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1.
PLoS One ; 17(6): e0269262, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35658063

RESUMO

BACKGROUND: Acute gastrointestinal (GI) bleeding is not an uncommon complication of oral anticoagulation (OAC) therapy that requires medication cessation. However, drug cessation may cause fatal stroke or systemic embolization in patients at high thromboembolic risk. Here we sought to find an appropriate anticoagulation cessation strategy in cases of GI bleeding during OAC therapy. METHODS: This single-center retrospective cohort analysis was performed between 2010 and 2018. Patients were enrolled if the following three consecutive conditions were met: 1) electrocardiography electrocardiography-proven atrial fibrillation; 2) OAC therapy; and 3) GI bleeding. We divided the drug cessation strategy into the continuation and discontinuation groups. During 1-year follow-up, the rates of major thromboembolic and rebleeding events were calculated. RESULTS: One hundred and forty-six patients (continuation [n = 54] vs. discontinuation [n = 92] group) were enrolled. Patients in the discontinuation group were more likely to be older (69.8 ± 9.0 yrs vs. 74.9 ± 8.9 yrs, p = 0.001), while patients in the continuation group were more likely to have undergone cardiac valve surgery (51.9% vs. 20.7%, p<0.001). The presence of a mechanical mitral valve was a determinant of continuation strategy (38.9% vs. 7.5%, p<0.001). However, the mean CHA2DS2-VASc (3.4±1.3 vs. 4.1±1.6, p = 0.010) and Glasgow-Blatchford (8.0±2.4 vs. 8.9±2.5, p = 0.037) scores were higher in the discontinuation group. Two major embolic strokes occurred in each group (3.7% vs. 2.2%, p = 0.585). Four of 54 (7.4%) and five of 92 (5.4%) patients had rebleeding events during follow-up (p = 0.632). One embolic event in the continuation group and one rebleeding event in the discontinuation group were fatal. The Glasgow-Blatchford score was a predictor of 1-year rebleeding events (odds ratio [OR], 1.36; 95% confidence interval [CI], 0.68-2.20; p = 0.028). The high CHA2DS2-VASc score showed a strong trend (OR, 1.71; 95% CI, 0.92-3.20; p = 0.089) in 1-year thromboembolic events. CONCLUSION: No single risk factor or drug cessation strategy was attributed to adverse clinical events after GI bleeding. The risk of future thrombotic or rebleeding events should be individualized and controlled for based on a pre-existing stratification system.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Tromboembolia , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/induzido quimicamente , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/complicações , Humanos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/complicações , Tromboembolia/complicações
2.
BMJ Open ; 12(6): e057991, 2022 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-35697453

RESUMO

INTRODUCTION: Proton pump inhibitors (PPIs) are widely used for primary and secondary prevention of upper gastrointestinal bleeding. However, there remains controversy about the overall net clinical benefit of PPIs (omeprazole, rabeprazole, pantoprazole, lansoprazole) when coprescribed with direct oral anticoagulants (DOACs; dabigatran, rivaroxaban, apixaban, edoxaban). Our objective is to explore the risk of clinically relevant events, including bleeding, thromboembolic events and death, in patients prescribed DOACs while taking PPIs versus no PPI. METHODS AND ANALYSIS: The protocol describes a retrospective cohort study of all Ontario residents aged 66 years or older with atrial fibrillation and at least one pharmacy dispensation for a DOAC identified using linked administrative healthcare databases covering 2009-2020. Ontario drug benefit dispensation records will be used to ascertain PPI exposure during DOAC therapy. The primary outcome is a composite of clinically relevant bleeding, thrombotic events or all-cause death. A minimum of 520 patients in total with at least one of the components of the composite outcome are needed. Poisson regression with a generalised estimating equation model will be used to calculate the adjusted incidence rate difference, incidence rate ratios 95% CI, adjusting for propensity for PPI use using inverse probability of treatment weights. ETHICS AND DISSEMINATION: This research is exempt from REB review under section 45 of Ontario's Personal Health Information Protection Act. We will report our findings in a peer-reviewed biomedical journal and present them at conferences. The study will provide useful evidence to optimise the coprescription of DOACs and PPIs in practice.


