Nalini M. Guda

Use of intravenous proton pump inhibitors in community practice: an explanation for the shortage?

BACKGROUND:Since 2001, one intravenous proton pump inhibitor (pantoprazole) has been available in the United States. A drug shortage bulletin was issued for this agent in 2003.AIM:To evaluate the patterns of use of intravenous proton pump inhibitors (IV PPIs) in routine clinical practice.METHODS:Prospective evaluation of IV PPI use in two community-based teaching hospitals. A computerized pharmacy ordering system was used to identify all patients for whom an IV PPI was ordered. Trained investigators obtained clinical data from patient records and these data were mapped to establish clinical criteria for the use of IV PPIs.RESULTS:Intravenous PPIs were prescribed in 238 patients over a 30-day period and a total of 1,631 doses were prescribed. Primary care providers prescribed 46% of prescriptions. Fifty-six percent of patients who received IV PPIs had no acceptable indication for their use. Of the 126 (81%) patients who were started on PPIs for the first time during their hospital stay, 102 were discharged on a PPI.CONCLUSIONS:Intravenous PPIs are widely used for poor indications, which may contribute to the shortage of these agents.

Proton pump inhibitors and the time trends for esophageal dilation.

AIM:Little is known about the impact of widespread proton pump inhibitor use on the need for dilation of esophageal strictures. To determine the time trends for upper endoscopy and stricture dilation before and after the availability of proton pump inhibitors.METHODS:The computerized databases of two large community hospitals were analyzed. Annual data on dilation procedures (by all methods) and upper endoscopy were obtained and analyzed in quartiles from 1986 to 2001 to determine if the relative or absolute need for dilation changed following the introduction of proton pump inhibitors in the United States. The number of prescriptions for acid suppressive agents (H2 receptor antagonists and proton pump inhibitors) for the corresponding time period was obtained from the IMS health database.RESULTS:A total of 57,496 upper GI endoscopies and 2,868 esophageal dilations were performed. The proportion of patients undergoing esophageal dilation increased from 4% in 1986–1989 to 6% in 1990–1993 (p < 0.001), remained unchanged (5.8%) in the period from 1994 to 1997 but declined significantly to 3.9% (p < 0.001) in the next quartile (1998–2001). Absolute numbers of dilation procedures declined significantly in the last quartile (1998–2001) and the proton pump inhibitor prescriptions in the United States increased markedly from 1995 onward.CONCLUSIONS:The need for stricture dilation peaked in 1994 and has declined thereafter, corresponding to an increase in the use of proton pump inhibitors. The widespread use of proton pump inhibitors has not, however, abolished the need for esophageal dilation.

Symptomatic gastro‐oesophageal reflux, arousals and sleep quality in patients undergoing polysomnography for possible obstructive sleep apnoea

Introduction : Nocturnal acid reflux is common and could disturb sleep by causing arousals that fragment sleep.

Inter- and intra-observer variability in the measurement of length at endoscopy: implications for the measurement of Barrett's esophagus

BACKGROUND Endoscopic measurements are frequently used to determine the length of Barretts epithelium. Decreases in measured length also are used to assess response to pharmacotherapy. The aim of this study was to determine the accuracy of the endoscopic measurement of length under standardized conditions. METHODS A life-size model of the esophagus was built by using an opaque polyvinyl tube. Transparent plastic inserts designed to resemble Barretts epithelium were created. Ten different insert lengths were randomly studied. Trained endoscopists and fellows in training blinded to the lengths of the inserts performed measurements twice in random order. RESULTS A total of 240 measurements were made by 12 endoscopists. The mean difference (1 standard deviation) between the measured and correct length was 1.10 (1.7) cm. Overestimation of the length occurred in 47% and underestimation in 37%. The kappa statistic for the first and second measurement (within 0.5 cm) performed by the same individual (intra-observer) was 0.40, suggesting only fair agreement. There was considerable variability between endoscopists. CONCLUSIONS Accurate measurement of length at endoscopy is difficult even under ideal conditions. Intra-observer agreement is fair, but results obtained by different endoscopists are widely divergent. Small improvements in the length of Barretts epithelium observed in some clinical trials could be because of chance instead of therapeutic effect.

Recurrent and Relapsing Pancreatitis

Recurrent acute pancreatitis is a common clinical problem. Most cases of pancreatitis are identified by a careful history and physical examination. Despite advanced evaluation, the cause is not apparent in about 10% of cases. The etiology of recurrent acute pancreatitis appears to be multifactorial, with genetic and environmental influences playing a significant role. The strength of evidence for certain etiologies is highly variable, and natural history data are limited. Controversy exists regarding the most appropriate diagnostic and therapeutic approach. Recurrent acute pancreatitis often represents a continuum with chronic pancreatitis.

The effect of over-the-counter ranitidine 75 mg on night-time heartburn in patients with erosive oesophagitis on daily proton pump inhibitor maintenance therapy

Background  H2‐receptor antagonists are widely used with proton pump inhibitors.

Oral buffered esomeprazole is superior to i.v. pantoprazole for rapid rise of intragastric pH: a wireless pH metry analysis.

