Use Of Acid Suppression Research Articles

Use of anti-reflux medications in infants under 1 year of age: a retrospective drug utilization study using national prescription reimbursement data

Non-specific symptoms such as irritability, vomiting, and back arching during the infant period are often attributed to gastroesophageal reflux. While numerous studies have shown no significant benefit to the use of acid suppressant medications in this population, these medications are frequently prescribed in response to these symptoms. Our goals were to understand how often children were being prescribed this medication. To do this, data was extracted from a national database for reimbursement of prescribed medications through the General Medical Services scheme (GMS). Infants aged less than 1 year and eligible for reimbursement under GMS were included for analysis. A total of 450 infants per 10,000 eligible population received an anti-reflux preparation from the following drug classes (H2 antagonists, proton pump inhibitors, or alginate preparations) in 2018. This is compared with that in 2009 where only 137 per 10,000 eligible infants received these medications. This increase was predominantly attributable to an increase in ranitidine prescriptions.Conclusion: Despite a change in clinical guidelines, anti-reflux preparations are increasingly being prescribed to infants aged less than 1 year. The reasons behind the increase in prescriptions containing these medications cannot be ascertained from this data. This may suggest a proportion of these prescriptions may be unwarranted in this population. What is Known: • The prescription of PPIs in infants has increased in a number of countries. • Use of anti-reflux medications has a very poor evidence base in infancy. What is New: • This data focuses only on an infant age group in a "well" cohort. • Ranitidine may contribute to increased acid-suppressant use in infancy.

S0506 Efficacy and Safety of Plecanatide in Patients With Chronic Idiopathic Constipation: Pooled Analysis of Two Phase 3 Trials Stratified by Concomitant Acid Suppression Use

INTRODUCTION: Plecanatide, an approved treatment for chronic idiopathic constipation (CIC), replicates the pH-sensitive activity of uroguanylin in binding to guanylate cyclase-C receptors on intestinal epithelium. Since many individuals with CIC experience reflux and use concomitant acid suppression therapy, we explored the impact of concomitant acid suppressor use on the efficacy and safety of plecanatide in adults with CIC. METHODS: Data on two 12-week, randomized, double-blind, placebo-controlled phase 3 clinical trials of plecanatide were pooled and results were stratified by concomitant acid suppressor use. For each group, durable overall complete spontaneous bowel movement (CSBM) response rates, changes from baseline in bowel movement frequency, stool consistency (Bristol Stool Form Scale), and daily CIC symptom scores (Likert Scale, 0 = none to 4 = very severe) were assessed. Safety was analyzed in patients who received ≥1 dose. RESULTS: The intention-to-treat population (N = 2639) included 12.6% of patients with concomitant acid suppressor use. Patients using acid suppressors were 54.8 years (mean), vs 43.9 years in those not using acid suppressors. Gastroesophageal reflux disease was more common in patients using acid suppressors (83.1%), compared to those not on acid suppressors (6.1%). Proton pump inhibitors (PPIs) were used by 86.4% of patients using acid suppressors with omeprazole as the most common PPI (45.1%); H2 blockers were used by 17.8% of subjects with ranitidine as the most common H2 blocker (9.8%). Regardless of acid suppressor use, plecanatide-treated patients demonstrated significant improvements in the durable overall CSBM responder rates (Figure 1) and greater efficacy across almost all reported endpoints (Table 1) vs placebo, with benefits observed as early as Week 1. Comparisons between acid suppressor use groups (yes vs no) were not significantly different for plecanatide-treated patients (both doses, Table 1). Of the plecanatide-treated patients on acid suppressors, 6.4% experienced diarrhea, 1.4% discontinued due to diarrhea, and 2.3% had ≥ 1 serious adverse event (SAE), compared to 5.0% (diarrhea), 2.1% (discontinued due to diarrhea), and 1.0% (SAE) of patients not using acid suppressors. CONCLUSION: Plecanatide is a safe and effective treatment for CIC when administered with acid suppression therapy. Regardless of acid suppressor use, efficacy responses in plecanatide groups were significantly greater than placebo.Figure 1.: Percentage of Patients With Durable Overall CSBM Response Stratified by Concomitant Acid Suppressor Use (ITT).Table 1.: Change From Baseline in Bowel Movement Frequency, Stool Consistency, and CIC Symptoms in Patients With and Without Concomitant Acid Suppression Therapy (ITT)

Effect of Acid Suppressants on the Risk of COVID-19: A Propensity Score-Matched Study Using UK Biobank

Effect of Acid Suppressants on the Risk of COVID-19: A Propensity Score-Matched Study Using UK Biobank

Infant acid suppression use is associated with the development of eosinophilic esophagitis.

