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Practical Approach in  Managing NSAID Risks: GI and CV Prof. Chutima Pramoolsinsap Division of Gastroenterology and Tropic...
Content <ul><li>Overview: Aspirin and NSAIDs </li></ul><ul><li>GI adverse effects of NSAIDs </li></ul><ul><ul><li>Mechanis...
<ul><li>Pharmacological Effects </li></ul><ul><li>Analgesic  </li></ul><ul><li>Antipyretic  </li></ul><ul><li>Anti-inflamm...
Major Diseases Attributable to Disability-Adjusted Life Years (DALYs) Lost of Thai People by Sex,  2002  Bureau of Policy ...
Death and Injury Rates from Road Traffic Accidents, Thailand,  1984-2002 Police Information System Centre, Royal Thai Poli...
Growing proportion of the  Thai elderly M  F  M  F  M  F  M  F Year 1960  1980  2000  2020 <ul><li>It is estimated that th...
Proportion of Thai elders with most common diseases/symptoms by age group,2002 Surveys on Elderly People in Thailand 2002,...
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) <ul><li>WHO 2005: worldwide   10-50% suffer from musculoskeletal disorders <...
Willow leaf extracts for musculoskeletal conditions Aspirin first synthesised NSAIDs – a Long History of Analgesia and Tox...
NSAIDs inhibit the COX enzyme, which exists in two forms Arachidonic acid COX-1 (constitutive) COX-2 (induced by inflammat...
The  9  chemical groupings of NSAIDs  http://www.fda.gov/cder/drug/infopage/COX2/NSAIDmedguide.htm
Range of COX-1 and COX-2 selectivity of NSAIDs  COX   =  cyclooxy-genase; IC50   =  concentration of NSAID that inhibits C...
<ul><li>Pharmacological Effects </li></ul><ul><li>Analgesic  </li></ul><ul><li>Antipyretic  </li></ul><ul><li>Anti-inflamm...
Gastrointestinal adverse effects and NSAIDs
GI  Side effects of NSAIDs <ul><li>Dyspepsia </li></ul><ul><li>E sophagitis </li></ul><ul><li>E sophageal strictures </li>...
Gastric acid plays a central role in NSAID-associated gastroduodenal damage Acidic environment Bicarbonate layer Ionic gra...
Gastric acid plays a central role in NSAID-associated gastroduodenal damage Acidic environment Bicarbonate layer Ionic gra...
NSAIDs increase neutrophil – endothelial adhesion NSAIDs Decreased prostaglandin,  increased tumour necrosis factor Increa...
NSAID induced GI damage <ul><li>3  main types  of GI lesions : </li></ul><ul><li>Superficial damage  i.e.  mucosal hemorrh...
NSAID ingestion and GI injury JIACM 2003; 4(4): 315-22
GI symptoms Endoscopic ulcers Clinical ulcers Serious GI events Relative severity Relative frequency NSAID-related GI Effe...
Spectrum of lesions / side effects induced by NSAIDs <ul><li>Lesion / side effects Frequency Clinical Relevance </li></ul>...
MUCOSA  CLASS    VIGOR    TARGET  (N=4439)  (N=3981)   (N=4029)   (N=9127) Arthritis  RA  OA(73%); RA   OA RA (27%) NSAID ...
Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) Trial   Life-threatening or major bleeding 0 1 2 3 4 5 %...
CURE: Aspirin plus clopidogrel All bleeding episodes 1.9 2.3 3.9 3.0 3.2 5.0 0 1 2 3 4 5  100 mg 110–162 mg  200 mg % of...
Relative risk (RR) and 95% confidence interval of upper GI bleeding for individual NSAIDs <ul><li>Non-use Reference </li><...
Risk of Hospitalization for Upper GI Bleeding with COXIBs 3.0 4.0 1.9 1 2 3 4 5 6 7 Adjusted Rate Ratio 0 Non-use celecoxi...
Risk Factors for NSAID-Induced Gastropathy Definite: •  Age •  Prior history of ulcer •   Duration of NSAID therapy •  Con...
Risk Factors for NSAID-Associate d  GI Complications NSAIDs, nonsteroidal antiinflammatory drugs; SSRIs, selective seroton...
Distribution of Patients with GI Complications From NSAIDs  by Age and Sex Am J Gastroenterol 2005;100:1685–93
Risk of UGI Complication for  NSAID Users Impact of Ulcer History 20-60   60-69   70-79   >=80 Men complic ulcer +NSAID   ...
Rates of symptomatic ulcers and ulcer complications with naproxen in patients with rheumatoid arthritis Bombadlar C et al....
Annualized Incidence  % Ulcer Complications Symptomatic Ulcers and Ulcer Complications 49 / 1384 30 / 1441 11 / 1441 20 / ...
Low-dose aspirin excluded
Cumulative Incidence (%) *P<0.001 vs placebo and vs aspirin ROF = Rofecoxib Gastroduodenal ulcers at 12 weeks in patients ...
Low-Dose Aspirin Combined with NSAID or Coxib Drug R.R 95% CI Aspirin only 3.6 2.9-4.3 NSAID only 5.0 4.3-5.9 Combined 10....
Risk of UGI Complication for  NSAID Users Impact of ASA use 20-60   60-69   70-79 >=80 Incidence per 1,000 person-years Ba...
Non-aspirin antiplatelet agents combined with NSAIDs Drug   R.R   95% CI Aspirin only   3.6   2.9-4.3 NSAID only   5.0   4...
NSAID-Induced Small Bowel Lesions Endoscopic photograph of terminal ileum, demonstrating inflamed diaphragm in patient rec...
I ncrease in risk owing   to NSAID use for upper GI  and  lower GI complications <ul><li>Lanas et al.    10.7 (95% CI,4.5–...
Liver Warning over L umiracoxib <ul><li>Australia, Aug.  11, 2007 </li></ul><ul><li>Therapeutic Goods Administratio n ( TG...
Mortality Study ASA-attributed Complications and Deaths <ul><li>>5% of people take low-dose ASA  (secondary CV prevention)...
Mortality Rate Attributed to NSAID/Aspirin-Associated GI Complications Am J Gastroenterol 2005;100:1685–93 Mortality rate ...
Cardiovascular Risks Associated With COX-2–Selective Inhibitors and Nonselective NSAIDs
COX-2 Inhibitors: The “Promise” <ul><li>Lower incidence of  GI side effects when compared to traditional NSAIDs </li></ul>...
NSAID Effects on Thromboxane and Prostacylin
Serious Thromboembolic Cardiovascular Adverse Events in Nonaspirin Users 1. Silverstein FE, et al. JAMA. 2000;284:1247–125...
APPROVe Trial: Confirmed Thrombotic Cardiovascular Events Over Time Bresalier RS, et al. N Engl J Med.  2005; 352: 1092-11...
April  7, 2005 , Bextra (valdecoxib) withdrawal  Parecoxib/Valdecoxib: Cardiovascular Complications After Cardiac Surgery
Cardiovascular Risks in NSAID Users  This black box warning statement now appears in the package insert (July  2005)  for ...
Black box warning for COX-2–selective drugs.  This black box warning statement now appears in the package insert (July  20...
APC Trial: Concomitant Aspirin Use Does Not Decrease Cardiovascular Risk of COX-2 Selective Inhibitors
MEDAL Program: Confirmed Thrombotic Cardiovascular Events Over Time Cannon CP, et al; MEDAL Steering Committee. Lancet. 20...
BMJ 2006;332;1302-1308 Comparison of effects of different selective COX 2 inhibitors versus myocardial infarction
BMJ 2006;332;1302-1308 Comparison of effects of different selective COX 2 inhibitors versus placebo on stroke
Comparison of effects of different selective COX2 inhibitors versus placebo on vascular death. BMJ 2006;332;1302-1308
Is conventional NSAIDs safe for cardiovascular events?
