Meta-analysis of the effectiveness of esomeprazole in gastroesophageal reflux disease and Helicobacter pylori infection

WHAT IS KNOWN AND OBJECTIVE

Proton pump inhibitors (PPIs) are one of the most widely used classes of drugs. However, the quantum clinical benefit of newer and more expensive PPIs over the older generation PPIs remains uncertain. This meta-analysis sought to assess the clinical and safety profiles of esomeprazole versus omeprazole at pharmacologically equivalent doses in healing gastroesophageal reflux disease (GERD), peptic ulcer disease and eradicating Helicobacter pylori (H. pylori) infection.

METHODS

PubMed and the Cochrane Library were searched for randomized controlled trials comparing esomeprazole with omeprazole at all doses up to February 2015. Trials were assessed by two reviewers for eligibility according to predefined study inclusion criteria. Meta-analysis was conducted using a random effects model, and heterogeneity in the estimated effects was investigated using meta-regression. Sensitivity analysis was performed to test the robustness of the findings.

RESULTS AND DISCUSSION

Fifteen trials were included and none of which compared esomeprazole with omeprazole in peptic ulcer disease. The included studies had not evaluated esomeprazole 20 mg versus omeprazole 40 mg. In GERD, esomeprazole 40 mg (relative risk (RR) = 1·07; 95% confidence interval (CI) 1·02 to 1·12) and 20 mg (RR=1·04; 95% CI 1·01 to 1·08) significantly improved esophagitis healing when compared with omeprazole 20 mg at week 8. The corresponding numbers needed to treat were 17 and 30, respectively. No significant difference was observed between esomeprazole 20 mg and omeprazole 20 mg at week 4. In H. pylori eradication, there was no difference in the treatment effects between esomeprazole 20 mg and omeprazole 20 mg (RR = 1·01;95% CI 0·96 to 1·05). Their safety profiles were comparable.

WHAT IS NEW AND CONCLUSION

Esomeprazole demonstrated better esophagitis healing rate in patients with GERD than omeprazole at week 8. However, this clinical advantage diminished when both drugs were given at the same doses at week 4. Superiority of esomeprazole was not observed in the H. pylori eradication rates.

Inhibition of beta-carotene-15,15'-dioxygenase activity by dietary flavonoids

Beta-carotene-15,15'-dioxygenase is an enzyme responsible for providing vertebrates with vitamin A by catalyzing oxidative cleavage of beta-carotene at its central double bond to two molecules of retinal in intestinal cells. However, little data have been reported regarding regulation of the enzyme activity. We have evaluated the effects of antioxidants and dietary flavonoids on the beta-carotene dioxygenase activity in vitro using a pig intestinal homogenate as the enzyme source. 2,6-Di-tert-butyl-4-methylphenol (BHT), a synthetic antioxidant, strongly inhibited the activity at the level of 10(-6) M (a mixed-type inhibition), whereas butylated hydroxyanisole, nor-dihydroguaiaretic acid, n-propyl gallate, and curcumin were moderately inhibitory. Flavonoids such as luteolin, quercetin, rhamnetin, and phloretin remarkably inhibited the dioxygenase activity noncompetitively, whereas flavanones, isoflavones, catechins, and anthocyanidins were less inhibitory. The structure-activity relationship indicated that catechol structure of ring B and a planar flavone structure were essential for inhibition. The enzyme inhibition was also indicated in the cultured Caco-2 cells by the significantly reduced conversion of beta-carotene to retinol when incubated with BHT and rhamnetin at 2 microM and 5 microM, respectively. The results suggest that some dietary antioxidants derived from food sources modulate conversion of beta-carotene to vitamin A in intestinal cells.

Antioxidant activity of xanthophylls on peroxyl radical-mediated phospholipid peroxidation

The ability of xanthophylls (canthaxanthin, zeaxanthin, and astaxanthin) as chain-breaking antioxidants was investigated in peroxyl radical-mediated peroxidation of phosphatidylcholine (PC) liposomes under atmospheric conditions using lipid-soluble and water-soluble radical generators. These xanthophylls retarded the chain propagation reaction of phosphatidylcholine hydroperoxides (PC-OOH) formation, although their activities to trap chain-carrying peroxyl radical were much less than that of alpha-tocopherol. In chick plasma studies, it was observed that endogenious xanthophylls participated in the antioxidant defenses against the attack of aqueous peroxyl radical. It was concluded that xanthophylls possess the ability to act as chain-breaking antioxidants in the peroxidation of membraneous phospholipids. Dietary xanthophylls may, therefore, be helpful in resisting membraneous phospholipids against oxidative damage in vivo.