Eosinophilic esophagitis (EoE) is an esophageal allergic inflammatory disorder often presenting with infant/toddler gastroesophageal reflux symptoms refractory to treatment, including acid suppression trials with histamine H2 antagonists and proton pump inhibitors. We propose to evaluate the impact of infant acid suppressant exposure in EoE. Geisinger's pediatric EoE cases were matched to controls (1:5 EoE case control ratio) using age, race, sex, and ages at other diagnoses of asthma, eczema, and environmental allergies, totaling 526 EoE cases and 2,630 controls. Comparisons between EoE cases and matched controls were tested with regard to rates of acid suppression use with H2 antagonists and PPIs during infancy. Our analyses found the use of acid suppression in infancy was positively associated with EoE: PPI (5.7% EoE cases vs. 1.6% controls; P < 0.0001), H2 antagonists (8.8% EoE cases vs. 4.5% controls; P < 0.0001). Additionally, analysis of EoE cases using acid suppression during infancy indicated a likelihood for the diagnosis with EoE at an earlier age. Early acid suppression use in infants is significantly associated with the diagnosis of EoE in childhood in this well-matched retrospective cohort study. The potential link warrants additional investigation. Our study further reinforces the evidence-based stewardship of acid suppressant use, especially in our most vulnerable populations.

P-371 The use of gastric acid suppression in surgical oncology patients

The use of gastric acid suppression medications during oncologic surgery has become a mainstay within the perioperative period. Recent literature suggests that the use of these medications may be associated with significant adverse effects, including an increase in post-operative infections. However, surgical oncology patients have never been particularly studied and the impact of acid suppression in this cohort is generally unknown. We intended to compare the rates of postoperative morbidity including various types of infections and organ dysfunction in cancer patients who take acid-suppressing medications versus those who are not taking said medications during their surgical course.

Association of Gastric Acid Suppression and Sorafenib Efficacy in Advanced Hepatocellular Carcinoma.

Recent studies have revealed that coadministration of gastric acid suppressants reduces the efficacy of the tyrosine kinase inhibitors erlotinib and sunitinib in patients with non-small cell lung cancer and renal cell carcinoma, respectively. The authors have therefore assessed if the concurrent use of gastric acid suppressants and sorafenib impairs outcomes in patients with advanced hepatocellular carcinoma (HCC). A retrospective analysis was conducted on all patients treated with sorafenib for advanced HCC at a single tertiary referral unit in the United Kingdom, between January 2008 and January 2014. A multivariate Cox proportional hazard model was used to assess the effect of the concomitant use of gastric acid suppression and sorafenib on progression-free survival (PFS) and overall survival (OS). Data were collected from 197 patients, of which 182 could be assessed for this study; 77 (42%) were on concurrent gastric acid suppression therapy. After adjusting for imbalances between the groups, a Cox regression analysis gave an adjusted hazard ratio for the concurrent acid suppression group compared with the no acid suppression group of 5.4 (95% confidence interval, 3.6-7.9) for PFS and 1.85 (95% confidence interval, 1.3-2.6) for OS. This single-center experience shows that patients with advanced HCC taking sorafenib and concomitant gastric acid suppression therapy have significantly inferior PFS and OS. This is the first time that this negative interaction has been reported and further prospective validation is warranted.

Acid Suppressants Increase Risk of Colonization with Multidrug-Resistant Microorganisms.

According to this study: Use of acid suppressants is associated with a 75% increase in the risk of intestinal tract colonization with multidrug-resistant microorganisms in both the community and health care settings.More prudent use of acid suppressants may help to reduce the risks of colonization with multidrug-resistant microorganisms.

Impact of Use of Gastric-Acid Suppressants and Oral Anti-Cancer Agents on Survival Outcomes: A Systematic Review and Meta-Analysis.