Acute Myocardial Infarction NSAID Use:  Case-Control Study of MediCal* FDA Advisory Committee Meeting. Rockville, MD; Febr...
Risk of Acute Myocardial Infarction Associated With Current NSAID Use <ul><li>*A d justed for other NSAID use, hypertensio...
Meta-analysis :  Cardiovascular Risk Associated With the Use of COX-2 Selective Inhibitors and Nonselective NSAIDs <ul><li...
Black Box Warning for A ll  NSAIDs  <ul><li>A ugust 1, 2005  </li></ul><ul><li>FDA  g ives  b lack  b ox  w arning to  all...
Black box warning for &quot;traditional&quot; NSAID group This example is from the package insert (January  2006 ) of dicl...
Comparison of effects of selective COX - 2 inhibitors versus traditional NSAIDs on myocardial infarction,  BMJ 2006;332;13...
BMJ 2006;332;1302-1308 Comparison of effects of selective COX - 2 inhibitors versus traditional NSAIDs on stroke
BMJ 2006;332;1302-1308 Comparison of effects of selective COX - 2 inhibitors versus traditional NSAIDs on vascular death.
 
Protective Strategies in  Preventing NSAIDs-induced Ulcers and Ulcer Complications
<ul><li>Reduce the impact of risk factors </li></ul><ul><li>Avoid inhibition or restore mucosal prostagladin levels </li><...
H2-receptor antagonist, (H2RA)  <ul><li>B lock the action of histamine on parietal cells, decreasing acid production  </li...
 
Proton pump inhibitors (PP I s)  <ul><li>Omeprazole (Losec®) </li></ul><ul><li>Lansoprazole (Prevacid®)  </li></ul><ul><li...
Misoprostol (cytotec®) <ul><li>PGE 1 analogue </li></ul><ul><ul><li>Stimulates increased mucus secretion </li></ul></ul><u...
<ul><li>Di rectly targets COX-2,  </li></ul><ul><li>R educes risk of peptic ulceration </li></ul><ul><li>D oes not seem to...
Risk of adverse upper G.I. events associated with NSAIDs  according to use of ulcer healing drugs.  UK study: 9407 inciden...
 
Prevention of NSAID-induced ulcer  Endoscopic remission rates for patients with endoscopically normal  or hyperaemic gastr...
Efficacy of pantoprazole in the primary prevention of NSAID-induced gastroduodenal damage Patient population Treatment  Tr...
<ul><li>112 RCTS  ( 74,666  participants) </li></ul><ul><li>138  deaths and  248  serious  GI  events  </li></ul><ul><li>O...
The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by  NSAIDs : systematic revie...
<ul><li>Misoprostol </li></ul><ul><ul><li>All doses of misoprostol significantly reduced the risk of endoscopic ulcers.  <...
Prevention of NSAID-induced gastroduodenal ulcers   <ul><li>Standard doses of H2RAs </li></ul><ul><ul><li>E ffective at re...
 
PPIs reduce the relative risk of Ulcer bleeding in patients taking NSAIDs 0  0.5  1  2  3  4  5  6  7  8  9  10  27 Adjust...
Effect of PPIs,H2-RA and nitrates on the RR of ulcer bleeding in patients taking Low-dose ASA or Clopidogrel 0  0.5  1  2 ...
PPI plus COX-2 inhibitor Ulcer incidence at 6 months by NSAID type ** P <.01, *** P <.001, **** P <.0001  vs . placebo.  *...
Coxibs versus standard-NSAIDs :  Effect on serious upper GI events Adjusted relative risk (95% IC) 0   0.5   1   2   3   4...
M anagement of UGIB from  NSAID-induced Ulcers
Approach to UGI Bleeding <ul><li>Assess severity </li></ul><ul><li>Resuscitate </li></ul><ul><li>Establish the site of ble...
Assessing severity: Rockall criteria <ul><li>Criterion     Score </li></ul><ul><li>Age <60 years  0 </li></ul><ul><ul><ul>...
High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer ...
Endoscopic Stigmata of Ulcer Hemorrhage Active arterial bleeding Visible Vessel Adherent clot Flat spot Clean base ulcer
Endoscopic Stigmata of Ulcer Hemorrhage: Prevalence, Risks of  R ebleeding and Reduced Risk of Rebleeding following Endosc...
High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer ...
Endoscopic modalities available for management of Non-variceal  UGIB <ul><li>I njection </li></ul><ul><li>Adrenaline  (1:1...
High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer ...
Pharmacotherapy for Nonvariceal Bleeding <ul><li>48-72 hrs after endoscopic therapy, patient should  receive acid-suppress...
Brunner, et al. Aliment Pharmacol Ther 1995 Omeprazole 80 mg loading dose+ 40 mg q. 8 hours  Omeprazole 80 mg loading dose...
0 8 6 4 2 0 8 16 24 32 40 48 Median Intragastric  pH Time [h] Van Rensburg, et al.  Gastroenterology  1997. (Abstract) 80 ...
<ul><li>Recommendation:  An intravenous bolus followed by continuous-infusion proton-pump inhibitor is effective in decrea...
High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer ...
Proton pump inhibitor treatment for acute peptic ulcer bleeding  <ul><li>No evidence to suggest that results on mortality ...
H .  pylori  and NSAIDs
H.pylori , NSAID Use and the Risk of PU Bleeding Prevalence  (%)   PU bleeding  +  -  +  -  +  -  OR 1.79  95% CI; 0.97-3....
Recommendations for H pylori eradication in  Maastricht III Consensus  1b ;  Individual RCT with narrow confidence interva...
H pylori  and Low dose ASA <ul><li>H .  pylori  infection increases complications for patients taking low-dose aspirin.  <...
Summary Practical Approach in   Managing NSAID Risks: GI and CV
Strategy in patients who need NSAIDs <ul><li>Step 1 :  Evaluate presence of risk factor :  </li></ul><ul><li>Estimate the ...
The most important risk factors <ul><li>Age Most Frequent </li></ul><ul><li>Low-dose ASA >20% of patients </li></ul><ul><l...
Definition of GI risks <ul><li>GI risk Complication Rate  NNT   Cost of </li></ul><ul><li>  100 pt-yrs   prevention </li><...
Assess Cardiac Risk First <ul><li>When choosing an NSAID </li></ul><ul><ul><li>Assess cardiac risk factors first because o...
<ul><li>Assess the presence of high-risk factors for serious NSAID-induced GI adverse events i.e elderly people,, if neces...
<ul><li>Coxibs are contraindicated in: </li></ul><ul><ul><li>ischemic heart disease </li></ul></ul><ul><ul><li>cerebrovasc...
<ul><li>If high risk of NSAID-induced GI adverse effects and requires concomitant use of low-dose aspirin prophylaxis and ...
Strategies to Reduce NSAID-induced Mucosal Injury and Platelet Dysfunction <ul><li>Avoid NSAIDs or minimize dosage </li></...
NSAID required? High risk Low risk - No prophylaxis -Monitor clinical signs and symptoms  -Use non-NSAIDs analgesic -Use l...
Recommendations for the use of NSAIDs according to GI and cardiovascular risk. <ul><li>*High cardiovascular risk: requirem...
