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Nogueira RC, Sanches-Lopes JM, Oliveira-Paula GH, Tanus-Santos JE. Inhibitors of gastric acid secretion increase oxidative stress and matrix metalloproteinase-2 activity leading to vascular remodeling. Mol Cell Biochem 2024:10.1007/s11010-023-04921-x. [PMID: 38302836 DOI: 10.1007/s11010-023-04921-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/20/2023] [Indexed: 02/03/2024]
Abstract
The use of inhibitors of gastric acid secretion (IGAS), especially proton pump inhibitors (PPI), has been associated with increased cardiovascular risk. While the mechanisms involved are not known, there is evidence supporting increased oxidative stress, a major activator of matrix metalloproteinases (MMP), as an important player in such effect. However, there is no study showing whether other IGAS such as histamine H2-receptor blockers (H2RB) cause similar effects. This study aimed at examining whether treatment with the H2RB ranitidine promotes oxidative stress resulting in vascular MMP activation and corresponding functional and structural alterations in the vasculature, as compared with those found with the PPI omeprazole. Male Wistar rats were treated (4 weeks) with vehicle (2% tween 20), omeprazole (10 mg/Kg/day; i.p.) or ranitidine (100 mg/Kg/day; gavage). Then the aorta was collected to perform functional, biochemical, and morphometric analysis. Both ranitidine and omeprazole increased gastric pH and oxidative stress assessed in situ with the fluorescent dye dihydroethidium (DHE) and with lucigenin chemiluminescence assay. Both IGAS augmented vascular activated MMP-2. These findings were associated with aortic remodeling (increased media/lumen ratio and number of cells/μm2). Both IGAS also impaired the endothelium-dependent relaxation induced by acetylcholine (isolated aortic ring preparation). This study provides evidence that the H2RB ranitidine induces vascular dysfunction, redox alterations, and remodeling similar to those found with the PPI omeprazole. These findings strongly suggest that IGAS increase oxidative stress and matrix metalloproteinase-2 activity leading to vascular remodeling, which helps to explain the increased cardiovascular risk associated with the use of those drugs.
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Affiliation(s)
- Renato C Nogueira
- Department of Pharmacology, Ribeirao Preto Medical School, University of São Paulo, Av. Bandeirantes 3900, Ribeirão Preto, 14049-900, Brazil
| | - Jéssica M Sanches-Lopes
- Department of Pharmacology, Ribeirao Preto Medical School, University of São Paulo, Av. Bandeirantes 3900, Ribeirão Preto, 14049-900, Brazil
| | - Gustavo H Oliveira-Paula
- Department of Pharmacology, Ribeirao Preto Medical School, University of São Paulo, Av. Bandeirantes 3900, Ribeirão Preto, 14049-900, Brazil
- Division of Cardiology, Department of Medicine, Wilf Family Cardiovascular Research Institute, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jose E Tanus-Santos
- Department of Pharmacology, Ribeirao Preto Medical School, University of São Paulo, Av. Bandeirantes 3900, Ribeirão Preto, 14049-900, Brazil.
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Edmonston D, Isakova T, Wolf M. Plasma Serotonin and Cardiovascular Outcomes in Chronic Kidney Disease. J Am Heart Assoc 2023; 12:e029785. [PMID: 37609990 PMCID: PMC10547345 DOI: 10.1161/jaha.123.029785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 07/11/2023] [Indexed: 08/24/2023]
Abstract
Background Platelet-poor plasma serotonin levels are associated with adverse cardiovascular outcomes. Although plasma serotonin levels increase in chronic kidney disease, the cardiovascular implications remain unknown. Methods and Results In 1114 participants from the prospective CRIC (Chronic Renal Insufficiency Cohort) Study, we evaluated the association between plasma serotonin, categorized as undetectable, intermediate, and high (≥20 ng/mL) levels, and cross-sectional findings on echocardiography, including left ventricular hypertrophy, left ventricular ejection fraction, and pulmonary hypertension. We also analyzed whether serotonin was associated with time-to-event cardiovascular outcomes, including heart failure hospitalization and atherosclerotic cardiovascular disease (ASCVD) events, in addition to mortality. Because selective serotonin reuptake inhibitors decrease plasma serotonin levels, we specifically evaluated the influence of selective serotonin reuptake inhibitor use in the relationship between serotonin and outcomes. Plasma serotonin level inversely correlated with estimated glomerular filtration rate and directly correlated with blood pressure. High plasma serotonin was associated with left ventricular hypertrophy (adjusted odds ratio, 2.74 [95% CI, 1.11-7.41]). In contrast, undetectable plasma serotonin level was associated with the highest risk of heart failure (adjusted hazard ratio [HR], 2.26 [95% CI, 1.40-3.66]) and ASCVD events (adjusted HR, 1.96 [95% CI, 1.15-3.32]). Conclusions In a large chronic kidney disease cohort, plasma serotonin levels correlated with blood pressure, and elevated serotonin levels were associated with left ventricular hypertrophy. In contrast, undetectable plasma serotonin was associated with the highest risk of heart failure and ASCVD events.