We performed a systematic review and meta-analysis to evaluate the role of gastric acid suppressant use on outcomes of tyrosine kinase inhibitors (TKIs) and oral chemotherapy. We identified all research evaluating the effect of GAS (gastric acid suppressants) use on patients receiving oral chemotherapy or TKIs for solid tumors. The pooled hazard ratios (HRs) and 95% confidence interval (95%CI) for overall survival (OS) and progression-free survival (PFS) were calculated with a fixed-effects or a random effects model. The study population included n = 16 retrospective studies and 372,418 patients. The series concerned gastrointestinal tract tumors (n = 5 studies), renal cell carcinomas (RCC, n = 3 studies), non-small cell lung cancers (NSCLC, n = 5 studies), and soft tissue sarcomas or mixed histologies solid tumors in n = 3 studies. The pooled HRs for OS and PFS were 1.31 (95%CI: 1.20–1.43; p < 0.01) and 1.3 (95%CI 1.07–1.57; p < 0.01) for GAS and no GAS users, respectively. Only studies of EGFR (epidermal growth factor receptor) mutated NSCLC patients receiving TKIs and those with colorectal cancer receiving oral chemotherapy showed a significant correlation between GAS and poor survival. Our study supports the evidence of a possible negative impact of concomitant GAS therapy on survival outcomes of patients receiving oral anti-cancer drugs.

Clinical Impact of Gastric Acid Suppressants Use on the Efficacy of Gefitinib in Patients with Advanced Adenocarcinoma of the Lung Harboring Common EGFR Mutations

Background: Gefitinib was approved by the Food and Drug Administration (FDA) of the United States (US) for the treatment of advanced non-small cell carcinoma harboring sensitizing epidermal growth factor receptor (EGFR) mutations. The use of gastric acid-suppressing medication inhibits gefitinib absorption and reduces its plasma concentration, but retrospective studies on whether there is the corresponding repercussion on progression-free survival (PFS) have yielded variable results, mainly due to heterogeneity in study cohorts and study designs. Objectives: To assess the clinical impact of the use of gastric acid-suppressing medication in patients on first-line gefitinib for NSLC harboring common EGFR mutation. Methods: This is a retrospective cohort study conducted in a single, tertiary referral center in Hong Kong S.A.R., which included 193 Chinese patients with advanced adenocarcinoma of lung harboring common sensitizing EGFR mutations who received gefitinib as the first-line treatment. The progression- free survival (PFS) and overall survival (OS) for patients who took gastric acid-suppressing agents, namely histamine-2 receptor antagonists (H2RA) or proton pump inhibitors (PPI), were compared with those who did not take such medication (control group). Results: Despite the universal practice to separate the medicating time of gastric acid suppressants and EGFR-TKIs by 12 hours, patients who were on gastric acid suppressants had significantly shorter PFS, especially for those on proton pump inhibitor (Median 368 vs. 189 vs. 166 days - For control, H2RA group and PPI group respectively, p-value &lt;0.001). The OS is also significantly shorter for those taking gastric acid suppressants (Median 825 vs. 485 vs. 422 days - For control, H2RA group and PPI group respectively, p-value &lt;0.001). Conclusions: The co-administration of gastric acid suppressants with gefitinib is associated with shorter progression-free survival and overall survival.

Prophylactic use of acid suppressants in adult acutely ill hospitalised patients: A systematic review with meta-analysis and trial sequential analysis.

Acutely ill patients are at risk of stress-related gastrointestinal (GI) bleeding and prophylactic acid suppressants are frequently used. In this systematic review, we assessed the effects of stress ulcer prophylaxis (SUP) with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) versus placebo or no prophylaxis in acutely ill hospitalised patients. We conducted the review according to the PRISMA statement, the Cochrane Handbook and GRADE, using conventional meta-analysis and trial sequential analysis (TSA). The primary outcomes were all-cause mortality, clinically important GI bleeding and serious adverse events (SAEs). The primary analyses included overall low risk of bias trials. We included 65 comparisons from 62 trials (n=9713); 43 comparisons were from intensive care units. Only three trials (n=3596) had overall low risk of bias. We did not find an effect on all-cause mortality (RR 1.03, 95% CI 0.94 to 1.14; TSA-adjusted CI 0.90 to 1.18; high certainty). The rate of clinically important GI bleeding was lower with SUP (RR 0.62, 95% CI 0.43 to 0.89; TSA-adjusted CI 0.14 to 2.81; moderate certainty). We did not find a difference in pneumonia rates (moderate certainty). Effects on SAEs, Clostridium difficile enteritis, myocardial ischaemia and health-related quality of life (HRQoL) were inconclusive due to sparse data. Analyses of all trials regardless of risk of bias were consistent with the primary analyses. We did not observe a difference in all-cause mortality or pneumonia with SUP. The incidence of clinically important GI bleeding was reduced with SUP, whereas any effects on SAEs, myocardial ischaemia, Clostridium difficile enteritis and HRQoL were inconclusive. PROSPERO registration number CRD42017055676; published study protocol: Marker, et al 2017 in Systematic Reviews.