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NSAIDs ASA GI protection

  1. 1. Practical Approach in Managing NSAID Risks: GI and CV Prof. Chutima Pramoolsinsap Division of Gastroenterology and Tropical Medicine Ramathibodi Hospital 1 st Emergency Medicine Update 2550 สมาคมเวชศาสตร์ฉุกเฉินแห่งประเทศไทย 1 September 2007
  2. 2. Content <ul><li>Overview: Aspirin and NSAIDs </li></ul><ul><li>GI adverse effects of NSAIDs </li></ul><ul><ul><li>Mechanism </li></ul></ul><ul><ul><li>Risk factors </li></ul></ul><ul><li>Cardiovascular (CV) risks associated with NSAIDs </li></ul><ul><li>Prevention strategy with NSAIDs based on GI and CV patient risk factors </li></ul><ul><li>Summary </li></ul>
  3. 3. <ul><li>Pharmacological Effects </li></ul><ul><li>Analgesic </li></ul><ul><li>Antipyretic </li></ul><ul><li>Anti-inflammatory </li></ul><ul><li>Anti-platelet </li></ul><ul><li>Familial Adenomatous Polyposis </li></ul><ul><li>Alzheimer’s </li></ul><ul><li>Some are uricosuric </li></ul><ul><li>Adverse effects </li></ul><ul><li>Platelet dysfunction </li></ul><ul><li>Gastritis / PUD + bleeding </li></ul><ul><li>Cardiovascular </li></ul><ul><li>Acute Renal Failure </li></ul><ul><li>Sodium+ water retention </li></ul><ul><li>Edema </li></ul><ul><li>Analgesic nephropathy </li></ul><ul><li>Prolongation of gestation </li></ul><ul><li>and inhibition of labor </li></ul><ul><li>Hypersenstivity </li></ul>Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
  4. 4. Major Diseases Attributable to Disability-Adjusted Life Years (DALYs) Lost of Thai People by Sex, 2002 Bureau of Policy and Strategy. Burden of Disease and Injuries in Thailand, 2002
  5. 5. Death and Injury Rates from Road Traffic Accidents, Thailand, 1984-2002 Police Information System Centre, Royal Thai Police.
  6. 6. Growing proportion of the Thai elderly M F M F M F M F Year 1960 1980 2000 2020 <ul><li>It is estimated that the number of Thai people > 60 years will increase from 4.02 million (7.36 % of total population) in 1990 to become 10.78 million (15.28%of the total population) in 2020 </li></ul>J Med Assoc Thai 2005; 88 (9): 1257-60
  7. 7. Proportion of Thai elders with most common diseases/symptoms by age group,2002 Surveys on Elderly People in Thailand 2002, National Statistical Office. Age (yrs) 17.7 22.3 27.5 34.4 34.1 42.8 72.7 60-64 20.3 26.5 31.1 35.6 38.1 46.7 74.7 65-69 21.9 33.2 37.3 38.7 42.0 49.8 77.8 70-74 21.6 20.0 Hyper/ hypotension 45.2 29.8 Dementia 42.8 33.2 Eye diseases 41.2 36.8 Vertigo 44.9 38.7 Insomnia 54.9 47.5 Joint pain (degeneration) 77.3 75.1 Body ache, backache > 75 Total Disease/Symptom of Thai Elders
  8. 8. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) <ul><li>WHO 2005: worldwide 10-50% suffer from musculoskeletal disorders </li></ul><ul><li>P harmaceutical market value for pain relief = $23 billion in 2004. </li></ul><ul><li>Worldwide: 70 million people/day prescribed NSAIDs </li></ul><ul><li>230 million people/day take OTC NSAIDs </li></ul>Inflammopharmacology. 2005;13(4):343-70.
  9. 9. Willow leaf extracts for musculoskeletal conditions Aspirin first synthesised NSAIDs – a Long History of Analgesia and Toxicity 4 00 B.C. Greek physician 1899 1938 1950 1970 1982 1992 1998 Hippocrates Non-selective NSAIDs identified and developed. COX-2 selective NSAIDs discovered First COX-2 selective NSAIDs approved first endoscopic evidence that aspirin caused gastric mucosal damage. Lancet 1938;ii:1222­5 M echanism of action for aspirin
  10. 10. NSAIDs inhibit the COX enzyme, which exists in two forms Arachidonic acid COX-1 (constitutive) COX-2 (induced by inflammatory stimuli) Non-selective NSAIDs <ul><li>Gastrointestinal cytoprotection </li></ul><ul><li>Platelet activity </li></ul><ul><li>Inflammation </li></ul><ul><li>Pain </li></ul><ul><li>Fever </li></ul>Prostaglandins Prostaglandins    COX-2 selective NSAIDs Vane & Botting 1995
  11. 11. The 9 chemical groupings of NSAIDs http://www.fda.gov/cder/drug/infopage/COX2/NSAIDmedguide.htm
  12. 12. Range of COX-1 and COX-2 selectivity of NSAIDs COX = cyclooxy-genase; IC50 = concentration of NSAID that inhibits COX by 50%,
  13. 13. <ul><li>Pharmacological Effects </li></ul><ul><li>Analgesic </li></ul><ul><li>Antipyretic </li></ul><ul><li>Anti-inflammatory </li></ul><ul><li>Anti-platelet </li></ul><ul><li>Familial ddenomatous polyposis </li></ul><ul><li>Alzheimer’s </li></ul><ul><li>Some are uricosuric </li></ul><ul><li>Adverse effects </li></ul><ul><li>Platelet dysfunction </li></ul><ul><li>Gastritis / PUD + bleeding </li></ul><ul><li>Cardiovascular </li></ul><ul><li>Acute Renal Failure </li></ul><ul><li>Sodium+ water retention </li></ul><ul><li>Edema </li></ul><ul><li>Analgesic nephropathy </li></ul><ul><li>Prolongation of gestation </li></ul><ul><li>and inhibition of labor </li></ul><ul><li>Hypersenstivity </li></ul>Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
  14. 14. Gastrointestinal adverse effects and NSAIDs
  15. 15. GI Side effects of NSAIDs <ul><li>Dyspepsia </li></ul><ul><li>E sophagitis </li></ul><ul><li>E sophageal strictures </li></ul><ul><li>Gastric and duodenal petechiae, erosions, ulceration, bleeding, and perforation </li></ul><ul><li>Type C gastritis </li></ul><ul><li>Small and large bowel ulceration, bleeding, and perforation </li></ul><ul><li>Exacerbation of colitis </li></ul>
  16. 16. Gastric acid plays a central role in NSAID-associated gastroduodenal damage Acidic environment Bicarbonate layer Ionic gradient Gastric acid NSAIDs Pepsin Surface epithelial cells Mucus layer Neutral environment Mucosal blood supply Alkaline environment Prostaglandin production Bicarbonate production Mucus production NSAIDs normal gastric mucosa 16 minutes after administration of aspirin Direct effect
  17. 17. Gastric acid plays a central role in NSAID-associated gastroduodenal damage Acidic environment Bicarbonate layer Ionic gradient Gastric acid NSAIDs Pepsin Surface epithelial cells Mucus layer Neutral environment Mucosal blood supply Alkaline environment Prostaglandin production Bicarbonate production Mucus production NSAIDs Systemic effect
  18. 18. NSAIDs increase neutrophil – endothelial adhesion NSAIDs Decreased prostaglandin, increased tumour necrosis factor Increased neutrophil– endothelial adhesion Ischaemic/hypoxic cell injury Endothelial and epithelial injury Mucosal ulceration Wallace et al 1997 Neutrophil release of proteases and oxygen-derived free radicals Capillary obstruction
  19. 19. NSAID induced GI damage <ul><li>3 main types of GI lesions : </li></ul><ul><li>Superficial damage i.e. mucosal hemorrhages and erosions </li></ul><ul><li>Endoscopically documented non-symptomatic (‘silent’) ulcers </li></ul><ul><li>Symptomatic ulcers causing complications i.e. GI hemorrhage . </li></ul>
  20. 20. NSAID ingestion and GI injury JIACM 2003; 4(4): 315-22
  21. 21. GI symptoms Endoscopic ulcers Clinical ulcers Serious GI events Relative severity Relative frequency NSAID-related GI Effects
  22. 22. Spectrum of lesions / side effects induced by NSAIDs <ul><li>Lesion / side effects Frequency Clinical Relevance </li></ul><ul><li>Erosions > 50% Low </li></ul><ul><li>Endoscopic Ulcers 10-30% </li></ul><ul><li>Dyspepsia >30% </li></ul><ul><li>Symptomatic Ulcers 2-4% </li></ul><ul><li>UGI Complications 1-1.5% </li></ul><ul><li>LGI Complications ≊ 0.8% </li></ul><ul><li>High </li></ul>Lanas A, Hunt R, Ann Meds 2006.