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Affiliation(s)
- Daniel Edmonston
- Division of Nephrology, Department of MedicineDuke University School of MedicineDurhamNC
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, and Center for Translational Metabolism and Health, Institute for Public Health and MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Myles Wolf
- Division of Nephrology, Department of MedicineDuke University School of MedicineDurhamNC
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
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Assimon MM, Pun PH, Al-Khatib SM, Brookhart MA, Gaynes BN, Winkelmayer WC, Flythe JE. Proton pump inhibitors may enhance the risk of citalopram- and escitalopram-associated sudden cardiac death among patients receiving hemodialysis. Pharmacoepidemiol Drug Saf 2022; 31:670-679. [PMID: 35285107 PMCID: PMC9064943 DOI: 10.1002/pds.5428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/17/2022] [Accepted: 03/10/2022] [Indexed: 11/08/2022]
Abstract
PURPOSE Polypharmacy is common in the hemodialysis population and increases the likelihood that patients will be exposed to clinically significant drug-drug interactions. Concurrent use of proton pump inhibitors (PPIs) with citalopram or escitalopram may potentiate the QT-prolonging effects of these selective serotonin reuptake inhibitors through pharmacodynamic and/or pharmacokinetic interactions. METHODS We conducted a retrospective cohort study using data from the U.S. Renal Data System (2007-2017) and a new-user design to examine the differential risk of sudden cardiac death (SCD) associated with citalopram/escitalopram initiation vs. sertraline initiation in the presence and absence of PPI use among adults receiving hemodialysis. We studied 72 559 patients:14 983 (21%) citalopram/escitalopram initiators using a PPI; 26 503 (36%) citalopram/escitalopram initiators not using a PPI;10 779 (15%) sertraline initiators using a PPI; and 20 294 (28%) sertraline initiators not using a PPI (referent). The outcome of interest was 1-year SCD. We used inverse probability of treatment weighted survival models to estimate weighted hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS Compared with sertraline initiators not using a PPI, citalopram/escitalopram initiators using a PPI had the numerically highest risk of SCD (HR [95% CI] = 1.31 [1.11-1.54]), followed by citalopram/escitalopram initiators not using a PPI (HR [95% CI] = 1.22 [1.06-1.41]). Sertraline initiators using a PPI had a similar risk of SCD compared with those not using a PPI (HR [95% CI] = 1.03 [0.85-1.26]). CONCLUSIONS Existing PPI use may elevate the risk of SCD associated with citalopram or escitalopram initiation among hemodialysis patients.