Assuntos
Fibrilação Atrial , Inibidores da Bomba de Prótons , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Estudos de Coortes , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/epidemiologia , Humanos , Inibidores da Bomba de Prótons/efeitos adversos , Piridonas/uso terapêutico , Estudos Retrospectivos
3.
Front Immunol ; 13: 840916, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35720298

RESUMO

Introduction: Immune checkpoint inhibitors (ICIs) have now become the standard therapy for malignancies like non-small cell lung cancer and classical Hodgkin's lymphoma. ICIs are associated with unique immune-related adverse events (irAEs) caused by dysregulated immune activation. Treatment of lower gastrointestinal (GI) tract irAEs, such as colitis, is more common. However, for upper gastrointestinal tract irAEs, there is a lack of consensus in terms of globally standardized disease classification and treatment guidelines. Here, we report a case of sintilimab-induced acute erosive hemorrhagic gastritis. Case Presentation: A 54-year-old man with metastatic NSCLC (PT2N2M1 stage IV) underwent treatment with eight courses of sintilimab + bevacizumab, followed by maintenance therapy with sintilimab alone. However, he presented with epigastric pain and melena at the end of the first sintilimab treatment, and the symptoms occurred repeatedly after regular treatment with acute erosive hemorrhagic gastritis. Repeat esophagogastroduodenoscopy (EGD) showed severe hemorrhagic gastritis; symptomatic relief and improvement in EGD images were noted for as long as he was being treated with steroids, methylprednisolone sodium. Conclusion: As far as we are aware, we here describe the first case of sintilimab-associated acute erosive hemorrhagic gastritis, an upper gastrointestinal toxicity event. Throughout the treatment progression, differential diagnosis, multidisciplinary discussion, and the use of immunosuppressants were instrumental in clarifying the diagnosis and were crucial to the prognosis of the patient and continued treatment with ICIs.


Assuntos
Antineoplásicos Imunológicos , Carcinoma Pulmonar de Células não Pequenas , Gastrite , Neoplasias Pulmonares , Trato Gastrointestinal Superior , Anticorpos Monoclonais Humanizados , Antineoplásicos Imunológicos/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Gastrite/induzido quimicamente , Gastrite/diagnóstico , Gastrite/tratamento farmacológico , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/diagnóstico , Humanos , Neoplasias Pulmonares/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Trato Gastrointestinal Superior/patologia
4.
J Gastrointestin Liver Dis ; 31(2): 176-183, 2022 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-35574622

RESUMO

BACKGROUND AND AIMS: Considering the lack of knowledge regarding the influence of the variable number of repeats of 27 pb in intron 4 (4b/4a VNTR - rs61722009) of the endothelial nitric oxide synthase (eNOS) on the drug response, we assessed the influence of this polymorphism for the risk of upper gastrointestinal bleeding (UGIB). METHODS: A case-control study, including 200 cases and 706 controls, was conducted in a Brazilian hospital complex. Cases were participants with UGIB diagnosis. Controls were participants admitted to surgical procedures not related to gastrointestinal problems. The 4b/4a VNTR was determined through polymerase chain reaction followed by fragment analysis. Conditional logistic regression models were designed. The additive interaction between the presence of the 4b/4a VNTR variant and the use of low-dose aspirin (LDA) and nonsteroidal anti-inflammatory drugs (NSAIDs) was calculated by fitting the Cox regression model through the parameters of Synergism index (S) and Relative Excess Risk Due To Interaction (RERI). RESULTS: The presence of the 4b/4a VNTR variant did not increase the risk of UGIB: carriers of the 4a/4a genotype (OR=0.37, 95%CI: 0.09-1.45) and of the variant allele "4a" (OR=0.91, 95%CI: 0.55-1.51). The risk of UGIB in LDA users carriers of the wild genotype (OR=4.96, 95%CI: 2.04- 2.06) and the variant allele "4a" (OR=3.49, 95%CI: 1.18-10.38) is similar, as well as for NSAID users carriers of the wild genotype (OR=5.73, 95%CI: 2.61-12.60) and variant allele "4a" (OR=5.51, 95%CI: 1.42-15.82). No additive interaction was identified between the presence of the genetic variant and the use of LDA [RERI: -1.44 (95%CI: -6.02-3.14; S: 0.63 (95%CI: -1.97-1.15)] and NSAIDs [RERI: -0.13 (95%CI: -6.79-6.53; S: 0.97 (95%CI: -0.23-4.19)] on the UGIB risk. CONCLUSION: Our data suggests that there is no increase in the magnitude of UGIB risk in LDA and NSAIDs users' carrying the variant allele "4a".