  23. 23. MUCOSA CLASS VIGOR TARGET (N=4439) (N=3981) (N=4029) (N=9127) Arthritis RA OA(73%); RA OA RA (27%) NSAID (N) 10 specified Ibuprofen naproxen Ibuprofen NSAIDs diclofenac naproxen Low-dose aspirin Not stated 20% 0 24% Median follow-up 6 mo 9 mo 9 mo 12 mo Upper GI complications 1.5% 1.0% 1.4% 1.3% (annualized incidence) Upper GI clinical events 2.7% 2.8% 4.5% 2.8% (annualized incidence) Incidences of Upper GI Complications and Clinical Events (Complications plus Symptomatic Ulcers) From NSAID-only Arms of GI Outcome Studies J Cardiovasc Pharmacol 2006; 47(1):S60-6
  24. 24. Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) Trial Life-threatening or major bleeding 0 1 2 3 4 5 % of patients By aspirin dose, n=6293 <100 mg 1.9 n=990 100–150 mg 2.2 n=2857 151–300 mg 3.3 n=1385 >300 mg n=1061 3.8 Eur Heart J 2002;4:Suppl, 510
  25. 25. CURE: Aspirin plus clopidogrel All bleeding episodes 1.9 2.3 3.9 3.0 3.2 5.0 0 1 2 3 4 5  100 mg 110–162 mg  200 mg % of patients n=5259 n=3115 n=4172 Aspirin Clopidogrel + aspirin p < 0.001 Eur Heart J 2002;4:Suppl, 510
  26. 26. Relative risk (RR) and 95% confidence interval of upper GI bleeding for individual NSAIDs <ul><li>Non-use Reference </li></ul><ul><li>Celecoxib 1.0 (0.4-2.1) </li></ul><ul><li>Aceclofenac 2.6 (1.5-4.6) </li></ul><ul><li>Diclofenac 3.1 (2.3-4.2) </li></ul><ul><li>Ibuprofen 4.1 (3.1-5.3) </li></ul><ul><li>Naproxen 7.3 (4.7-11.4) </li></ul><ul><li>Lomoxicam 7.7 (2.4-24.4) </li></ul><ul><li>Ketoprofen 8.6 (2.5-29.2) </li></ul><ul><li>Indomethacin 9.0 (3.9-20.7) </li></ul><ul><li>Meloxicam 9.8 (4.0-23.8) </li></ul><ul><li>Piroxicam 12.6 (7.8-20.3) </li></ul><ul><li>Ketorolac 14.1 (5.2-39.9) </li></ul>Low High Individual NSAID Relative Risk (95% CI) Lanas A et al. Gut (2006) <ul><li>*Adjusted for age, sex, calendar semester, ulcer history, nitrates, anticoagulants, antiplatelets, acid-suppressing drugs, coxib and aspirin use. </li></ul>Cases (n = 2777) and Controls (n = 5532)
  27. 27. Risk of Hospitalization for Upper GI Bleeding with COXIBs 3.0 4.0 1.9 1 2 3 4 5 6 7 Adjusted Rate Ratio 0 Non-use celecoxib rofecoxib diclo+miso NSAIDs Mamdani et al. BMJ 2002;325(7365):624-7 1.0 1.0 >55% women Mean age >75 yrs >1% with Hx of GI bleed >16% Use of gastroprotective agent >12% Use of aspirin 100,000 (2.2)* 18,908 (3.6)* 14,583 (7.3)* 5,087 (9.6)* 5,391 (12.6)* *n (no. upper GI bleeds per 1000 person-yrs)
  28. 28. Risk Factors for NSAID-Induced Gastropathy Definite: • Age • Prior history of ulcer • Duration of NSAID therapy • Concomitant corticosteroid therapy • Concomitant warfarin therapy • Concomitant ASA / NSAID • NSAID dose • Serious systemic illness (CHF, RA, CAD, others) Possible: • Concomitant H. Pylori infection? • Smoking • Alcohol
  29. 29. Risk Factors for NSAID-Associate d GI Complications NSAIDs, nonsteroidal antiinflammatory drugs; SSRIs, selective serotonin reuptake inhibitors. Dalton SO, et al. Arch Intern Med. 2003;163:59–64. Gabriel SE, et al. Ann Intern Med. 1991;115:787–796; Garcia Rodriguez LA, et al. Lancet. 1994;343:769–772. Silverstein FE, et al. Ann Intern Med. 1995;123:241–249.
  30. 30. Distribution of Patients with GI Complications From NSAIDs by Age and Sex Am J Gastroenterol 2005;100:1685–93
  31. 31. Risk of UGI Complication for NSAID Users Impact of Ulcer History 20-60 60-69 70-79 >=80 Men complic ulcer +NSAID Men ulcer + NSAIDs Men No ulcer +NSAIDs Incidence per 1,000 person-years Based on Hemandez & Garcia-Rodriguez, BMC Medicine 2006;4:22.