Background and Aims:  A pH of more than 6 is required for clot stability and hemostasis. Intravenous proton pump inhibitors have a rapid onset of action compared to oral and have been preferred for management of non‐variceal bleeding. Intravenous pantoprazole has been used extensively. Buffered esomeprazole (BE) is an oral preparation consisting of an inner core of non‐enteric‐coated esomeprazole with a shell of sodium bicarbonate. The buffer protects against acid degradation of esomeprazole in addition to immediate antacid action. The aim of this study was to assess the efficacy of BE for raising and maintaining an intragastric pH of more than 6 in comparison to i.v. pantoprazole in equivalent dosing.

Quality of Life in Chronic Pancreatitis is Determined by Constant Pain, Disability/Unemployment, Current Smoking, and Associated Co-Morbidities

Objectives:Chronic pancreatitis (CP) has a profound independent effect on quality of life (QOL). Our aim was to identify factors that impact the QOL in CP patients.Methods:We used data on 1,024 CP patients enrolled in the three NAPS2 studies. Information on demographics, risk factors, co-morbidities, disease phenotype, and treatments was obtained from responses to structured questionnaires. Physical and mental component summary (PCS and MCS, respectively) scores generated using responses to the Short Form-12 (SF-12) survey were used to assess QOL at enrollment. Multivariable linear regression models determined independent predictors of QOL.Results:Mean PCS and MCS scores were 36.7±11.7 and 42.4±12.2, respectively. Significant (P<0.05) negative impact on PCS scores in multivariable analyses was noted owing to constant mild–moderate pain with episodes of severe pain or constant severe pain (10 points), constant mild–moderate pain (5.2), pain-related disability/unemployment (5.1), current smoking (2.9 points), and medical co-morbidities. Significant (P<0.05) negative impact on MCS scores was related to constant pain irrespective of severity (6.8–6.9 points), current smoking (3.9 points), and pain-related disability/unemployment (2.4 points). In women, disability/unemployment resulted in an additional 3.7 point reduction in MCS score. Final multivariable models explained 27% and 18% of the variance in PCS and MCS scores, respectively. Etiology, disease duration, pancreatic morphology, diabetes, exocrine insufficiency, and prior endotherapy/pancreatic surgery had no significant independent effect on QOL.Conclusions:Constant pain, pain-related disability/unemployment, current smoking, and concurrent co-morbidities significantly affect the QOL in CP. Further research is needed to identify factors impacting QOL not explained by our analyses.

Mechanism, assessment and management of pain in chronic pancreatitis: Recommendations of a multidisciplinary study group

DESCRIPTION Pain in patients with chronic pancreatitis (CP) remains the primary clinical complaint and source of poor quality of life. However, clear guidance on evaluation and treatment is lacking. METHODS Pancreatic Pain working groups reviewed information on pain mechanisms, clinical pain assessment and pain treatment in CP. Levels of evidence were assigned using the Oxford system, and consensus was based on GRADE. A consensus meeting was held during PancreasFest 2012 with substantial post-meeting discussion, debate, and manuscript refinement. RESULTS Twelve discussion questions and proposed guidance statements were presented. Conference participates concluded: Disease Mechanism: Pain etiology is multifactorial, but data are lacking to effectively link symptoms with pathologic feature and molecular subtypes. Assessment of Pain: Pain should be assessed at each clinical visit, but evidence to support an optimal approach to assessing pain character, frequency and severity is lacking. MANAGEMENT There was general agreement on the roles for endoscopic and surgical therapies, but less agreement on optimal patient selection for medical, psychological, endoscopic, surgical and other therapies. CONCLUSIONS Progress is occurring in pain biology and treatment options, but pain in patients with CP remains a major problem that is inadequately understood, measured and managed. The growing body of information needs to be translated into more effective clinical care.

Unrecognized GERD Symptoms Are Associated with Excessive Daytime Sleepiness in Patients Undergoing Sleep Studies

Sleep disturbances are commonly reported by patients who suffer from gastroesophageal reflux disease (GERD) but it is uncertain if GERD plays a role in patients with sleep disorders of undetermined origin. The prevalence of GERD in patients with sleep disorders of unknown etiology is uncertain; the aim of this study was to determine this prevalence. Three hundred eighty-five consecutive patients reporting to an outpatient clinic for evaluation of sleep disorders were assessed for their sleepiness in relation to reflux symptom intensity. Reflux symptoms that met the survey criteria for a diagnosis of GERD were present in 45 of the 385 subjects (12.8%). These subjects did not have a diagnosis of GERD and were not being treated. Multiple regression analysis showed that excessive sleepiness was associated with intensity of GERD symptoms. Patients with GERD had significantly higher Epworth sleep scores than patients without GERD (12.8 vs. 10.6; p=0.007), indicating more daytime sleepiness. We conclude that unrecognized and untreated GERD are present in many patients presenting with sleep disorders. Patients with GERD had significantly greater sleepiness. Further studies of the impact of GERD treatment in this population are necessary.