Assuntos
Óxido Nítrico Sintase Tipo III , Polimorfismo Genético , Anti-Inflamatórios não Esteroides , Aspirina , Estudos de Casos e Controles , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/genética , Predisposição Genética para Doença , Genótipo , Humanos , Íntrons , Repetições Minissatélites , Óxido Nítrico Sintase Tipo III/genética , Fatores de Risco
5.
Ulus Travma Acil Cerrahi Derg ; 28(4): 541-544, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35485515

RESUMO

Both suburothelial hemorrhage and intestinal mural hemorrhage are very rare causes of abdominal pain and gross hematuria. Com-puted tomography (CT) is very valuable in both diagnoses. We present left suburothelial hemorrhage and intestinal mural hemorrhage with CT findings, in a case of Coumadin use for mitral valve replacement.


Assuntos
Hemorragia Gastrointestinal , Varfarina , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/diagnóstico por imagem , Humanos , Tomografia Computadorizada por Raios X/métodos
7.
Sci Rep ; 12(1): 5798, 2022 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-35388113

RESUMO

Acute upper gastrointestinal bleeding (UGIB) in acute coronary syndrome (ACS) patients are not uncommon, particularly under dual antiplatelet therapy (DAPT). The efficiency and safety of early endoscopy (EE) for UGIB in these patients needs to be elucidated. This multicenter randomized controlled trial randomized recent ACS patients presenting acute UGIB to non-EE and EE groups. All eligible patients received intravenous proton pump inhibitor therapy. Those in EE group underwent therapeutic endoscopy within 24 h after bleeding. The data regarding efficacy and safety of EE were analyzed. It was early terminated because the UGIB rate was lower than expected and interim analysis was done. In total, 43 patients were randomized to non-EE (21 patients) and EE (22 patients) groups. The failure rate of control hemorrhage (intention-to-treat [ITT] 4.55% vs. 23.81%, p < 0.001; per-protocol [PP] 0% vs. 4.55%, p = 0.058) and 3-day rebleeding rate (ITT 4.55% vs. 28.57%, p = 0.033; PP 0% vs. 21.05%, p = 0.027) were lower in EE than non-EE group. The mortality, minor and major complication rates were not different between two groups. Male patients were at higher risk of minor and major complications after EE with OR (95% CI) of 3.50 (1.15-10.63) and 4.25 (1.43-12.63), respectively. In multivariate analysis, EE was associated with lower needs for blood transfusion (HR 0.13, 95% CI 0.02-0.98). Among patients who discontinued DAPT during acute UGIB, a higher risk (OR 5.25, 95% CI 1.21-22.74) of coronary artery stent re-thrombosis within 6 months was noticed. EE for acute UGIB in recent ACS patients has higher rate of bleeding control, lower 3-day rebleeding rate and lower needs for blood transfusion, but more complications in male patients. Further enrollment is mandatory to avoid bias from small sample size (ClinicalTrial.gov Number NCT02618980, registration date 02/12/2015).