  32. 32. Rates of symptomatic ulcers and ulcer complications with naproxen in patients with rheumatoid arthritis Bombadlar C et al. N Engl J Med 343;1520-8(2000): Lenas A. Gastroenterol Gastro 2007. Number events x 100 patient-years No NSAID use <65 65-74 >74 Ulcer Hx Ulcer complications >65+Hx Ulcer >65+Hx Ulcer+sterolds Age
  33. 33. Annualized Incidence % Ulcer Complications Symptomatic Ulcers and Ulcer Complications 49 / 1384 30 / 1441 11 / 1441 20 / 1384 p = 0.02 p = 0.09 All Patients 32 / 1101 16 / 1143 5 / 1143 14 / 1101 p = 0.02 p = 0.04 Patients Not Taking Aspirin 17 / 283 14/ 298 6 / 298 6 / 283 p = 0.49 p = 0.92 Patients Taking Aspirin CLASS Trial: Upper GI Complications Alone and With Symptomatic Ulcers Silverstein et al. JAMA 2000; 284:1247-1255 = celecoxib = NSAIDs (ibuprofen + diclofenac)
  34. 34. Low-dose aspirin excluded
  35. 35. Cumulative Incidence (%) *P<0.001 vs placebo and vs aspirin ROF = Rofecoxib Gastroduodenal ulcers at 12 weeks in patients with OA Aspirin Negates the GI-sparing Effect of COX-2 Inhibitors Gastroenterology 2004; 127: 395-402. * * N=381 N=387 N=377 N=374 %
  36. 36. Low-Dose Aspirin Combined with NSAID or Coxib Drug R.R 95% CI Aspirin only 3.6 2.9-4.3 NSAID only 5.0 4.3-5.9 Combined 10.2 6.2-16.7 Aspirin only 3.3 2.8-4.0 Coxib only 1.1 0.7-1.9 Combined 9.5 2.5-36.2 Lanas et al. Gut 2006
  37. 37. Risk of UGI Complication for NSAID Users Impact of ASA use 20-60 60-69 70-79 >=80 Incidence per 1,000 person-years Based on Hermandez & Garcla-Rodriguez. BMC Medicine 2006;4:22
  38. 38. Non-aspirin antiplatelet agents combined with NSAIDs Drug R.R 95% CI Aspirin only 3.6 2.9-4.3 NSAID only 5.0 4.3-5.9 Combined 10.2 6.2-16.7 Clopidogrel/Ticlid only 3.1 2.2-4.4 NSAID only 5.0 4.3-5.8 Combined 15.5 4.7-50.4 Lanas et al. Gut 2006
  39. 39. NSAID-Induced Small Bowel Lesions Endoscopic photograph of terminal ileum, demonstrating inflamed diaphragm in patient receiving long-term NSAIDs
  40. 40. I ncrease in risk owing to NSAID use for upper GI and lower GI complications <ul><li>Lanas et al. 10.7 (95% CI,4.5–26.0) 18.4 (95% CI,4.7–51.4) </li></ul><ul><li>Wilcox et al. 3.2 (95% CI,2.6 –4.0) 2.6 (95% CI,1.7–3.9) </li></ul><ul><li>Lanas et al. 6.3 (95% CI,3.1– 12.9) 8.1 (95% CI,2.3–31.9) </li></ul>O dds ratios for use of NSAIDs in patients with upper GI bleeding lower GI bleeding O dds ratios for use of NSAIDs and GI perforation upper GI lower GI Gastroenterology 2003;124:288–92
  41. 41. Liver Warning over L umiracoxib <ul><li>Australia, Aug. 11, 2007 </li></ul><ul><li>Therapeutic Goods Administratio n ( TGA ) had received 8 reports of serious liver adverse reactions associated with use of lumiracoxib (prexige®) </li></ul><ul><ul><li>2 deaths and 2 patients requiring liver transplants. </li></ul></ul><ul><li>All these reports have been received since March 2007 , with 6 reports received in the last 6 weeks. </li></ul>
  42. 42. Mortality Study ASA-attributed Complications and Deaths <ul><li>>5% of people take low-dose ASA (secondary CV prevention) </li></ul><ul><li>Almost a third of all NSAID use detected in patients hospitalized with ulcer bleeding is low-dose ASA. </li></ul><ul><li>321 GI Bleedings per 100,000 users </li></ul><ul><li>18 Deaths per 100,000 users </li></ul>Lanas et al. Am J Gastroenterol 2005
  43. 43. Mortality Rate Attributed to NSAID/Aspirin-Associated GI Complications Am J Gastroenterol 2005;100:1685–93 Mortality rate per 1 million people Entire country population NSAID/aspirin users
  44. 44. Cardiovascular Risks Associated With COX-2–Selective Inhibitors and Nonselective NSAIDs
  45. 45. COX-2 Inhibitors: The “Promise” <ul><li>Lower incidence of GI side effects when compared to traditional NSAIDs </li></ul><ul><li>Potentially attenuate intestinal tumor development </li></ul><ul><li>COX-2 increased in atherosclerotic plaque </li></ul><ul><ul><li>COX-2 may play a role in inflammation that underlies cardiovascular risk </li></ul></ul>
  46. 46. NSAID Effects on Thromboxane and Prostacylin
  47. 47. Serious Thromboembolic Cardiovascular Adverse Events in Nonaspirin Users 1. Silverstein FE, et al. JAMA. 2000;284:1247–1255. 2. Bombardier C, et al. N Engl J Med. 2000;343:1520–1528.
  48. 48. APPROVe Trial: Confirmed Thrombotic Cardiovascular Events Over Time Bresalier RS, et al. N Engl J Med. 2005; 352: 1092-1102 . September 2004 , Vioxx (rofecoxib) withdrawal from worldwide market
  49. 49. April 7, 2005 , Bextra (valdecoxib) withdrawal Parecoxib/Valdecoxib: Cardiovascular Complications After Cardiac Surgery
  50. 50. Cardiovascular Risks in NSAID Users This black box warning statement now appears in the package insert (July 2005) for celecoxib
  51. 51. Black box warning for COX-2–selective drugs. This black box warning statement now appears in the package insert (July 2005 ) for celecoxib
  52. 52. APC Trial: Concomitant Aspirin Use Does Not Decrease Cardiovascular Risk of COX-2 Selective Inhibitors
  53. 53. MEDAL Program: Confirmed Thrombotic Cardiovascular Events Over Time Cannon CP, et al; MEDAL Steering Committee. Lancet. 2006;368:1771–1781.
  54. 54. BMJ 2006;332;1302-1308 Comparison of effects of different selective COX 2 inhibitors versus myocardial infarction
  55. 55. BMJ 2006;332;1302-1308 Comparison of effects of different selective COX 2 inhibitors versus placebo on stroke
  56. 56. Comparison of effects of different selective COX2 inhibitors versus placebo on vascular death. BMJ 2006;332;1302-1308
  57. 57. Is conventional NSAIDs safe for cardiovascular events?
  58. 58. Acute Myocardial Infarction NSAID Use: Case-Control Study of MediCal* FDA Advisory Committee Meeting. Rockville, MD; February 17, 2005. Singh G, et al. Ann Rheum Dis , 2005: 64 (Suppl 3 ) : 263.
  59. 59. Risk of Acute Myocardial Infarction Associated With Current NSAID Use <ul><li>*A d justed for other NSAID use, hypertension, congestive heart disease, cerebrovascular disease, hyperlipidemia, diabetes , rheumatoid arthritis, smoking and body mass index. </li></ul>Circulation. 2006; 113: 1950-1957.
  60. 60. Meta-analysis : Cardiovascular Risk Associated With the Use of COX-2 Selective Inhibitors and Nonselective NSAIDs <ul><li>17 case-control and 6 cohort studies reporting on CV events (mostly myocardial infarction) with COX-2 selective inhibitors, NSAIDs or both with nonuse/remote use of the agents as the reference exposure. </li></ul>JAMA. 2006; 296: 1633-1644 .
  61. 61. Black Box Warning for A ll NSAIDs <ul><li>A ugust 1, 2005 </li></ul><ul><li>FDA g ives b lack b ox w arning to all NSAIDs </li></ul><ul><ul><li>Cardiovascular r isk </li></ul></ul><ul><ul><li>GI r isk </li></ul></ul>
  62. 62. Black box warning for &quot;traditional&quot; NSAID group This example is from the package insert (January 2006 ) of diclofenac,
  63. 63. Comparison of effects of selective COX - 2 inhibitors versus traditional NSAIDs on myocardial infarction, BMJ 2006;332;1302-1308
  64. 64. BMJ 2006;332;1302-1308 Comparison of effects of selective COX - 2 inhibitors versus traditional NSAIDs on stroke
  65. 65. BMJ 2006;332;1302-1308 Comparison of effects of selective COX - 2 inhibitors versus traditional NSAIDs on vascular death.