Hospital-acquired Pneumonia and Ventilator-associated Pneumonia in Children: A Prospective Natural History and Case-Control Study.

Clinical trials for antibiotics designed to treat hospital-acquired and ventilator-associated bacterial pneumonias (HABP/VABP) are hampered by making these diagnoses in a way that is acceptable to the United States Food and Drug Administration and consistent with standards of care. We examined laboratory and clinical features that might improve pediatric HABP/VABP trial efficiency by identifying risk factors predisposing children to HABP/VABP and describing the epidemiology of pediatric HABP/VABP. We prospectively reviewed the electronic medical records of patients <18 years of age admitted to intensive and intermediate care units (ICUs) if they received qualifying respiratory support or were started on antibiotics for a lower respiratory tract infection or undifferentiated sepsis. Subjects were followed until HABP/VABP was diagnosed or they were discharged from the ICU. Clinical, laboratory and imaging data were abstracted using structured chart review. We calculated HABP/VABP incidence and used a stepwise backward selection multivariable model to identify risk factors associated with development of HABP/VABP. A total of 862 neonates, infants and children were evaluated for development of HABP/VABP; 10% (82/800) of those receiving respiratory support and 12% (103/862) overall developed HABP/VABP. Increasing age, shorter height/length, longer ICU length of stay, aspiration risk, blood product transfusion in the prior 7 days and frequent suctioning were associated with increased odds of HABP/VABP. The use of noninvasive ventilation and gastric acid suppression were both associated with decreased odds of HABP/VABP. Food and Drug Administration-defined HABP/VABP occurred in 10%-12% of pediatric patients admitted to ICUs. Risk factors vary by age group.

Evaluation of the Association Between Gastric Acid Suppression and Risk of Intestinal Colonization With Multidrug-Resistant Microorganisms

Acid suppressants inhibit gastric acid secretion and disrupt the intestinal microbiome. Whether acid suppression increases the risk of colonization with multidrug-resistant microorganisms (MDROs) is unclear. To systematically examine the association of use of acid suppressants with the risk of colonization with MDROs and to perform a meta-analysis of current evidence. PubMed, Embase, the Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials were searched from database inception through July 8, 2019. Study selection was performed independently by 2 authors (R.P.J.W. and C.M.J.E.V.-G.) on the basis of predefined selection criteria; conflicts were resolved by consensus or by an adjudicator (K.v.D.). Human observational studies (case control, cohort, and cross-sectional) and clinical trial designs were selected if they quantified the risk of MDRO colonization in users of acid suppressants in comparison with nonusers. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) recommendations were followed. Data were extracted independently by the same 2 authors, and adjudication was conducted when necessary. Risk of bias was assessed according to a modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) were estimated using random-effects models; heterogeneity was evaluated using the I2 method. The primary outcome measure was intestinal colonization with MDROs of the Enterobacterales order (producing extended-spectrum β-lactamases, carbapenemases, or plasmid-mediated AmpC β-lactamases), vancomycin-resistant enterococci, methicillin-resistant or vancomycin-resistant Staphylococcus aureus, or multidrug-resistant Pseudomonas or Acinetobacter species. A total of 26 observational studies including 29 382 patients (11 439 [38.9%] acid suppressant users) met the selection criteria. Primary meta-analysis of 12 studies including 22 305 patients that provided adjusted ORs showed that acid suppression increased the odds of intestinal carriage of MDROs of the Enterobacterales order and of vancomycin-resistant enterococci by roughly 75% (OR = 1.74; 95% CI, 1.40-2.16; I2 = 68%). The odds were concordant with the secondary pooled analysis of all 26 studies (OR = 1.70; 95% CI, 1.44-1.99; I2 = 54%). Heterogeneity was partially explained by variations in study setting and the type of acid suppression. Acid suppression is associated with increased odds of MDRO colonization. Notwithstanding the limitations of observational studies, the association is plausible and is strengthened by controlling for confounders. In view of the global increase in antimicrobial resistance, stewardship to reduce unnecessary use of acid suppressants may help to prevent MDRO colonization.