Assuntos
Síndrome Coronariana Aguda , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/tratamento farmacológico , Endoscopia Gastrointestinal/efeitos adversos , Hemorragia Gastrointestinal/induzido quimicamente , Humanos , Masculino , Inibidores da Agregação Plaquetária/efeitos adversos , Fatores de Risco , Resultado do Tratamento
8.
BMJ Open ; 12(4): e055469, 2022 04 19.
Artigo em Inglês | MEDLINE | ID: mdl-35440453

RESUMO

BACKGROUND AND OBJECTIVE: Aspirin combined with edaravone is more effective than aspirin or edaravone alone in the treatment of ischaemic stroke. Aspirin is defined as a nephrotoxic drug while the renal safety of edaravone is controversial. We aimed to evaluate whether edaravone will increase the nephrotoxicity of aspirin in patients with ischaemic stroke. DESIGN: A propensity score-matched retrospective cohort study. SETTING: A tertiary hospital in China. PARTICIPANTS: Patients with ischaemic stroke were treated with aspirin from February 2007 to May 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: Acute kidney injury (AKI, diagnosed by the Acute Kidney Injury Network), decreased estimated glomerular filtration rate (eGFR,>10%), gastrointestinal bleeding and in-hospital adverse outcomes (defined as dying or giving up treatment in our hospital). RESULTS: We included 3061 patients, and 986 pairs were successfully matched. Of the 986 pairs of patients included, the incidence of AKI between the aspirin group and the combination group showed no significant difference (7.71% vs 6.29%, p=0.217). While the incidence of eGFR decline (24.75% vs 16.94%, p<0.001) was significantly lower in the combination group. The protective effect was significant in patients with baseline eGFR >30 mL/min/1.73 m2, especially in eGFR 60-90 mL/min/1.73 m2. In patients with different complications, the incidence of AKI showed no significant differences in patients with chronic kidney injury, hypertension, anaemia, age above 75 years, except in patients with cardiovascular disease (OR, 2.82; 95% CI 1.50 to 5.29; p<0.001). However, the incidence of gastrointestinal bleeding (1.22% vs 2.84%, p=0.011) and in-hospital adverse outcomes (3.25% vs 7.00%, p<0.001) were significantly higher in the combination group. CONCLUSIONS: Our study indicated that edaravone in patients with ischaemic stroke didn't increase the nephrotoxicity of aspirin, and even had a protective effect on mild renal deterioration. Nevertheless, there is a need to be cautious when patients are in bad pathophysiological conditions and at high risk of bleeding.


Assuntos
Injúria Renal Aguda , Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Injúria Renal Aguda/induzido quimicamente , Injúria Renal Aguda/tratamento farmacológico , Idoso , Aspirina/efeitos adversos , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/tratamento farmacológico , Edaravone/efeitos adversos , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/tratamento farmacológico , Humanos , Rim , Masculino , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia
9.
Intern Med J ; 52(4): 663-666, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-35419961

RESUMO

Low-dose aspirin is commonly used for primary or secondary prophylaxis against cardiovascular disease in older people. However, the potential risk of upper gastrointestinal (UGI) ulceration and bleeding associated with low-dose aspirin use is often not appreciated by prescribers and older consumers. Among 133 serial patients with UGI bleeding, aspirin-users aged ≥70 years had a ninefold increased likelihood of overt UGI bleeding compared with non-users, reducing by 90% in regular proton-pump inhibitor users (adjusted odds ratio 0.10). We recommend risk-versus-benefit discussions when recommending aspirin to older people.


