Tag: gastrointestinal bleeding

Categories : HospitalsTags :

Global Trial Confirms Benefit of Antacids on Bleeding Prevention for Ventilated Patients

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A widely available drug helps prevent upper gastrointestinal bleeding in critically ill adults on a breathing machine, according to the results of a global study and meta-analysis led by researchers at McMaster University. 

The research, published on June 14, 2024 in The New England Journal of Medicine and NEJM Evidence, investigated the effect of the gastric acid suppressant pantoprazole, which is primarily used to treat heartburn caused by gastroesophageal reflux disease (GERD). 

Patients in the intensive care unit (ICU) who need a breathing machine (mechanical ventilator) also receive pantoprazole to prevent upper gastrointestinal bleeding, caused by stress-induced ulcers in the stomach. Concerns emerged about whether this complication of critical illness had disappeared over the years, and about side effects of pantoprazole, including increased risk of death in the sickest patients. The research provides critical care teams with certainty about whether the medications should be used in practice.   

“This is the largest randomized trial on this topic in the world, led by Canada. Physicians, nurses, and pharmacists working in the ICU setting will use this information in practice right away, and the trial results and the updated meta-analysis will be incorporated into international practice guidelines,” said lead author and principal investigator Deborah Cook, a professor in the Department of Medicine at McMaster. 

Global randomized control trial  

The Reevaluating the Inhibition of Stress Erosions (REVISE) Trial was a randomised control trial that compared the effect of pantoprazole to placebo in critically ill adults on a breathing machine. The trial was run in 68 centres in eight countries and over 4800 patients underwent randomization. Among patients undergoing invasive ventilation, pantoprazole resulted in a significantly lower risk of clinically important upper gastrointestinal bleeding than placebo but not in a lower risk of death. 

Clinically important upper gastrointestinal bleeding occurred in 25 of 2417 patients (one per cent) receiving pantoprazole and in 84 of 2404 patients (nearly four per cent) receiving placebo. At 90 days, death was reported in 696 of 2390 patients (29 per cent) in the pantoprazole group and in 734 of 2379 patients (30 per cent) in the placebo group.   

Updated systematic review 

Researchers conducted a meta-analysis of 12 randomised trials of proton-pump inhibitors for GI bleeding prevention in 10 000 critically ill patients to summarise the current evidence on the outcomes of gastrointestinal bleeding, mortality, pneumonia and C. difficile infection. 

The medications were associated with a reduced incidence of clinically important upper gastrointestinal bleeding and may have little or no effect on mortality. The evidence also showed the medications may have no effect on pneumonia and little or no effect on C. difficile infection. 

The research was funded by the Canadian Institutes for Health Research, the Accelerating Clinical Trials Fund, Physicians Services Incorporated of Ontario, Hamilton Association of Health Sciences Organization, and the National Health Medical Research Council of Australia. 

The original text of this story is licensed under a Creative Commons Attribution-No Derivs 2.5 Canada (CC BY-ND 2.5 CA).

Source: McMaster University

Categories : Antibiotics Cardiovascular DiseaseTags :

Antibiotics Reduce the Gastrointestinal Bleeding Risk of Long-term Aspirin

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A major clinical trial found that the risk of gastrointestinal bleeding caused by long-term aspirin use can be reduced with a short course of antibiotics, potentially improving the safety of aspirin when used to prevent heart attacks, strokes and possibly some cancers.

The results of the HEAT (Helicobacter pylori Eradication Aspirin) trial, which was led by Professor Chris Hawkey from the University of Nottingham, are published in The Lancet.

Aspirin in low doses is a very useful preventative drug in people at high risk of strokes or heart attacks. However, on rare occasions, its blood thinning effect can provoke internal ulcer bleeding. These ulcers may be caused by Helicobacter pylori.

The STAR (Simple Trials for Academic Research) team from the University of Nottingham investigated whether a short course of antibiotics to remove these bacteria would reduce the risk of bleeding in aspirin users.

The HEAT trial, conducted in 1208 UK general practices, was a real-life study which used clinical data routinely stored in GP and hospital records, instead of bringing patients back for follow up trial visits.

The researchers recruited 30 166 who were taking aspirin. Those who tested positive for H. pylori were randomised to receive antibiotics or placebos (dummy tablets) and were followed for up to 7 years.

Over the first two and a half years, those who had antibiotic treatment were less likely to be hospitalised for ulcer bleeding than those taking placebo (6 versus 17). Protection occurred rapidly: with the placebo group, the first hospitalisation for ulcer bleeding occurred after 6 days, compared to 525 days following antibiotic treatment.

Over a longer time period, protection appeared to wane. However, the overall rate of hospitalisation for ulcer bleeding was lower than expected and this in line with other evidence that ulcer disease is on the decline. Risks for people already on aspirin are low. Risks are higher when people first start aspirin, when searching for H. pylori and treating it is probably worthwhile.