Antibiotic Prescribing Choices and Their Comparative C. Difficile Infection Risks: A Longitudinal Case-Cohort Study

Antibiotic use is the strongest modifiable risk factor for the development of Clostridioides difficile infection, but prescribers lack quantitative information on comparative risks of specific antibiotic courses. Our objective was to estimate risks of C. difficile infection associated with receipt of specific antibiotic courses. We conducted a longitudinal case-cohort analysis representing over 90% of Ontario nursing home residents, between 2012 and 2017. Our primary exposure was days of antibiotic receipt in the prior 90 days. Adjustment covariates included: age, sex, prior emergency department or acute care stay, Charlson comorbidity index, prior C. difficile infection, acid suppressant use, device use, and functional status. We examined incident C. difficile infection, including cases identified within the nursing home, and those identified during subsequent hospital admissions. Adjusted and unadjusted regression models were used to measure risk associated with 5- to 14-day courses of 18 different antibiotics. We identified 1708 cases of C. difficile infection (1.27 per 100 000 resident-days). Longer antibiotic duration was associated with increased risk: 10- and 14-day courses incurred 12% (adjusted relative risk [ARR] = 1.12, 95% confidence interval [CI]: 1.09, 1.14) and 27% (ARR = 1.27, 95% CI: 1.21,1.30) more risk compared to 7-day courses. Among 7-day courses with similar indications: moxifloxacin resulted in 121% more risk than amoxicillin (ARR = 2.21, 95% CI: 1.67, 3.08), ciprofloxacin engendered 89% more risk than nitrofurantoin (ARR = 1.89, 95% CI: 1.45, 2.68), and clindamycin resulted in 112% (ARR = 2.12, 95% CI: 1.32, 3.78) more risk than cloxacillin. C. difficile infection risk increases with antibiotic duration, and there are wide disparities in risks associated with antibiotic courses used for similar indications.

Helicobacter pylori Treatment Strategies in Singapore.

The management of Helicobacter pylori infection in Singapore remains a clinical challenge. Similar to other regions, there has been an increase in antibiotic resistance rates through the years. Nonetheless, over the past two decades, clarithromycin-based triple therapy has continued to be used as the first line treatment option, with an eradication rate exceeding 90%, although the accepted treatment duration must now be lengthened from 1 to 2 weeks to maintain efficacy. Concomitant and sequential therapies did not demonstrate superiority over standard triple therapy. Current empiric second line treatment utilizes either bismuth-based quadruple therapy or levofloxacin-based triple therapy, but outcomes remain less than ideal. Identifying options to further improve treatment success rates is challenging. Strategies being considered include the use of potent acid suppressants, such as vonoprazan, and H. pylori culture and antibiotic susceptibility testing-guided therapy.

2370. Risk Factors for Clostridioides difficile Colonization Among Adult Inpatients: A Meta-Analysis

Background Clostridioides difficile is one of the most common causes of healthcare-associated infections in the United States. The prevalence of asymptomatic C. difficile colonization has been demonstrated to range from 3 to 21% for hospitalized adults. Patients colonized with C. difficile may serve as potential reservoirs for transmission of C. difficile infection (CDI) within inpatient units. The purpose of this meta-analysis was to identify the risk factors for colonization at hospital admission among adult patients, to inform strategies for infection prevention.MethodsWe searched MEDLINE, Scopus, Web of Science, and Embase from inception to 2019 for articles related to C. difficile colonization on hospital admission. Studies with multivariate analyses evaluating risk factors for asymptomatic colonization in adult inpatients were eligible. Odds ratios were pooled using a random effects model. Study quality and publication bias analyses were also conducted.ResultsAmong 2,982 studies identified in the search, 21 studies met the inclusion criteria. Included studies reported 18,468 adult patients of which 1,243 were asymptomatically colonized with C.difficile. Factors associated with an increased risk of colonization were CDI in the last 3 months (OR 4.18, 95% CI 2.56–6.82, I2 = 0%), hospitalization in the last 6 months (OR 2.45, 95% CI 2.06–2.92, I2 = 0%) and use of gastric acid suppression therapy within the last 8 weeks (OR 1.46, 95% CI 1.17–1.73, I2 = 1%). Receipt of antibiotics in the last 3 months (OR 1.37, 95% CI 0.94–2.01, I2 = 48%) and use of non-steroidal anti-inflammatory drugs (OR 0.90, 95% CI 0.52–1.55, I2 = 65%) were not associated with statistically significant effects on risk of colonization. There were insufficient studies to determine the association between most antibiotic classes and the risk of colonization.ConclusionC.difficile colonization on hospital admission was significantly associated with previous CDI, recent hospitalization, and gastric acid suppression therapy. Recognition of these risk factors may assist in identifying potential carriers of C. difficile. These findings also emphasize the importance of judicious use of gastric acid suppression and other preventative measures in reducing C. difficile acquisition. Disclosures All authors: No reported disclosures.