Assuntos
Aspirina , Inibidores da Bomba de Prótons , Idoso , Anti-Inflamatórios não Esteroides/efeitos adversos , Aspirina/efeitos adversos , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/epidemiologia , Humanos , Inibidores da Bomba de Prótons/efeitos adversos , Fatores de Risco , Prevenção Secundária
10.
Thromb Res ; 214: 29-36, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35452869

RESUMO

INTRODUCTION: The gastrointestinal (GI) tract is a frequent site of bleeding in patients receiving anticoagulant therapy for venous thromboembolism (VTE). At-risk patients have not been consistently identified yet. METHODS: We used the RIETE registry to assess the clinical characteristics of patients developing major GI bleeding during the course of anticoagulation. Then, we built a predictive score based on multivariable analysis, aiming to identify patients at increased risk for major GI bleeding. RESULTS: We included 87,431 patients with acute VTE. During the course of anticoagulation, 778 (0.89%) suffered major GI bleeding, 815 (0.93%) non-major GI bleeding and 1462 (1.67%) had major bleeding outside the GI tract. During the first 30 days after major GI bleeding, 7.6% of patients re-bled, 3.9% had VTE recurrences and 33% died. On multivariable analysis, male sex, age ≥70 years, initial VTE presentation as pulmonary embolism, active cancer, prior VTE, recent major bleeding in the GI tract, esophageal varicosities, anemia, abnormal prothrombin time, renal insufficiency and use of corticosteroids were associated to an increased risk for major GI bleeding. Using the predictive score, 39,591 patients (45%) were at low risk; 36,602 (42%) at intermediate-risk; 9315 (11%) at high-risk; and 1923 (2.2%) at very high risk. Their rates of major GI bleeding were: 0.21%, 0.96%, 2.41% and 6.08%, respectively. The c-statistics was 0.771 (95%CI. 0.755-0.786). CONCLUSIONS: We have developed a score which has the potential to identify patients at increased risk for GI bleeding, but needs to be externally validated."


Assuntos
Embolia Pulmonar , Tromboembolia Venosa , Idoso , Anticoagulantes/efeitos adversos , Hemorragia Gastrointestinal/induzido quimicamente , Humanos , Masculino , Embolia Pulmonar/tratamento farmacológico , Sistema de Registros , Tromboembolia Venosa/induzido quimicamente , Tromboembolia Venosa/tratamento farmacológico
12.
JAMA ; 327(16): 1598-1607, 2022 04 26.
Artigo em Inglês | MEDLINE | ID: mdl-35471506

RESUMO

Importance: The US Preventive Services Task Force (USPSTF) is updating its 2016 recommendation on the use of aspirin for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC). Objective: To provide updated model-based estimates of the net balance in benefits and harms from routine use of low-dose aspirin for primary prevention. Design, Setting, and Participants: Microsimulation modeling was used to estimate long-term benefits and harms for hypothetical US cohorts of men and women aged 40 to 79 years with up to 20% 10-year risk for an atherosclerotic CVD event and without prior history of CVD or elevated bleeding risks. Exposures: Low-dose (≤100 mg/d) aspirin for lifetime use, unless contraindicated by a bleeding event, and with stopping ages in 5-year intervals from age 65 to 85 years. Main Outcomes and Measures: Primary outcomes were lifetime net benefits measured in quality-adjusted life-years (QALYs) and life-years. Benefits included reduced nonfatal myocardial infarction and ischemic stroke. Harms included increased nonfatal major gastrointestinal bleeding and intracranial hemorrhage. Reduced CRC incidence was considered in sensitivity analysis. Results: Estimated lifetime net QALYs were positive for both men and women at 5% or greater 10-year CVD risk when starting between ages 40 and 59 years and at 10% or greater 10-year CVD risk when starting between ages 60 and 69 years. These estimates ranged from 2.3 (95% CI, -2.7 to 7.4) to 66.2 (95% CI, 58.2 to 74.1) QALYs per 1000 persons. Lifetime net life-years were positive for men at 5% or greater and women at 10% or greater 10-year CVD risk starting aspirin at ages 40 to 49 years and for men at 7.5% or greater and women at 15% or greater 10-year CVD risk at ages 50 to 59 years. These estimates ranged from 0.4 (95% CI, -6.1 to 6.9) to 52.4 (95% CI, 43.9 to 60.9) life-years per 1000 persons. Lifetime net life-years were negative in most cases for persons starting aspirin between ages 60 and 79 years, as were lifetime net QALYs for persons aged 70 to 79 years. Stopping aspirin between ages 65 and 85 years generally showed little advantage compared with lifetime use. Sensitivity analyses showed lifetime net benefits may be higher if aspirin reduced CRC incidence or CVD mortality and lower if aspirin increased fatal major gastrointestinal bleeding or reduced quality of life with routine use. Conclusions and Relevance: This microsimulation study suggested that several population groups may benefit from taking aspirin for the primary prevention of CVD, primarily in persons starting at younger ages with higher 10-year CVD risk.


