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NSAID gastropathy OTC self treatment
AJG – September, Suppl., 2001
833 Use of a national endoscopic database to determine the adoption of emerging pharmacological and endoscopic technologies in the every day care of patients with upper GI bleeding: the RUGBE initiative Alan N. Barkun1, Naoki Chiba6, Rob Enns5, John Marshall2, David Armstrong2, Sandrine Sabbagh1, Jamie Gregor3, Richard Fedorak4, Norm Marcon8, Jonathan Love8, Raymond Lahale8, Alan Cockeram7 and all other RUGBE investigators8*. 1McGill University; 2McMaster University; 3University of Western Ontario; 4University of Alberta; 5 University of British Columbia; 6Guelph General Hospital; 7Saint John Regional Hospital; and 8all other participating institutions, Canada. Purpose: We used a national GI bleed registry to track the adoption of new therapies such as intravenous PPI’s, combined endoscopic therapy, and clipping devices across different health care settings and geographic areas. Methods: A Registry of patients presenting with acute Upper Gastrointestinal Bleeding and undergoing Endoscopy (RUGBE) was initiated 12 months ago. Data were abstracted from the records of randomly selected patients at 17 institutions across Canada in varying care settings. The information was denominalized, entered electronically using a common endoscopic database, and downloaded into a central repository monthly following extensive data validation procedures. Pre-set clinical variables were recorded. Results: To date, 1042 procedures (median:55 per site) have been performed on 767 patients (37% females, mean age 66 ⫾ 17 years, mean: 1.4 procedures per patient). Both cardiac (44%) and respiratory (22%) comorbid conditions were frequent. Medication use included ASA (41%), NSAIDs (22%), warfarin (11%), and steroids (8%). COX-2 selective inhibitors comprised 39% of all NSAID use. The first endoscopy was carried out within 24 hours of the onset of symptoms in 34%. A second endoscopy was performed in 27% of patients (for follow-up or “second look” (51%), and continued or re-bleeding (31%)). Relevant endoscopic lesions were noted in the esophagus (24%), stomach (40%), and duodenum (35%) with multiple lesions noted in 6% of patients. Acid-related causes predominated (70%) (esophagitis (10%), duodenal ulcers (28%), and gastric ulcers (20%)). 32% of lesions required endoscopic therapy according to their description which was actually performed in 37% (injection (51%), thermal treatment (30%), a combination thereof (29%), ligating/clipping devices (9%)). The first dose of pharmacotherapy was given within 10.7 ⫾ 16.7 hrs of presentation and included an oral or intravenous PPI in 81%. Bleeding stopped spontaneously in 56%. The mean duration of hospital stay was 6.4 ⫾ 7.6 days (1.1 ICU days). A mean of 2 units of blood were transfused in 52% of patients. Surgery was needed in 3%. The overall mortality was 6.1%. Conclusions: These effectiveness data seem to indicate rapid, widespread acceptance of the use of proton pump inhibition in this patient population. Further analyses are required to determine the appropriateness of therapeutic approaches and any regional variations in the care provided.
834 NSAID gastropathy OTC self treatment Bernard S. Bloom, Ph.D.1, Walter L. Straus, M.D.2, and Joseph Thomas, Ph.D.3 1University of Pennsylvania, Department of Medicine, Philadelphia, PA; 2West Point, PA; 3West Lafayette, IN. Purpose: To estimate use of OTC NSAIDS, GI side effects, and professional and self-care for these side effects. Methods: Random telephone survey of age-stratified US national probability sample of OTC NSAID users and nonusers. Population was 535 English-speaking persons ⱖ 40 years old, who used an OTC NSAID for 4 of the previous 7 days, and a comparison population of 1,068 persons who reported no NSAID use within the previous 30 days. Telephone survey asked about current OTC NSAID use, GI symptoms and treatment, and prescription and OTC GI medications. Results: Most commonly used OTC NSAID was aspirin (alone or in combination compounds). Prevention (of MI or stroke) was most common reason for use (43.2%), followed by all forms of pain relief (44.2%) and
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relief of arthritis symptoms (24.5%). NSAID users were twice as likely as nonusers to report GI side effects (19.6% vs. 9.5%, p ⫽ 0.0001), including ulcer and bleeding, and more than twice as likely to use an OTC GI medication when they had GI symptoms (46.7% vs. 20.8%, p ⫽ 0.001). Conclusion: Low dose OTC NSAIDs were associated with a 2-fold increase in GI side effects, similar to prescription NSAIDs. Physicians may be unaware that patients self-medicate with OTC NSAIDs and GI medications and, therefore should routinely ask every patient about all self-treatment.