  66. 67. Protective Strategies in Preventing NSAIDs-induced Ulcers and Ulcer Complications
  67. 68. <ul><li>Reduce the impact of risk factors </li></ul><ul><li>Avoid inhibition or restore mucosal prostagladin levels </li></ul><ul><ul><li>Misoprostol (cytotec®) </li></ul></ul><ul><ul><li>Coxibs </li></ul></ul><ul><li>Reduce acid </li></ul><ul><ul><li>H2-receptor antagonist (H2RA) </li></ul></ul><ul><ul><li>Proton pump inhibitors (PPI) </li></ul></ul>Protective Strategies in Preventing NSAIDs-induced Ulcers and Ulcer Complications
  68. 69. H2-receptor antagonist, (H2RA) <ul><li>B lock the action of histamine on parietal cells, decreasing acid production </li></ul><ul><li>H2RA drugs </li></ul><ul><ul><li>cimetidine (Tagamet) </li></ul></ul><ul><ul><li>ranitidine (Zantac) </li></ul></ul><ul><ul><li>famotidine ( Famoc ) </li></ul></ul><ul><ul><li>nizatidine (Axid) </li></ul></ul>
  69. 71. Proton pump inhibitors (PP I s) <ul><li>Omeprazole (Losec®) </li></ul><ul><li>Lansoprazole (Prevacid®) </li></ul><ul><li>Pantoprazole ( Contro loc®) </li></ul><ul><li>Rabeprazole (Pariet®) </li></ul><ul><li>Esomeprazole (Nexium®) </li></ul><ul><li>The cu rrently available 3 PPIs which have an IV formulation : Omeprazole , Pantoprazole , Esomeprazole </li></ul>
  70. 72. Misoprostol (cytotec®) <ul><li>PGE 1 analogue </li></ul><ul><ul><li>Stimulates increased mucus secretion </li></ul></ul><ul><ul><li>Increases mucosal blood flow </li></ul></ul><ul><li>Side effects </li></ul><ul><ul><li>Diarrhea, abdominal pain, nausea, flatulence, headache, dyspepsia, vomiting, and constipation </li></ul></ul><ul><li>Contraindications: S hould not use in pregnant women because </li></ul><ul><ul><li>I ncreases uterine tone and contractions which may cause partial or complete abortions </li></ul></ul><ul><ul><li>B irth defects </li></ul></ul>
  71. 73. <ul><li>Di rectly targets COX-2, </li></ul><ul><li>R educes risk of peptic ulceration </li></ul><ul><li>D oes not seem to affect other adverse-effects of NSAIDs ( i.e. renal failure) </li></ul><ul><li>I ncrease in the risk for heart attack, thrombosis and stroke by a relative increase in thromboxane. </li></ul>Selective COX-2 Inhibitors <ul><li>September 2004 , Vioxx (rofecoxib) withdrawal </li></ul><ul><li>April 7, 2005, Bextra (valdecoxib) withdrawal </li></ul>
  72. 74. Risk of adverse upper G.I. events associated with NSAIDs according to use of ulcer healing drugs. UK study: 9407 incident cases and 88,867 matched controls. BMJ 2005;331;1310-1316 Values are adjusted odds ratios* Not prescribed Prescribed Drug prescribed < 90 ulcer healing ulcer healing Interaction ratio ‡ P value for Days before index drugs in past drugs in past (95% Cl) interaction date † 90 days 90 days Celecoxib 1.44 1.06 0.73 (0.46 to 1.16) 0.18 Rofecoxib 2.33 1.06 0.45 (0.32 to 0.65) <0.001 Other selective 2.40 1.29 0.54 (0.36 to 0.81) <0.001 NSAIDs Ibuprofen 1.65 0.90 0.55 (0.43 to 0.70) <0.001 Diclofenac 2.17 1.49 0.69 (0.56 to 0.84) <0.001 Naproxen 2.73 0.83 0.31 (0.19 to 0.49) <0.001 Other non selective 2.03 1.16 0.57 (0.42 to 0.77) <0.001 NSAIDs Aspirin 1.87 0.81 0.43 (0.38 to 0.49) <0.001
  73. 76. Prevention of NSAID-induced ulcer Endoscopic remission rates for patients with endoscopically normal or hyperaemic gastric mucosa at baseline [a subset of patients with grade 0 of Lanza classification, who were treated with either pantoprazole 40 mg od or placebo for up to 12 weeks 0 4 8 12 P=0.036 92% 82% 75% 55% BIanchi Parro G, et a. Digest Liver Dis 2000 Endoscopic remission rate (%) Time (wks)
  74. 77. Efficacy of pantoprazole in the primary prevention of NSAID-induced gastroduodenal damage Patient population Treatment Treatment n Remission rate (%) duration Rheumatic 6 months Pantoprazole 20 mg od 257 89 disease; Continuous NSAID; Misoprostol 200 mg bid 258 70 high risk (p<0.001) Rheumatic 6 months Pantoprazole 20 mg od 196 90 Disease; Continuous NSAID; Pantoprazole 40 mg od 199 93 high risk Omeprazole 20 mg o.d. 200 89 (NS) SINGH, G. Int J Clin Pract 2005
  75. 78. <ul><li>112 RCTS ( 74,666 participants) </li></ul><ul><li>138 deaths and 248 serious GI events </li></ul><ul><li>On comparing gastroprotective strategies vs placebo </li></ul><ul><ul><li>N o evidence of effectiveness of H2 receptor antagonists for any primary outcomes </li></ul></ul><ul><ul><li>P roton pump inhibitors </li></ul></ul><ul><ul><ul><li>R educe risk of symptomatic ulcers ( RR 0.09, 95% CI 0.02 - 0.47 ) </li></ul></ul></ul><ul><ul><li>M isoprostol </li></ul></ul><ul><ul><ul><li>R educes risk of serious GI (RR 0.57, 95% CI 0.36 - 0.91 ) </li></ul></ul></ul><ul><ul><ul><li>R educes symptomatic ulcers (RR 0.36, 95% CI 0.20 - 0.67 ) </li></ul></ul></ul>S ystematic review : E ffectiveness of five strategies for the prevention of GI toxicity induced by NSAIDs BMJ  2004; 329: 948
  76. 79. The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by NSAIDs : systematic review <ul><li>COX-2 selectives </li></ul><ul><ul><li>R educe risk of symptomatic ulcers ( 0.41, 95% CI; 0.26-0.65 ) </li></ul></ul><ul><ul><li>No reduce the risk of endoscopic ulcers (at least 3 mm d iameter). </li></ul></ul><ul><li>COX-2 specifics </li></ul><ul><ul><li>R educe risk of symptomatic ulcers ( 0.49 , 95% CI; 0.38-0.62 ) </li></ul></ul><ul><ul><li>R educe risk of serious GI complications ( 0.55 , 95% CI; 0.38-.80 ) </li></ul></ul>BMJ 2004;329:948 
  77. 80. <ul><li>Misoprostol </li></ul><ul><ul><li>All doses of misoprostol significantly reduced the risk of endoscopic ulcers. </li></ul></ul><ul><ul><li>Misoprostol 800 ug/day was superior to 400 ug/day for prevention of endoscopic GU (RR= 0.17 , and RR= 0.39 respectively, p= 0.0055) </li></ul></ul><ul><ul><li>A dose response relationship was not seen with DU </li></ul></ul><ul><ul><li>Misoprostol caused diarrhea at all doses, although significantly more at 800 ug/day than 400 ug/day (p= 0012 ). </li></ul></ul><ul><ul><li>Misoprostol was the only prophylactic agent documented to reduce ulcer complications. </li></ul></ul>Prevention of NSAID-induced gastroduodenal ulcers ochrane Database of Systematic Reviews 2007 Issue 3
  78. 81. Prevention of NSAID-induced gastroduodenal ulcers <ul><li>Standard doses of H2RAs </li></ul><ul><ul><li>E ffective at reducing the risk of endoscopic DU (RR= 0.36 ; 95% CI: 0.18-0.74) but not GU (RR= 0.73; 95% CI: 0.50-1.09) </li></ul></ul><ul><li>D ouble dose H2RAs and PPIs were effective at reducing the risk of endoscopic DU and GU (RR= 0.44 ; 95% CI: 0.26-0.74 and RR =0.40; 95% CI: 0.32-0.51 respectively for gastric ulcer, and were better tolerated than misoprostol. </li></ul>Cochrane Database of Systematic Reviews 2007 Issue 3