Assuntos
Aspirina , Doenças Cardiovasculares , Neoplasias Colorretais , Adulto , Idoso , Aspirina/efeitos adversos , Aspirina/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , Neoplasias Colorretais/tratamento farmacológico , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/prevenção & controle , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Prevenção Primária , Qualidade de Vida
13.
G Ital Cardiol (Rome) ; 23(2): 113-119, 2022 Feb.
Artigo em Italiano | MEDLINE | ID: mdl-35343515

RESUMO

Antithrombotic therapy, in particular oral anticoagulation, is associated with an increased risk of bleeding. During anticoagulant treatment bleedings may also be caused by occult cancer, allowing its early diagnosis. The use of direct oral anticoagulants is associated with a lower risk of bleeding compared to vitamin K antagonists, but in the presence of a cancer lesion the risk of bleeding is not inferior. Atrial fibrillation patients with gastrointestinal bleeding during warfarin therapy are 6 times more likely to be diagnosed with cancer than patients without bleeding. In patients with hematuria, the probability of cancer is almost triple if treated with warfarin. With all the four direct oral anticoagulants newly colon cancer diagnoses have been reported in association with bleedings in phase III randomized clinical trials. In the real world, a 4.5% incidence of newly diagnosed cancer has been reported, mainly in the early stage and preceded by a bleeding event. Gastrointestinal bleeding is associated with a 13 times higher risk of newly diagnosed gastrointestinal cancer, genitourinary bleeding with a 18 times higher risk of newly diagnosed genitourinary cancer, and bronchopulmonary bleeding with a 15 times higher risk of newly diagnosed lung cancer. In the presence of bleeding during oral anticoagulant therapy, a diagnostic screening is warranted in order to detect occult cancer. An adverse event such as bleeding can become a favorable opportunity.


Assuntos
Fibrilação Atrial , Neoplasias , Administração Oral , Anticoagulantes , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Detecção Precoce de Câncer , Hemorragia Gastrointestinal/induzido quimicamente , Humanos , Neoplasias/complicações , Neoplasias/tratamento farmacológico
14.
Medicina (Kaunas) ; 58(3)2022 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-35334586

RESUMO

A 60-year-old woman was diagnosed with nonfunctional pancreatic neuroendocrine neoplasm with multiple liver metastases and was administered everolimus. Due to persistent epigastric pain and diarrhea, a colonoscopy was performed on the 14th day after the start of everolimus administration, which revealed small bleeding ulcers in the ileocecal region, transverse colon, and rectum. These adverse effects were attributed to the everolimus; it was immediately discontinued, and the patient's clinical symptoms and imaging findings improved. We concurred that the administration of calcium channel blockers resulted in the inhibition of everolimus metabolism and the disease onset. The everolimus was discontinued. There was no subsequent recurrence of hemorrhagic colitis.


Assuntos
Antineoplásicos , Colite , Neoplasias Pancreáticas , Antineoplásicos/uso terapêutico , Colite/induzido quimicamente , Everolimo/efeitos adversos , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Humanos , Pessoa de Meia-Idade , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/tratamento farmacológico
15.
Eur J Clin Pharmacol ; 78(7): 1057-1067, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35296907