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Affiliation(s)
- Magdalene M. Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC
| | - Patrick H. Pun
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham NC
| | - Sana M. Al-Khatib
- Duke Clinical Research Institute, Durham NC
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | - M. Alan Brookhart
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Bradley N. Gaynes
- Department of Psychiatry, UNC School of Medicine, Chapel Hill, NC
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, TX
| | - Jennifer E. Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
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Nogueira RC, Pinheiro LC, Sanches-Lopes JM, Parente JM, Oliveira-Paula GH, Conde SO, Castro MM, Tanus-Santos JE. Omeprazole induces vascular remodeling by mechanisms involving xanthine oxidoreductase and matrix metalloproteinase activation. Biochem Pharmacol 2021; 190:114633. [PMID: 34058185 DOI: 10.1016/j.bcp.2021.114633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/14/2021] [Accepted: 05/26/2021] [Indexed: 11/20/2022]
Abstract
Proton pump inhibitors (PPI) are commonly used drugs that may increase the cardiovascular risk by mechanisms not entirely known. We examined whether the PPI omeprazole promotes vascular oxidative stress mediated by xanthine oxidoreductase (XOR) leading to activation of matrix metalloproteinases (MMPs) and vascular remodeling. We studied Wistar rats treated with omeprazole (or vehicle) combined with the XOR inhibitor allopurinol (or vehicle) for four weeks. Systolic blood pressure (SBP) measured by tail-cuff plethysmography was not affected by treatments. Omeprazole treatment increased the aortic cross-sectional area and media/lumen ratio by 25% (P < 0.05). Omeprazole treatment decreased gastric pH and induced vascular remodeling accompanied by impaired endothelium-dependent aortic responses (assessed with isolated aortic ring preparation) to acetylcholine (P < 0.05). Omeprazole increased vascular active MMP-2 expression and activity assessed by gel zymography and in situ zymography, respectively (P < 0.05). Moreover, omeprazole enhanced vascular oxidative stress assessed in situ with the fluorescent dye DHE and with the lucigenin chemiluminescence assay (both P < 0.05). All these biochemical changes caused by omeprazole were associated with increased vascular XOR activity (but not XOR expression assessed by Western blot) and treatment with allopurinol fully prevented them (all P < 0.05). Importantly, treatment with allopurinol prevented the vascular dysfunction and remodeling caused by omeprazole. Our results suggest that the long-term use of omeprazole induces vascular dysfunction and remodeling by promoting XOR-derived reactive oxygen species formation and MMP activation. These findings provide evidence of a new mechanism that may underlie the unfavorable cardiovascular outcomes observed with PPI therapy. Clinical studies are warranted to validate our findings.
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Abstract
PURPOSE OF REVIEW The current review summarizes and attempts to place in proper perspective the past year's literature regarding purported adverse effects of proton pump inhibitors (PPIs). RECENT FINDINGS Although generally considered safe, physicians are inundated with retrospective database-driven epidemiologic studies, and meta-analyses on the same studies, claiming a panoply of serious adverse effects associated with long-term use of PPIs. The quality of the evidence underlying most of these associations is very low and cannot ascribe cause and effect. Nonetheless, these reports have stoked fears, in both prescribers and patients. As a result, patients are being harmed. Physicians are not prescribing PPIs when medically indicated and patients are stopping PPIs without consulting their caregivers. It is reassuring that a cross-sectional analysis of data from the National Ambulatory Medical Care Survey as well as a double-blinded, placebo-controlled trial report no safety concerns with PPIs, other than a possible small association with enteric infection. SUMMARY Most of the publicized serious putative adverse effects attributed to PPIs have been debunked in more recent and properly designed studies. Nevertheless, PPIs should be prescribed for valid indications and, when prescribed long-term, they should be used at the lowest effective dose and their ongoing need periodically assessed.
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Abstract
Background The rate of sudden cardiac death in the hemodialysis population exceeds that of the general population by >20-fold. Hemodialysis patients may be particularly susceptible to sudden cardiac death provoked by drug-induced QT prolongation because of their substantial cardiovascular disease burden, exposure to electrolyte shifts during dialysis, and extensive polypharmacy. However, population-specific data regarding the frequency and patterns of QT prolonging medication use are limited. Methods and Results We conducted a descriptive drug utilization study using 3 administrative databases, the United States Renal Data System, MarketScan, and Medicare claims. We characterized the extent and patterns of QT prolonging medication use by adult hemodialysis patients and individuals without end-stage kidney disease annually from 2012 to 2016. We also identified instances of high-risk QT prolonging medication use among hemodialysis patients. In total, 338 515 hemodialysis patients and 40.7 million individuals without end-stage kidney disease were studied. Annual utilization rates of QT prolonging medications with known torsades de pointes risk in hemodialysis patients were ~1.4 to ~2.5 times higher than utilization rates in individuals without end-stage kidney disease. Hemodialysis patients with demographic and clinical risk factors for drug-induced QT prolongation were exposed to medications with known torsades de pointes risk more often than patients without risk factors. Conclusions Hemodialysis patients use QT prolonging medications with known torsades de pointes risk more extensively than individuals without end-stage kidney disease. Given the widespread use and instances of high-risk prescribing, future studies evaluating the cardiac safety of these drugs in the hemodialysis population are needed.