  79. 83. PPIs reduce the relative risk of Ulcer bleeding in patients taking NSAIDs 0 0.5 1 2 3 4 5 6 7 8 9 10 27 Adjusted RR (95% IC) Non-ASA NSAIDs 5.0 +PPI ASA (>500 mg/day) +PPI Lanas et al. AJG 2007 <ul><li>> 70% GI risk reduction with PPI </li></ul><ul><li>Reduction similar among different NSAIDs </li></ul>8.7 0.30 0.14
  80. 84. Effect of PPIs,H2-RA and nitrates on the RR of ulcer bleeding in patients taking Low-dose ASA or Clopidogrel 0 0.5 1 2 3 4 5 6 7 8 9 10 27 Adjusted RR (95% IC) Low dose ASA 3.6 +PPI 0.32 +H2-RA 0.40 +Nitrate 0.69 Clopidogrel 3.1 +PPI 0.19 +H2-RA 0.83 +Nitrate 0.88 Lanas et al. AJG 2007
  81. 85. PPI plus COX-2 inhibitor Ulcer incidence at 6 months by NSAID type ** P <.01, *** P <.001, **** P <.0001 vs . placebo. ** *** *** **** 134 141 125 318 326 334 n= Scheiman et al. DDW 2004
  82. 86. Coxibs versus standard-NSAIDs : Effect on serious upper GI events Adjusted relative risk (95% IC) 0 0.5 1 2 3 4 5 Type of event 51% reduction Symptomatic 0.49 (0.38-0.62) Ulcers Upper GI 45% reduction Complications 0.55 (0.38-0.80) Hooper L et al. BMJ 320:948-58 (2004)
  83. 87. M anagement of UGIB from NSAID-induced Ulcers
  84. 88. Approach to UGI Bleeding <ul><li>Assess severity </li></ul><ul><li>Resuscitate </li></ul><ul><li>Establish the site of bleeding </li></ul><ul><li>Endoscopic intervention </li></ul><ul><li>Reassess severity </li></ul><ul><li>Medical treatment </li></ul><ul><li>Indications for surgery </li></ul>
  85. 89. Assessing severity: Rockall criteria <ul><li>Criterion Score </li></ul><ul><li>Age <60 years 0 </li></ul><ul><ul><ul><ul><ul><li>60-79 yrs 1 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>>80 years 2 </li></ul></ul></ul></ul></ul><ul><li>Shock None 0 </li></ul><ul><ul><li>Pulse & sBP >100 1 </li></ul></ul><ul><ul><li>sBP <100 2 </li></ul></ul><ul><li>Co-morbidity None 0 </li></ul><ul><ul><li>Cardiac / any major 2 </li></ul></ul><ul><ul><li>Renal / liver / malig. 3 </li></ul></ul><ul><li>Total initial score (max = 7) </li></ul>Mortality 50.0%
  86. 90. High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer Fail Antisecretory therapy Refer Guideline of UGIB Management Endoscopy available Yes No Others Variceal bleeding Ulcer bleeding Pharmacological therapy and monitoring Rebleed Re-endoscopy Fail
  87. 91. Endoscopic Stigmata of Ulcer Hemorrhage Active arterial bleeding Visible Vessel Adherent clot Flat spot Clean base ulcer
  88. 92. Endoscopic Stigmata of Ulcer Hemorrhage: Prevalence, Risks of R ebleeding and Reduced Risk of Rebleeding following Endoscopic Therapy Endoscopy 1997; 29 : 827-33 Not available 3 32 Clean base ulcer Not available 7 10 Flat spot Not available 10 14 Oozong without stigmata 5 33 10 Adherent clot 15-30 50 22 Visible Vessel 15-30 90 12 Active arterial bleeding Rebleed Rate with Endoscopic treatment (%) Rebleed Rate Prevalence (%) Endoscopic Appearance
  89. 93. High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer Fail Antisecretory therapy Refer Guideline of UGIB Management Endoscopy available Yes No Others Variceal bleeding Ulcer bleeding Pharmacological therapy and monitoring Rebleed Re-endoscopy Fail
  90. 94. Endoscopic modalities available for management of Non-variceal UGIB <ul><li>I njection </li></ul><ul><li>Adrenaline (1:10,000) </li></ul><ul><li>Fibrin glue </li></ul><ul><li>Human thrombin </li></ul><ul><li>Sclerosants </li></ul><ul><li>Alcohol </li></ul><ul><li>Thermal </li></ul><ul><li>Heater probe </li></ul><ul><li>Bicap probe </li></ul><ul><li>Gold probe </li></ul><ul><li>Argon plasma coagulation </li></ul><ul><li>Laser therapy </li></ul><ul><li>Mechanical </li></ul><ul><li>Hemoclips </li></ul><ul><li>Banding </li></ul><ul><li>Endoloops </li></ul><ul><li>Staples/sutures </li></ul>
  91. 95. High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer Fail Antisecretory therapy Refer Guideline of UGIB Management Endoscopy available Yes No Others Variceal bleeding Ulcer bleeding Pharmacological therapy and monitoring Rebleed Re-endoscopy Fail
  92. 96. Pharmacotherapy for Nonvariceal Bleeding <ul><li>48-72 hrs after endoscopic therapy, patient should receive acid-suppressive drug to maintain gastric pH >6. </li></ul><ul><li>In patients who do not require endoscopic therapy, oral PPI therapy is adequate. </li></ul><ul><li>In patients with arterial spurt or visible vessel require endoscopic therapy and a continuous infusion of high -dose intravenous PPI therapy. </li></ul><ul><li>Stop a spirin and NSAID . </li></ul><ul><li>H pylori therapy should be test and treat if presented. </li></ul>
  93. 97. Brunner, et al. Aliment Pharmacol Ther 1995 Omeprazole 80 mg loading dose+ 40 mg q. 8 hours Omeprazole 80 mg loading dose + CI 4 mg/ hour Effective PPI Dosage & Administration Intermittent Bolus V.S. Continuous Infusion
  94. 98. 0 8 6 4 2 0 8 16 24 32 40 48 Median Intragastric pH Time [h] Van Rensburg, et al. Gastroenterology 1997. (Abstract) 80 mg bolus then 8 mg/hour n = 14; median pH 6.3, 68% range IV Pantoprazole In Patients With UGI B After Endoscopic Hemostasis
  95. 99. <ul><li>Recommendation: An intravenous bolus followed by continuous-infusion proton-pump inhibitor is effective in decreasing rebleeding in patients who have undergone successful endoscopic therapy. </li></ul><ul><li>Recommendation: A;Evidence: I </li></ul>Consensus Recommendations for Managing Patients with Nonvariceal UGIB . <ul><li>Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding. Ann Intern Med  2003;139(10):843-57. </li></ul><ul><li>A Canadian clinical practice algorithm for the management of patients with nonvariceal upper gastrointestinal bleeding. Can J Gastroenterol 2004;18(10):605-609. </li></ul>
  96. 100. High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer Fail Antisecretory therapy Refer Guideline of UGIB Management Endoscopy available Yes No Others Variceal bleeding Ulcer bleeding Pharmacological therapy and monitoring Rebleed Re-endoscopy Fail
  97. 101. Proton pump inhibitor treatment for acute peptic ulcer bleeding <ul><li>No evidence to suggest that results on mortality and rebleeding were dependent on study quality, route of PPI administration, type of control treatment or application of initial endoscopic haemostatic treatment. </li></ul><ul><li>PPIs significantly reduced surgery compared with placebo but not when compared with H2RA. </li></ul><ul><li>Among patients with active bleeding or non-bleeding visible vessel, PPI treatment reduced mortality (OR 0.53; 95% CI 0.31 to 0.91), rebleeding and surgery. </li></ul>Cochrane Database of Systematic Reviews 2006 Issue 3
  98. 102. H . pylori and NSAIDs
  99. 103. H.pylori , NSAID Use and the Risk of PU Bleeding Prevalence (%) PU bleeding + - + - + - OR 1.79 95% CI; 0.97-3.32 OR 4.85 95% CI; 3.77-6.23 OR 6.13 95% CI; 3.93-9.56 Lancet 2002 HP+ NSAID uses HP+ NSAID use HP- No NSAID H pylori and NSAIDs independently and significantly increase risk of PU bleeding