RESUMO

PURPOSE: The objective of present study was to compare the safety and efficacy of resuming direct-acting oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) and prior gastrointestinal bleeding (GIB). METHODS: PubMed, Embase, Web of Science, and the Cochrane Library were searched from their inception until 2 June 2021 for observational cohort studies in patients with AF, who resumed VKAs or DOACs after a history of GIB. Studies that reported data on clinical outcomes including risk of recurrent GIB, thromboembolic events, or all-cause mortality were included. A network meta-analysis was performed to calculate the pooled hazard ratio (HR) and associated 95% credible intervals (CIs), using a random effects model in a Bayesian framework. RESULTS: A total of 10 studies were included in the final analysis, including 59,244 AF patients with prior GIB, of whom 27,793 resumed DOACs, 24,635 resumed warfarin, and 6816 did not resume anticoagulation. Compared with no resumption of anticoagulation, resumption of warfarin was associated with an increased risk of recurrent GIB (HR 1.33, 95% CI: 1.06-1.70), but no increased risk of recurrent GIB was found with resumption of DOACs (HR 1.22, 95% CI: 0.88-1.71); among individual DOACs, only rivaroxaban was associated with an increased risk of recurrent GIB (HR 1.67, 95% CI: 1.16-2.65). Compared with no resumption of anticoagulation, resumption of DOACs and warfarin was associated with a significant reduction in all-cause mortality (HR 0.57, 95% CI: 0.40-0.84; HR 0.58, 95% CI: 0.44-0.79), but no statistically significant reduction in thromboembolic events (HR 0.69, 95% CI: 0.4-1.2; HR 0.83, 95% CI: 0.55-1.29). CONCLUSIONS: In AF patients with prior GIB, resumption of DOACs may be safer, except for rivaroxaban.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Teorema de Bayes , Hemorragia Gastrointestinal/induzido quimicamente , Humanos , Metanálise em Rede , Rivaroxabana/efeitos adversos , Acidente Vascular Cerebral/tratamento farmacológico , Varfarina/efeitos adversos
17.
Drug Ther Bull ; 60(5): 69, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35273022

RESUMO

Overview of: Holt A, Blanche P, Zareini B, et al Gastrointestinal bleeding risk following concomitant treatment with oral glucocorticoids in patients on non-vitamin K oral anticoagulants. Heart doi:10.1136/heartjnl-2021-319503 [Epub ahead of print 13 Aug 2021].


Assuntos
Anticoagulantes , Fibrilação Atrial , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Hemorragia Gastrointestinal/induzido quimicamente , Glucocorticoides/efeitos adversos , Humanos
18.
Am J Gastroenterol ; 117(4): 542-558, 2022 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-35297395

RESUMO

We conducted systematic reviews of predefined clinical questions and used the Grading of Recommendations, Assessment, Development and Evaluations approach to develop recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute gastrointestinal (GI) bleeding and the elective endoscopic setting. The following recommendations target patients presenting with acute GI bleeding: For patients on warfarin, we suggest against giving fresh frozen plasma or vitamin K; if needed, we suggest prothrombin complex concentrate (PCC) compared with fresh frozen plasma administration; for patients on direct oral anticoagulants (DOACs), we suggest against PCC administration; if on dabigatran, we suggest against the administration of idarucizumab, and if on rivaroxaban or apixaban, we suggest against andexanet alfa administration; for patients on antiplatelet agents, we suggest against platelet transfusions; and for patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, we suggest against holding it, but if the ASA has been interrupted, we suggest resumption on the day hemostasis is endoscopically confirmed. The following recommendations target patients in the elective (planned) endoscopy setting: For patients on warfarin, we suggest continuation as opposed to temporary interruption (1-7 days), but if it is held for procedures with high risk of GI bleeding, we suggest against bridging anticoagulation unless the patient has a mechanical heart valve; for patients on DOACs, we suggest temporarily interrupting rather than continuing these; for patients on dual antiplatelet therapy for secondary prevention, we suggest temporary interruption of the P2Y12 receptor inhibitor while continuing ASA; and if on cardiac ASA monotherapy for secondary prevention, we suggest against its interruption. Evidence was insufficient in the following settings to permit recommendations. With acute GI bleeding in patients on warfarin, we could not recommend for or against PCC administration when compared with placebo. In the elective periprocedural endoscopy setting, we could not recommend for or against temporary interruption of the P2Y12 receptor inhibitor for patients on a single P2Y12 inhibiting agent. We were also unable to make a recommendation regarding same-day resumption of the drug vs 1-7 days after the procedure among patients prescribed anticoagulants (warfarin or DOACs) or P2Y12 receptor inhibitor drugs because of insufficient evidence.