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Affiliation(s)
- Magdalene M. Assimon
- University of North Carolina Kidney CenterDivision of Nephrology and HypertensionDepartment of MedicineUniversity of North Carolina School of MedicineChapel HillNC
| | - Lily Wang
- Cecil G. Sheps Center for Health Services ResearchUniversity of North CarolinaChapel HillNC
| | - Patrick H. Pun
- Division of NephrologyDepartment of MedicineDuke University School of MedicineDurhamNC
- Duke Clinical Research InstituteDuke University Medical CenterDurhamNC
| | | | - Jennifer E. Flythe
- University of North Carolina Kidney CenterDivision of Nephrology and HypertensionDepartment of MedicineUniversity of North Carolina School of MedicineChapel HillNC
- Cecil G. Sheps Center for Health Services ResearchUniversity of North CarolinaChapel HillNC
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Wu WT, Tsai CT, Chou YC, Ku PM, Chen YC, You SL, Hung CF, Sun CA. Cardiovascular Outcomes Associated With Clinical Use of Citalopram and Omeprazole: A Nationwide Population-Based Cohort Study. J Am Heart Assoc 2019; 8:e011607. [PMID: 31581860 PMCID: PMC6818043 DOI: 10.1161/jaha.118.011607] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Recent studies have raised concerns about the reduced efficacy of citalopram when used concurrently with proton pump inhibitors. The aim of this study was to evaluate the associations between clinical use of citalopram and omeprazole and the risk of sudden cardiac arrest (SCA) in an Asian population. Methods and Results A retrospective cohort study was conducted using the National Health Insurance Research Database of Taiwan dated from 2000 to 2013. The study cohorts comprised 3882 patients with citalopram use alone, 31 090 patients with omeprazole use alone, and 405 patients with concomitant use of citalopram and omeprazole (as the exposed cohort), and 141 508 patients received treatment with antidepressants without the risk of SCA and/or proton pump inhibitors other than omeprazole (as the comparison cohort). The primary outcome was the occurrence of SCA. The hazard ratios and 95% CIs derived from the time-dependent Cox regression model were used to assess the association between the proposed drug treatments and risk of SCA. The adjusted hazard ratios of SCA was 1.32 (95% CI, 1.17-1.50) for citalopram use alone, 1.08 (95% CI, 0.98-1.20) for omeprazole use alone, and 2.23 (95% CI, 1.79-2.78) for concomitant use of citalopram and omeprazole. The cumulative incidence of SCA over the Kaplan-Meier curves was more pronounced in patients with concomitant use of citalopram and omeprazole than those treated with citalopram alone and omeprazole alone. Conclusions This cohort study demonstrated use of citalopram and omeprazole either in isolation use or in concomitant use to be at increased risk for SCA.
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Affiliation(s)
- Wen-Tung Wu
- Department of Pharmacy Practice Tri-Service General Hospital National Defense Medical Center Taipei Taiwan.,School of Public Health National Defense Medical Center Taipei Taiwan
| | - Chun-Teng Tsai
- School of Public Health National Defense Medical Center Taipei Taiwan
| | - Yu-Ching Chou
- School of Public Health National Defense Medical Center Taipei Taiwan
| | - Po-Ming Ku
- Department of Cardiology Chi-Mei Medical Center Tainan City Taiwan
| | - Yong-Chen Chen
- Department of Medicine College of Medicine Fu-Jen Catholic University New Taipei City Taiwan.,Big Data Research Center College of Medicine Fu-Jen Catholic University New Taipei City Taiwan
| | - San-Lin You
- Department of Medicine College of Medicine Fu-Jen Catholic University New Taipei City Taiwan.,Big Data Research Center College of Medicine Fu-Jen Catholic University New Taipei City Taiwan
| | - Chi-Feng Hung
- Department of Medicine College of Medicine Fu-Jen Catholic University New Taipei City Taiwan.,Big Data Research Center College of Medicine Fu-Jen Catholic University New Taipei City Taiwan
| | - Chien-An Sun
- Big Data Research Center College of Medicine Fu-Jen Catholic University New Taipei City Taiwan.,Department of Public Health College of Medicine Fu-Jen Catholic University New Taipei City Taiwan
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