Aspirin has many benefits in terms of reducing the risk of heart attacks and strokes in people at increased risk. There is also evidence that it is able to slow down certain cancers. The HEAT trial is the largest UK-based study of its kind, and we are pleased that the findings have shown that ulcer bleeding can be significantly reduced following a one-week course of antibiotics. The long-term implications of the results are encouraging in terms of safe prescribing.

Professor Chris Hawkey, University of Nottingham’s School of Medicine and Nottingham Digestive Diseases Centre

Source: University of Nottingham

Categories : Cardiovascular DiseaseTags :

Apaxiban Has Lowest Gastrointestinal Bleeding Risk of Common DOACs

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A large-scale comparison of direct oral anticoagulants (DOACs), published in Annals of Internal Medicine, one of the two most common direct oral anticoagulants (DOACs), apixaban, has the lowest risk of gastrointestinal bleeding, with similar performance on stroke prevention and other side effects.

DOACs are used to prevent strokes for people with atrial fibrillation, a condition affecting over 33 million people worldwide. They have recently become gained popularity over warfarin, the previous standard treatment, as they do not require as much follow-up monitoring (which was particularly valuable during the COVID pandemic) and have less risk of side-effects.

For the new study, University College London researchers compared the efficacy and risk of side effects for the four most common DOACs. They reviewed data from more than 500 000 new DOAC users in the UK, France, Germany and the US, including 281 320 apixaban users, 61 008 dabigatran users, 12 722 edoxaban users, and 172 176 rivaroxaban users.

They found that all four drugs were comparable on outcomes for ischemic stroke, brain bleeds and all-cause mortality, while they did identify a difference in risk of gastrointestinal bleeding, which is one of the most common and concerning side effects of DOACs.

The study revealed that apixaban stood out as having lower risk of gastrointestinal bleeding, with 19-28% lower risks when compared directly to each of the other three DOACs.

The researchers found that their findings held true when looking at data only from those aged over 80, and those with chronic kidney disease, two groups that are often underrepresented in clinical trials.

Dr Wallis Lau (UCL School of Pharmacy), who jointly led the work along with her colleague Professor Ian Wong, said: “Direct oral anticoagulants have been prescribed with increasing frequency worldwide in recent years, but evidence comparing them directly has been limited. Our results indicate that apixaban may be preferable to other blood thinners because of the lower rate of gastrointestinal bleeding and similar rates of stroke, a finding that we hope will be supported by randomised controlled trials.

“As with all medications, potential risks and benefits can differ between people, so considering the full spectrum of outcomes and side effects will still be necessary for each individual patient.

Source: University College London

Categories : GastrointestinalTags :

Reducing the Rebleeding Risk from Obscure Gastrointestinal Bleeding

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In a study published in Gastrointestinal Endoscopy, clinical investigators found that the five-year risk of rebleeding in obscure gastrointestinal bleeding was found to be as high as 41.7%, but capsule endoscopy examinations and subsequent interventions substantially reduced the risk. Factors such as anticoagulant use were also found to be independent predictors of rebleeding risk.

Obscure gastrointestinal bleeding (OGIB) is defined as gastrointestinal bleeding from a source that cannot be identified on upper or lower gastrointestinal endoscopy. OGIB is considered an important indication for capsule endoscopy (CE). CE is particularly useful for the detection of vascular and small ulcerative lesions, conditions frequently associated with OGIB.

Previous studies have shown that patients with severe comorbidities have a higher rate of positive CE findings (observations of mucosal breaks, vascular lesions, tumours, or blood retention) for OGIB. Additionally, for OGIB in which the initial CE fails to identify bleeding lesions, repeated CE can detect lesions at a higher rate. However, there have been no reports with a sufficiently large number of cases on the long-term outcomes of OGIB detected by CE and the risk of rebleeding.

To fill this knowledge gap, investigators followed up on 389 patients who underwent CE as their initial small intestinal examination for OGIB and evaluated the risk of rebleeding over the long term. In addition, the team evaluated the risk of rebleeding in OGIB, in which no source of rebleeding was found in any part of the gastrointestinal tract, including the small intestine.

The overall cumulative rebleeding rate during the five years after CE was 41.7%. In patients with positive CE findings, the cumulative rebleeding rate was 48.0%. The cumulative rebleeding rate in patients who had therapeutic intervention resulting from positive CE findings was 31.8%.

Furthermore, overt OGIB, anticoagulants, positive balloon-assisted enteroscopy after CE, and iron supplements without therapeutic intervention were found to be independent predictors of rebleeding. Among the components of an index assessing the severity of complications, liver cirrhosis was an independent predictor associated with rebleeding in patients with OGIB.

“If capsule endoscopy can be used to properly diagnose and lead to therapeutic intervention, the risk of rebleeding can be reduced,” concluded study leader Dr Otani. “Even if the endoscopy does not detect any lesions, adequate follow-up is necessary. Here at Osaka Metropolitan University, we have been utilising this tool clinically since its early days and have accumulated some of the world’s leading clinical data. This study revealed a high rebleeding rate in OGIB patients and clarified the effects of rebleeding predictors and therapeutic intervention. We have high expectations that this will lead to better medical care in the future.”

Source: Osaka Metropolitan University