2865 Acid Suppressants and Erosive Tooth Wear: An Analysis of National Health and Nutrition Examination Survey Data

INTRODUCTION: Antacids and acid suppressants (i.e., proton pump inhibitors and histamine2-blockers) are commonly used by individuals with heartburn and gastroesophageal reflux disease (GERD). Frequent heartburn and breakthrough symptoms of GERD have been shown to contribute to dental complications. The aim of this study is to compare the likelihood of erosive tooth wear (ETW) among users of antacids or acid suppressants. METHODS: We used data from the National Health and Nutrition Examination Survey (NHANES, 2003-2004) to identify a nationally representative sample of adults (age ≥ 18) who underwent an oral health exam by trained dental examiners. Self-reports of use of antacids and prescribed acid suppressants were collected by trained personnel during a home interview and used to classify individuals into groups. Erosive tooth wear was defined in NHANES using Smith and Knight's Tooth Wear Index modified by Millward, et al., which rates the severity of ETW from 0 (sound tooth surface) to 3 (complete loss of enamel). Erosive tooth wear was evaluated for 40 tooth surfaces; 24 proximal (facial or incisal) and 16 distal (lingual or occlusal) surfaces. Erosions were categorized based on location and severity. We used weighted linear and logistic regression to compare means and estimate the prevalence of erosions for each group. Estimates were adjusted for age, sex, and race/ethnicity. RESULTS: NHANES ETW data were available for 4,414 adults; antacid users (n = 595), acid suppressant users (n = 386), and non-users (n = 3,433). The mean number of assessable tooth surfaces varied between groups (P &gt; 0.001). Erosive tooth wear was more prevalent among those who reported the use of antacids or acid suppressants compared with non-users, however the difference was not statistically significant (P = 0.06). The percent of patients with ETW on at least one distal tooth surface was higher for antacid and acid suppressant users (P = 0.01). In addition, acid suppressant users had a higher prevalence of extensive tooth wear (P = 0.007). CONCLUSION: Individuals using antacids or acid suppressants (potentially for control of acid-reflux symptoms) are associated with a higher rate of dental complications, as suggested by the prevalence of erosions on distal tooth surfaces. In addition, extensive erosions were more common among users of acid suppressants than non-users. Emphasizing the importance of following recommendations from the American Dental Association for routine dental care may be particularly important for these individuals.

Guideline implementation is effective at reducing proton pump inhibitor use in hematology-oncology units: A multidisciplinary intervention for reducing Clostridioides difficile risk.

We implemented a guideline for appropriate acid suppressant use in hematology-oncology patients. This intervention resulted in a sustained reduction in proton pump inhibitor (PPI) use without an increase in rates of gastrointestinal bleeding. Practice guidelines are effective in reducing PPI use, which is associated with risk of Clostridioides difficile infection.

Effectiveness of acid suppressants and other mucoprotective agents in reducing the risk of occult gastrointestinal bleeding in nonsteroidal anti-inflammatory drug users