  100. 104. Recommendations for H pylori eradication in Maastricht III Consensus 1b ; Individual RCT with narrow confidence interval Gut. 2006;55:1717-24 A Ib <ul><li>H. pylori eradication is of value in chronic NSAID users but is insufficient to prevent NSAID related ulcer disease completely </li></ul>A Ib <ul><li>In naı¨ve users of NSAIDs, H , pylori eradication may prevent PU and or bleeding </li></ul>A Ib <ul><li>In patients receiving long term NSAIDs and who have peptic ulcer and/or ulcer bleeding, PPI maintenance treatment is better than H. pylori eradication in preventing ulcer recurrence and/or bleeding </li></ul>Grade of recommendation Level of evidence Recommendations
  101. 105. H pylori and Low dose ASA <ul><li>H . pylori infection increases complications for patients taking low-dose aspirin. </li></ul><ul><li>R isk for UGI bleeding with low-dose aspirin and H . pylori infection (OR = 4.7 ; 95 % CI, 2.0-10.9 ) compared with aspirin alone but much lower than previous ulcer history (OR = 15.2 ; 95 % CI, 3.8 - 60.1 ). </li></ul><ul><li>Recommendation: Patients who are receiving long term aspirin who bleed should be tested for H . pylori and, if positive, receive eradication therapy. </li></ul>
  102. 106. Summary Practical Approach in Managing NSAID Risks: GI and CV
  103. 107. Strategy in patients who need NSAIDs <ul><li>Step 1 : Evaluate presence of risk factor : </li></ul><ul><li>Estimate the GI & CV risk </li></ul><ul><li>Step 2 : Minimize the risk according to these factors </li></ul><ul><li>Step 3 : Use the most appropriate therapeutic strategy </li></ul>
  104. 108. The most important risk factors <ul><li>Age Most Frequent </li></ul><ul><li>Low-dose ASA >20% of patients </li></ul><ul><li>Ulcer History Highest RR </li></ul>Factor Reason
  105. 109. Definition of GI risks <ul><li>GI risk Complication Rate NNT Cost of </li></ul><ul><li> 100 pt-yrs prevention </li></ul><ul><li>Low <1.5 >120 ≈ 120,000 ε </li></ul><ul><li>Intermediate 2-10 10-100 3,000-20,000 ε </li></ul><ul><li>High >20 <10 <3,000 ε </li></ul>Lanas et al. APT 2004;20:321-31.
  106. 110. Assess Cardiac Risk First <ul><li>When choosing an NSAID </li></ul><ul><ul><li>Assess cardiac risk factors first because of concern about CV safety of COX-2 inhibitors </li></ul></ul><ul><ul><ul><li>Naproxen may have cardioprotective </li></ul></ul></ul><ul><ul><li>Consider whether patient would be benefit from aspirin therapy </li></ul></ul><ul><ul><li>No GI benefit of COX-2 inhibitors for patients who take aspirin </li></ul></ul><ul><li>For patients with GI risk factors </li></ul><ul><ul><li>Consider non-NSAID therapies </li></ul></ul><ul><ul><li>For patients requiring NSAIDs, consider adding a PPI </li></ul></ul>
  107. 111. <ul><li>Assess the presence of high-risk factors for serious NSAID-induced GI adverse events i.e elderly people,, if necessary, keep the dose as low as possible. </li></ul><ul><li>Comorbidity (ie renal and hepatic disease) needs to be considered when prescribe NSAIDs. </li></ul><ul><li>Prescribe with caution in patients with underlying GI disease or risk factors for CVS disease. </li></ul><ul><li>Beware drug interactions of NSAIDs / COX-2 inhibitors </li></ul><ul><li>Patients with history of chronic or allergic skin conditions, </li></ul><ul><ul><li>A standard NSAID may be preferred to a COXIB (rarely COXIBs reported to be associated with increased risk of serious skin reactions) </li></ul></ul><ul><ul><li>Majority of cases occur in the first month of use </li></ul></ul>Minimizing risk of NSAIDs users
  108. 112. <ul><li>Coxibs are contraindicated in: </li></ul><ul><ul><li>ischemic heart disease </li></ul></ul><ul><ul><li>cerebrovascular disease </li></ul></ul><ul><ul><li>peripheral arterial disease </li></ul></ul><ul><ul><li>moderate or severe heart failure. </li></ul></ul><ul><li>In people with risk factors for heart disease the balance of GI and CV risk should be considered before prescribing a coxib. </li></ul><ul><li>People requiring low dose aspirin should generally not be prescribed a coxib because GI benefit has not been clearly demonstrated in this group. </li></ul>Practical Points for COX-2 selective NSAIDs Uses
  109. 113. <ul><li>If high risk of NSAID-induced GI adverse effects and requires concomitant use of low-dose aspirin prophylaxis and an NSAID: </li></ul><ul><ul><li>Do not stop aspirin. </li></ul></ul><ul><ul><li>Re-consider use paracetamol with or without codeine. </li></ul></ul><ul><ul><li>If NSAID is considered necessary, cautious to prescribe an NSAID with less COX-2 selectivity (e.g. naproxen, but not ibuprofen) together with a gastroprotective agent. </li></ul></ul><ul><li>Avoid concomitant use of aspirin with ibuprofen. </li></ul>Low-dose Aspirin and NSAID
  110. 114. Strategies to Reduce NSAID-induced Mucosal Injury and Platelet Dysfunction <ul><li>Avoid NSAIDs or minimize dosage </li></ul><ul><li>Alternative COX-2 inhibitors </li></ul><ul><li>Proton pump inhibitor s (PPIs) </li></ul><ul><ul><li>PPIs are more effective than H2RA in preventing NSAID-induced ulcer </li></ul></ul><ul><ul><li>PPIs are better tolerate than misoprostol </li></ul></ul><ul><li>Prostaglandin analogue – misoprostol </li></ul>
  111. 115. NSAID required? High risk Low risk - No prophylaxis -Monitor clinical signs and symptoms -Use non-NSAIDs analgesic -Use low dose, short acting NSAIDs -Limit duration of therapy -Avoid using combination of NSAIDs -Avoid to combine with corticosteriod or anticoagulant Risk assessment for NSAID-induced ulcer -Cotherapy with Gastroprotective drugs -Selective COX-2 inhibitors Yes
  112. 116. Recommendations for the use of NSAIDs according to GI and cardiovascular risk. <ul><li>*High cardiovascular risk: requirement for low-dose aspirin for primary prevention (calculated 10-year cardiovascular risk >10%) or secondary prevention of serious cardiovascular events. </li></ul><ul><li>**Gl risk: low (no risk factors), moderate (1-2 risk factors), or high (> 2 risk factors, previous ulcer complications, or concomitant use of corticosteroids or anticoagulants). All patients with a history of ulcers who require NSAIDs should be tested for H. pylori and if infection is present, eradication therapy should be given. </li></ul><ul><li>*** Naproxen is preferred NSAID in patients with a high cardiovascular risk. </li></ul>Nat Clin Pract Gastroenterol Hepatol. 2006;3(10):563-73. Avoid NSAIDs or COX2 inhibitors NSAID***+ PPI or misoprostol NSAID *** + PPI or misoprostol High COX2 inhibitor + PPI NSAID + PPI/misoprostol or COX2 inhibitor NSAID Low Severe Moderate Low Gastrointestinal risk** Cardiovascular risk*
  113. 117. Thank you

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