The modern lifestyle caters to an increase in the incidence of peptic ulcer disease,gastroesophageal reflux disease and several other acid-related conditions of the gut. The drugs to prevent these conditions work eith...The modern lifestyle caters to an increase in the incidence of peptic ulcer disease,gastroesophageal reflux disease and several other acid-related conditions of the gut. The drugs to prevent these conditions work either through H2 receptor blockade or inhibition of the H^+, K^+ ATPase enzyme. Although proton pump inhibitors have been proven to be efficacious, they have a slow onset of action with limited resolution of symptoms in most patients. Potassium-competitive acid blockers(P-CABs) are novel drugs that bind reversibly to K^+ ions and block the H^+, K^+ ATPase enzyme, thus preventing acid production. P-CABs have a fast onset of action and have dose-dependent effects on acid production. Animal studies exist that differentiate the better results of P-CABs from proton pump inhibitors; further human trials will give a comprehensive picture of the results and will help to elucidate the therapeutic benefits of this new group of drugs.展开更多
AIM:To evaluate the effect of proton pump inhibitors(PPIs) on the development of gastrointestinal tuberculosis.METHODS:All patients who were more than 20 years old and who had received a prescription for PPIs among th...AIM:To evaluate the effect of proton pump inhibitors(PPIs) on the development of gastrointestinal tuberculosis.METHODS:All patients who were more than 20 years old and who had received a prescription for PPIs among those who visited Seoul National University Hospital from January 1,2005 to December 31,2009 were identified.Due to the low sensitivity of the microbiologic test and the nonspecific pathologic findings,the diagnosis of gastrointestinal tuberculosis was confirmed through the presence of active ulcerations and the responses to anti-tuberculosis medications.The patients were divided into two groups according to treatment duration(group 1:≤ 3 mo;group 2:> 3 mo) and were followed up from the time they took the first prescription of PPIs until their last visit.Logistic regression analysis was used to calculate the relative risks(RR) and 95%CI,adjusting for covariates.RESULTS:Among the 61 834 patients exposed to PPIs(50 534 in group 1;11 300 in group 2),21 patients were diagnosed with PPI-associated gastrointestinal tuberculosis during 124 274 person-years of follow-up.Of 21 patients,the 12 who revealed only scar changes in the colonoscopy were excluded from the statistical analyses.Of those who remained,2 were excluded because they underwent gastrointestinal endoscopy within 4 wk of the first prescription for PPIs.Longer exposure to PPI was associated with a higher mean age(55.0 ± 14.5 in group 1 vs 58.2 ± 13.3 in group 2,P < 0.001) and a higher Charlson co-morbidity index(0.50 ± 0.93 in group 1 vs 0.77 ± 1.14 in group 2,P < 0.001).The true incidence of active gastrointestinal tuberculosis was 0.65 per 1000 person-years in group 1 and 0.03 per 1 000 person-years in group 2.Like the less-than-three-month PPI treatment period in group 1,the over-three-month PPI therapy period in group 2 was not associated with increased risk of acquiring gastrointestinal tuberculosis,after adjusting for age and co-morbidities,whereas the Charlson co-morbidity index was associated with increased risk of acquiring gastrointestinal tuberculosis based on the score [RR:(reference 1) in group 1 vs 1.518 in group 2;95% CI:1.040-2.216,P = 0.03].CONCLUSION:Long-term PPI therapy does not seem to be associated with increased risk of acquiring gastrointestinal tuberculosis,but a higher Charlson comorbidity index is associated with such.展开更多
Over the past two decades,proton pump inhibitors (PPIs)have emerged as highly effective and relatively safe agents for the treatment of a variety of gastrointestinal disorders.Unfortunately,this desirable pharmacologi...Over the past two decades,proton pump inhibitors (PPIs)have emerged as highly effective and relatively safe agents for the treatment of a variety of gastrointestinal disorders.Unfortunately,this desirable pharmacological profile has also contributed to superfluous and widespread use in both the inpatient and outpatient settings.While generally well-tolerated,research published over the last decade has associated these agents with increased risks of Clostridium difficile disease, fractures likely due to calcium malabsorption and both community-acquired(CAP)and hospital-acquired pneumonias(HAP).The mechanism behind PPI-associated pneumonia may be multifactorial,but is thought to stem from compromising the stomach's"acid mantle"against gastric colonization of acid-labile pathogenic bacteria which then may be aspirated.A secondary postulate is that PPIs,through their inhibition of extra-gastric H+/K+ATPase enzymes,may reduce the acidity of the upper aerodigestive tract,thus resulting in increased bacterial colonization of the larynx,esophagus and lungs.To date,several retrospective case control studies