Acid suppressants such as histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) are effective in preventing gastrointestinal (GI) bleeding in nonsteroidal anti-inflammatory drugs (NSAIDs) users. Despite widespread acid suppressant use, there remain concerns about several potential risks of long-term use. Therefore, we investigated whether gastroprotective agents (GPAs) other than acid suppression therapy are effective in preventing NSAID-related GI injury. To this end, we studied 9,133 patients with osteoarthritis or rheumatoid arthritis who used NSAIDs for ≥1 month. A decrease of 2 g/dL or more in the hemoglobin level was considered a GI injury indicator. The GPAs included acid suppressants and other mucoprotective agents. Acid suppressants included PPIs and H2RAs. Other mucoprotective agents included misoprostol, rebamipide, and eupatilin. During a median follow-up period of 27 (range, 4.3-51.3) weeks, occult GI bleeding occurred in 1,191 (13%) patients. A comparison of patients who used GPAs concomitantly with that of nonusers in a multivariable analysis revealed the hazard ratios (HRs; 95% confidence intervals [CIs]) for occult GI bleeding were 0.30 (0.20-0.44), 0.35 (0.29-0.43), 0.47 (0.23-0.95), 0.43 (0.35-0.51), and 0.98 (0.86-1.12) for PPIs, H2RAs, misoprostol, rebamipide, and eupatilin, respectively. Compared to PPI co-treatment, H2RA, misoprostol, rebamipide, and eupatilin co-treatments were associated with occult GI bleeding HRs (95% CIs) of 1.19 (0.79-1.79), 1.58 (0.72-3.46), 1.44 (0.96-2.16), and 3.25 (2.21-4.77), respectively. Our findings suggest that mucoprotective agents, such as rebamipide and misoprostol, as well as acid suppressants, are effective in reducing the risk for GI injury in NSAID users.

Incidence and risk factors of dysphagia after variceal band ligation.

Background/AimsThere is a lack of data on long-term morbidity, particularly dysphagia, following endoscopic variceal band ligation (EVL). The aim of this study are to assess the incidence of dysphagia and variables associated with this complication after EVL.MethodsWe identified individuals who completed at least one session of EVL as their sole treatment for varices from August 2012 to December 2017. Included patients achieved “complete eradication” of varices not requiring further therapy. Patients ≥90 days from their last EVL session completed a modified version of the Mayo Clinic Dysphagia Questionnaire. Individuals with dysphagia were invited to undergo a barium esophagram. Patients with pre-EVL dysphagia were excluded.ResultsOf the patients, 68 possessed inclusion criteria, nine (13.2%) died and 20 (29.4%) were lost to follow up. For the remaining 39 (57.4%) patients, 23 were males, mean age of 61.7±8.6 years. The most common etiology of liver disease was hepatitis C virus (n=18; 46.2%). The median number of banding sessions was 2.0 (interquartile range [IQR], 1.0–4.0) with a median of 9.0 bands placed (IQR, 3.0–14.0). Twelve patients (30.8%) developed new-onset dysphagia post-EVL. In univariate analysis, pre-EVL MELD score and non-emergent initial banding were associated with long-term dysphagia. In a regression model adjusted for age, sex, number of bands, and use of acid suppression after EVL, no factor was independently associated with dysphagia (all p>0.05). No strictures were identified on subsequent esophageal evaluation.ConclusionsApproximately 30% of patients developed new-onset, chronic dysphagia post-EVL. Incident dysphagia was associated with a non-emergent initial banding session. The mechanism for dysphagia remains unknown.

Educational intervention can improve appropriateness of acid suppression therapy in hospitalized geriatric patients

ABSTRACTBackground: Inappropriate use of acid suppression (AST) therapy may lead to unnecessary harms, especially in the geriatric population. Despite this, AST remains one of the most commonly prescribed medications in the hospital. Therefore, we aimed to assess its prevalence and create educational intervention to improve the appropriateness of inpatient acid suppression therapy.Methods: Using a time-series design, we established a historical control by performing a retrospective chart. Accepted indications for AST were based on those endorsed by the USA Food and Drug Administration and literature review. Inclusion criteria were: (1) age ≥ 65; (2) acid suppression therapy-initiated in the hospital; and (3) patients admitted to the medicine teaching services. We then created an educational intervention, which consisted of lectures and distribution of information pocket cards to residents. Data was collected for two months after the intervention. We used a two-tail fisher exact test and student’s t-test to analyze our results.Results: 65% of geriatric patients were inappropriately placed on acid suppression therapy, for which 13% were discharged without further indications. After the educational intervention, the inappropriate use of acid suppression therapy decreased to 45% (P < 0.05).Conclusion: There is a significant overuse of AST in hospitalized geriatric patients. Educational interventions are one potential method that may help improve the appropriateness of acid suppression therapy for elderly inpatients.