Assuntos
Anticoagulantes , Gastroenterologia , Administração Oral , Anticoagulantes/efeitos adversos , Canadá , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/tratamento farmacológico , Humanos , Sociedades Médicas
19.
Clin J Gastroenterol ; 15(2): 310-319, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35133625

RESUMO

BACKGROUND: EUS-guided combination therapy (coil and hemostatic glue) for bleeding and non-bleeding gastric varices has recently attracted considerable attention after promising results were published in multiple small studies. We performed a meta-analysis to investigate the safety and efficacy of EUS-guided combination therapy in the treatment of GVs. METHODS: Publications investigating the safety and efficacy of EUS-guided combination therapy in patients with gastric varices were searched in Medline, Ovid Journals, Medline non-indexed citations and Cochrane Central Register of Controlled Trials. Pooling was conducted by both fixed and random effects model. RESULTS: In pooled analysis of 10 studies (N = 323), the technical success of EUS-guided combination therapy was 98.66% (95% CI 97.14-99.62). The pooled variceal obliteration rate after first session of treatment was 78.31% (95% CI 73.05-83.14). In patients requiring single or multiple treatment sessions, the overall variceal obliteration rate was 96.79% (95% CI 94.28-98.60). The pooled rate of hemorrhage from treated gastric varices was 4.92% (95% CI 2.85-7.52). After EUS-guided combination therapy, the pooled percentage of patients developing abdominal pain was 9.79% (95% CI 6.82-13.24), pulmonary embolism was 2.20% (95% CI 0.89-4.06), febrile episodes was 1.17% (95% CI 0.30-2.61), and procedure-related bleeding was noted in 2.62% (95% CI 1.18-4.63) of the patients. Subgroup analysis of studies using coil embolization and cyanoacrylate injection showed pooled variceal obliteration rate of 77.92% (95% CI 72.35-83.01) after first session of treatment. In patients requiring single or multiple treatment sessions, the overall variceal obliteration rate was 96.76% (95% CI 94.11-98.65). The pooled rate of re-bleeding from treated gastric varices was 5.09% (95% CI 2.90-7.83). CONCLUSIONS: This meta-analysis suggests that EUS-guided combination therapy is safe and effective for patients with gastric varices and should be considered in the clinical management of these patients.


Assuntos
Varizes Esofágicas e Gástricas , Cianoacrilatos/efeitos adversos , Varizes Esofágicas e Gástricas/induzido quimicamente , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/terapia , Humanos , Resultado do Tratamento , Ultrassonografia de Intervenção
20.
Intern Med J ; 52(2): 318-321, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-35187830

RESUMO

We assessed hospitalisations for gastrointestinal bleeding directly related to primary prevention aspirin in lower risk patients for a 6-month period in three South Australian hospitals. Those with related underlying pathology or concurrent causative medication were excluded. Identified patients (n = 22) carried little co-morbidity, 41% received prior proton-pump inhibitors and 68% were aged >70 years. Mean hospital admission cost was $6769 (95% confidence interval $5198-$8340), with projected state and national annual costs of $0.57 and $8.12 million respectively. In light of recent guideline changes, clinicians need to vigorously assess the need for primary prevention aspirin.


Assuntos
Aspirina , Inibidores da Agregação Plaquetária , Idoso , Aspirina/efeitos adversos , Austrália , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/prevenção & controle , Hospitalização , Humanos , Inibidores da Agregação Plaquetária/efeitos adversos , Prevenção Primária , Inibidores da Bomba de Prótons/uso terapêutico , Estudos Retrospectivos , Austrália do Sul/epidemiologia
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