have been published looking at the association between PPI use and CAP.Some studies found a temporal relationship between PPI exposure and the incidence of pneumonia,but only two could define a dose-response re-lationship.Furthermore,other studies found an inverse correlation between duration of PPI use and risk of CAP. In terms of HAP,we reviewed two retrospective cohort studies and one prospective study.One retrospective study in a medical ICU found no increased association of HAP in PPI-exposed patients compared to no acid-lowering therapy,while the other in cardiothoracic surgery patients showed a markedly increased risk compared to those receiving H2RAs.The one prospective study in ICU patients showed an increased risk of HAP with PPIs, but not with H2RAs.In conclusion,the current literature shows a slight trend toward an association between PPI use and pneumonia and an increased risk with PPIs over H2RAs,but the findings are not consistent across all studies.Larger controlled trials still need to be done to better identify the risk that PPIs impart towards patients contracting CAP or HAP.Until these are completed, we will have to continue to extrapolate across smaller controlled trials to predict the associated risks in our respective patient populations.In the interim,it appears prudent to limit the use of PPIs to situations where they are clinically indicated and,in such cases,use them at the lowest effective dose.In the case of prescribing for stress ulcer prophylaxis in ICU patients,perhaps H2RAs should be used as the preferred agents over PPIs.展开更多
AIM: To assess the appropriateness of prescribing acid suppressive therapy (AST) in a general medicine service in a tertiary care hospital. METHODS: In this retrospective observational study, we reviewed the inpatient...AIM: To assess the appropriateness of prescribing acid suppressive therapy (AST) in a general medicine service in a tertiary care hospital. METHODS: In this retrospective observational study, we reviewed the inpatient records of all patients admitted to the general medical service in a tertiary care hospital in Beirut, Lebanon, from April 1 to May 31, 2011. Treatment with AST was considered appropriate if the patient had a specific indication or appropriate treatment purpose [e.g. , gastro-esophageal reflux disease (GERD), peptic ulcer disease, dyspepsia, acute or suspected gastrointestinal (GI) bleeding]. Appropriate administration of stress ulcer prophylaxis (SUP) was derived from an internal guideline that is based on the American Society of Health System Pharmacists guidelines. Prophylaxis was considered appropriate if a patient had 1 absolute indication (coagulopathy or requiring mechanical ventilation), or 2 or more relative indications (sepsis, occult bleeding, use of high dose corticosteroids, recent use of non-steroidal anti-inflammatory drugs for more than 3 mo, renal or liver failure, enteral feeding and anticoagulant use). RESULTS: Of the 153 patient admissions during the study period, 130 patients (85%) were started on AST, out of which 11 (8.5%) had a diagnosis that sup-ports the use of this therapy (GI bleed, gastritis and GERD), 16 (12.3%) had an absolute indication for SUP, 59 (45.4%) had 2 or more relative indications for SUP, and 44 (33.8%) received AST without an appropriate indication. In addition, one patient with an absolute indication for SUP and four with two or more relative indications did not receive AST. Rabeprazole was the most frequently used AST (59.2%), followed by omeprazole (24.6%), esomeprazole (11.6%) and ranitidine (4.6%). The dose of AST was appropriate in 126 patients (96.9%) and the route of administration was appropriate in 123 patients (94.6%). Fifteen of the admitted patients (10%) were discharged on AST, 7 of which (47%) did not have an appropriate indication. CONCLUSION: AST is overused in hospitalized noncritically ill patients and many patients are discharged on unnecessary AST which can increase cost, drug interactions and adverse events. Potential interventions include implementation of institutional protocols and prescriber education.展开更多
文摘The modern lifestyle caters to an increase in the incidence of peptic ulcer disease,gastroesophageal reflux disease and several other acid-related conditions of the gut. The drugs to prevent these conditions work either through H2 receptor blockade or inhibition of the H^+, K^+ ATPase enzyme. Although proton pump inhibitors have been proven to be efficacious, they have a slow onset of action with limited resolution of symptoms in most patients. Potassium-competitive acid blockers(P-CABs) are novel drugs that bind reversibly to K^+ ions and block the H^+, K^+ ATPase enzyme, thus preventing acid production. P-CABs have a fast onset of action and have dose-dependent effects on acid production. Animal studies exist that differentiate the better results of P-CABs from proton pump inhibitors; further human trials will give a comprehensive picture of the results and will help to elucidate the therapeutic benefits of this new group of drugs.