A rural outbreak of Legionnaires' disease linked to visiting a retail store

Between May 7 and June 7, 1986, 27 residents of a rural county in Maryland developed legionellosis, and two died. Legionella pneumophila serogroup 1 was cultured from the sputum of two patients and identified in lung tissue of a third patient by direct fluorescent antibody staining. An additional 11 patients had four-fold rises in antibody titer to L. pneumophila, and 13 had single titers greater than or equal to 1:256. To determine risk factors for disease, we performed a case-control study. Twelve of 16 case-patients reported visiting store A in the two weeks before onset of illness compared with four of 28 control-patients. A serologic survey of employees showed that employees of store A were 3.63 times more likely than control employees to have titers of antibody to L. pneumophila greater than or equal to 1:256 (95% confidence intervals 0.8, 16.7). Cultures of soil specimens, samples of water from the hot water system of store A and from stagnant ponds near store A collected five weeks after the end of the outbreak were negative for Legionella species. Store A was adjacent to a site of excavation and construction during May 1986, when the community was experiencing an extended drought. This investigation suggests that exposure to excavation and construction activity may be a risk factor for legionellosis.

Restaurant-associated outbreak of typhoid fever in Maryland: identification of carrier facilitated by measurement of serum Vi antibodies

Ten cases of typhoid fever occurred between 24 August and 1 September 1986 in the vicinity of Silver Spring, Md. Shrimp salad served in a fast-food restaurant was implicated as the source of infection. Stool cultures were obtained from 104 employees, and serum Vi antibodies were assayed in 97 of the employees. Salmonella typhi was isolated from stool cultures of an 18-year-old asymptomatic female employee, who was a food handler. A high level of Vi antibodies (79.0 micrograms/ml), measured by radioimmunoassay, was found in her serum. She had emigrated from an endemic area at the age of 14 years and had visited that endemic area 2 years previously. The causal relation between the carrier and the 10 cases of typhoid fever was confirmed by a common bacteriophage type, denoted "degraded Vi resembling O," in the S. typhi isolates. This phage type is rare in the western hemisphere but common in the endemic area from which the carrier had emigrated. The high level of Vi antibody in the asymptomatic carrier, in contrast to the lower levels in the convalescent- and postimmunization-phase sera, facilitated the identification of the source infection in this outbreak. This radioimmunoassay offers a rapid and standardized method for identifying carriers of S. typhi.

Quinone formation from carcinogenic benzo[a]pyrene mediated by lipid peroxidation in phosphatidylcholine liposomes

The behavior of benzo[a]pyrene (B[a]P) during peroxidation of phosphatidylcholine (PC) liposomes initiated by an azo compound was investigated to examine the mechanism of quinone formation from carcinogenic B[a]P mediated by nonenzymatic lipid peroxidation occurring in vivo. B[a]P had a retarding effect on the peroxidation of polyunsaturated fatty acid moiety of PC. The major oxidation products which accumulated in the peroxidized liposomes were B[a]P 1,6-, 3,6-, and 6,12-quinone. Antioxidants acting as scavengers of chain-propagating lipid peroxy radicals effectively prevented not only lipid peroxidation but also B[a]P oxidation in the liposomal suspension. PC hydroperoxides, the primary products of PC oxidation, did not react with B[a]P in the absence of the azo compound, indicating that lipid peroxy radicals, not lipid hydroperoxides, are responsible for the formation of these quinones. The experiments using 18O2 gas and 18O-labeled methyl linoleate hydroperoxides demonstrated that B[a]P quinones are formed by incorporating molecular oxygen and their origin is partly due to the lipid peroxy radical. The mechanism proposed for the formation of B[a]P quinones mediated by peroxidation of membrane lipids involves a direct attack of the lipid peroxy radical on B[a]P and subsequent autocatalytic oxidation. Weak carcinogenic and noncarcinogenic pentacyclic aromatic hydrocarbons showed little reactivity to the lipid peroxy radical in the liposomes. Thus, the facility of the peroxidative attack on B[a]P may be related to the powerful carcinogenic activity of this substance.

Escherichia coli bacteremia in cancer patients

During a 10-year period, 621 episodes of Escherichia coli bacteremia occurred in 575 cancer patients. The infection was most common in patients with acute leukemia and genitourinary and gastrointestinal malignancies. Most of the patients acquired their infection while in the hospital, and 38 percent had received antibiotics during the preceding 10 days. Fever occurred in 96 percent of patients, and afebrile patients had an especially poor prognosis. Only 4.5 percent of the patients had disseminated intravascular coagulation, although hemorrhage contributed to the death of 15 percent of the patients. The overall response rate was 66 percent, but it increased from 48 percent in 1972 to 76 percent in 1981. Patients without pulmonary infection had a response rate of 78 percent, whereas patients with pulmonary infection had a response rate of only 41 percent. Patients who had positive blood culture results while receiving appropriate antibiotic therapy had a poor prognosis. There was no correlation between the patients' initial neutrophil counts and response, but patients whose neutrophil count increased during therapy had a response rate of 75 percent, compared with a 47 percent response rate for patients whose neutrophil count decreased. The response rate was 71 percent for patients who received appropriate antibiotics, 38 percent for patients who received inappropriate antibiotics, and 8 percent for patients who received no antibiotics. A single appropriate antibiotic was as effective as a combination.