past decade. This article presents the main recommendations for the management of UGIB. Pre-endoscopic management (including use of scoring scales, nasogastric tube placement and blood pressure stabilization) is crucial for triage and optimal resuscitation of patients, and should include a multidisciplinary approach at an early stage. Unless the patient has specific comorbidities, transfusion should only be considered if their hemoglobin level is ≤70 g/l. Endoscopic therapy, the cornerstone of therapeutic management of high-risk lesions, should not be delayed for more than 24 h following admission. Several endoscopic techniques, mostly using clips or thermal methods, are available and new approaches are emerging. When endoscopy fails, surgery or arterial embolization should be considered. Although the efficacy of prokinetics and high-dose intravenous PPI prior to endoscopy is controversial, the use of an intravenous PPI following endoscopy is strongly recommended. Antiplatelet therapy should be suspended and resumed in 3-5 days. Finally, all patients should be tested for Helicobacter pylori by serology in the acute setting.

Esomeprazole for the treatment of peptic ulcer bleeding

Peptic ulcer bleeding is the most common cause of acute bleeding in the upper GI tract. The incidence of peptic ulcer bleeding has slowly decreased and endoscopic treatment options have improved; nevertheless, it remains a very common condition with a 7-15% mortality. Acidic environments have a negative effect on hemostasis. Therefore, acid inhibitors have been applied in the adjuvant treatment of peptic ulcer bleeding, both in preventing rebleeding and in treating the underlying cause. This requires profound acid suppressive therapy aiming for a rapid onset of effect and a persistent intragastric pH above 6. This can only be achieved by proton pump inhibitors (PPIs). Esomeprazole is the S-isomer of omeprazole, and the first PPI to consist of only the active isomer. A number of studies have compared esomeprazole with other PPIs, demonstrating a faster and more persistent increase in intragastric pH with the use of esomeprazole than with other agents. Continuous high-dose intravenous treatment with esomeprazole decreases rebleeding, surgery, transfusion rates and hospital days in peptic ulcer bleeding.