基金Supported by Basic Science Research Program through a National Research Foundation of Korea Grant Funded by the Ministry of Education,Science,and Technology,No. 2011-0018257Systems Biomedical Informatics National Core Research Center
文摘AIM:To evaluate the effect of proton pump inhibitors(PPIs) on the development of gastrointestinal tuberculosis.METHODS:All patients who were more than 20 years old and who had received a prescription for PPIs among those who visited Seoul National University Hospital from January 1,2005 to December 31,2009 were identified.Due to the low sensitivity of the microbiologic test and the nonspecific pathologic findings,the diagnosis of gastrointestinal tuberculosis was confirmed through the presence of active ulcerations and the responses to anti-tuberculosis medications.The patients were divided into two groups according to treatment duration(group 1:≤ 3 mo;group 2:> 3 mo) and were followed up from the time they took the first prescription of PPIs until their last visit.Logistic regression analysis was used to calculate the relative risks(RR) and 95%CI,adjusting for covariates.RESULTS:Among the 61 834 patients exposed to PPIs(50 534 in group 1;11 300 in group 2),21 patients were diagnosed with PPI-associated gastrointestinal tuberculosis during 124 274 person-years of follow-up.Of 21 patients,the 12 who revealed only scar changes in the colonoscopy were excluded from the statistical analyses.Of those who remained,2 were excluded because they underwent gastrointestinal endoscopy within 4 wk of the first prescription for PPIs.Longer exposure to PPI was associated with a higher mean age(55.0 ± 14.5 in group 1 vs 58.2 ± 13.3 in group 2,P < 0.001) and a higher Charlson co-morbidity index(0.50 ± 0.93 in group 1 vs 0.77 ± 1.14 in group 2,P < 0.001).The true incidence of active gastrointestinal tuberculosis was 0.65 per 1000 person-years in group 1 and 0.03 per 1 000 person-years in group 2.Like the less-than-three-month PPI treatment period in group 1,the over-three-month PPI therapy period in group 2 was not associated with increased risk of acquiring gastrointestinal tuberculosis,after adjusting for age and co-morbidities,whereas the Charlson co-morbidity index was associated with increased risk of acquiring gastrointestinal tuberculosis based on the score [RR:(reference 1) in group 1 vs 1.518 in group 2;95% CI:1.040-2.216,P = 0.03].CONCLUSION:Long-term PPI therapy does not seem to be associated with increased risk of acquiring gastrointestinal tuberculosis,but a higher Charlson comorbidity index is associated with such.
文摘Over the past two decades,proton pump inhibitors (PPIs)have emerged as highly effective and relatively safe agents for the treatment of a variety of gastrointestinal disorders.Unfortunately,this desirable pharmacological profile has also contributed to superfluous and widespread use in both the inpatient and outpatient settings.While generally well-tolerated,research published over the last decade has associated these agents with increased risks of Clostridium difficile disease, fractures likely due to calcium malabsorption and both community-acquired(CAP)and hospital-acquired pneumonias(HAP).The mechanism behind PPI-associated pneumonia may be multifactorial,but is thought to stem from compromising the stomach's"acid mantle"against gastric colonization of acid-labile pathogenic bacteria which then may be aspirated.A secondary postulate is that PPIs,through their inhibition of extra-gastric H+/K+ATPase enzymes,may reduce the acidity of the upper aerodigestive tract,thus resulting in increased bacterial colonization of the larynx,esophagus and lungs.To date,several retrospective case control studies have been published looking at the association between PPI use and CAP.Some studies found a temporal relationship between PPI exposure and the incidence of pneumonia,but only two could define a dose-response re-lationship.Furthermore,other studies found an inverse correlation between duration of PPI use and risk of CAP. In terms of HAP,we reviewed two retrospective cohort studies and one prospective study.One retrospective study in a medical ICU found no increased association of HAP in PPI-exposed patients compared to no acid-lowering therapy,while the other in cardiothoracic surgery patients showed a markedly increased risk compared to those receiving H2RAs.The one prospective study in ICU patients showed an increased risk of HAP with PPIs, but not with H2RAs.In conclusion,the current literature shows a slight trend toward an association between PPI use and pneumonia and an increased risk with PPIs over H2RAs,but the findings are not consistent across all studies.Larger controlled trials still need to be done to better identify the risk that PPIs impart towards patients contracting CAP or HAP.Until these are completed, we will have to continue to extrapolate across smaller controlled trials to predict the associated risks in our respective patient populations.In the interim,it appears prudent to limit the use of PPIs to situations where they are clinically indicated and,in such cases,use them at the lowest effective dose.In the case of prescribing for stress ulcer prophylaxis in ICU patients,perhaps H2RAs should be used as the preferred agents over PPIs.
文摘AIM: To assess the appropriateness of prescribing acid suppressive therapy (AST) in a general medicine service in a tertiary care hospital. METHODS: In this retrospective observational study, we reviewed the inpatient records of all patients admitted to the general medical service in a tertiary care hospital in Beirut, Lebanon, from April 1 to May 31, 2011. Treatment with AST was considered appropriate if the patient had a specific indication or appropriate treatment purpose [e.g. , gastro-esophageal reflux disease (GERD), peptic ulcer disease, dyspepsia, acute or suspected gastrointestinal (GI) bleeding]. Appropriate administration of stress ulcer prophylaxis (SUP) was derived from an internal guideline that is based on the American Society of Health System Pharmacists guidelines. Prophylaxis was considered appropriate if a patient had 1 absolute indication (coagulopathy or requiring mechanical ventilation), or 2 or more relative indications (sepsis, occult bleeding, use of high dose corticosteroids, recent use of non-steroidal anti-inflammatory drugs for more than 3 mo, renal or liver failure, enteral feeding and anticoagulant use). RESULTS: Of the 153 patient admissions during the study period, 130 patients (85%) were started on AST, out of which 11 (8.5%) had a diagnosis that sup-ports the use of this therapy (GI bleed, gastritis and GERD), 16 (12.3%) had an absolute indication for SUP, 59 (45.4%) had 2 or more relative indications for SUP, and 44 (33.8%) received AST without an appropriate indication. In addition, one patient with an absolute indication for SUP and four with two or more relative indications did not receive AST. Rabeprazole was the most frequently used AST (59.2%), followed by omeprazole (24.6%), esomeprazole (11.6%) and ranitidine (4.6%). The dose of AST was appropriate in 126 patients (96.9%) and the route of administration was appropriate in 123 patients (94.6%). Fifteen of the admitted patients (10%) were discharged on AST, 7 of which (47%) did not have an appropriate indication. CONCLUSION: AST is overused in hospitalized noncritically ill patients and many patients are discharged on unnecessary AST which can increase cost, drug interactions and adverse events. Potential interventions include implementation of institutional protocols and prescriber education.