835 Outcome of flexible sigmoidoscopy performed by physician assistants: impact of family history and prior screening on findings and analysis of polyp detection and insertion depth as compared to physicians Thomas J Byrne, M.D.1 and Williamson B Strum, M.D.1* 1 Gastroenterology and Hepatology, Scripps Clinic, La Jolla, California, United States. Purpose: We sought to determine the outcome of screening flexible sigmoidoscopy (FS) performed by physician assistants (PAs) regarding 1) the impact of family history of colorectal cancer (CRC), 2) the impact of prior screening, and 3) the rate of neoplasia detection and depth of insertion as compared to gastroenterologists (GEs). Methods: We reviewed the findings and pertinent histories of all patients who underwent screening FS performed by PAs at our institution between 9/1/99 and 4/3/00. 3 PAs participated. Patients undergoing FS for reasons other than screening and those in whom screening was performed by non-PAs were excluded. A positive family history was defined as having one or more first degree relatives with CRC. We compared the findings to a similar cohort of patients who had screening FS performed previously by GEs. Results: 1,937 of 3,214 patients (60.3%) met full entry criteria. 53.6% were male. Mean age was 61.8 years. Polyps were found in 232 patients (12.0%) and advanced polyps, defined as ⱖ1 cm or containing villous or dysplastic features on pathology, were found in 76 (3.9%). No cancers were found. 144 patients had a positive family history. Polyps were detected in 10.4% of these and in 12.1% of other patients. Advanced polyps were found in 5.5% and 3.8% of patients with and without a positive family history, respectively. These differences were not statistically significant. 838 study patients had undergone FS ⱖ5 years previously, 209 patients had FS within 5 years and 890 had never undergone FS. Polyps were detected in 92/838 (11.0%), 24/209 (11.5%) and 116/890 (13.0%), respectively. Advanced polyps were found in 28/838 (3.3%), 4/209 (1.9%) and 44/890 (4.9%), respectively. None of these differences were statistically significant. Data from screening FS performed previously by GEs in a similar cohort of 3,611 patients were used to compare neoplasia detection and insertion depth between PAs and GEs. Polyps and advanced polyps were found by PAs in 12.0% and 3.9% of patients, respectively, compared to 9.1% and 2.6% by GEs. Mean insertion depth using identical patient preparation and equipment was 57cm in PAs and 53cm in GEs. One complication of diverticulitis, treated medically, occurred in the PA group. Conclusions: A positive family history of CRC as defined for this study is not associated with increased polyp detection on FS. Previous FS within 5 years does not preclude discovery of advanced neoplasia. PAs perform as well or better than GEs in detection of neoplasia and depth of insertion at FS.
836 Cost-effectiveness of empiric PPI therapy vs. test and treat in uninvestigated dyspepsia: impact of decreasing H. pylori prevalence and increasing non-H. pylori ulcers William D Chey, MD, FACG, Uri Ladabaum, MD, A Mark Fendrick, MD, FACG and James M Scheiman, MD, FACG*. 1Internal MedicineGI, University of Michigan Health System, Ann Arbor, MI, United States; 2Internal Medicine-GI, UCSF, San Francisco, CA, United States; 3 Internal Medicine-General Medicine, University of Michigan Health System, Ann Arbor, MI, United States; and 4Internal Medicine-GI, University of Michigan Health System, Ann Arbor, MI, United States.
833 Use of a national endoscopic database to determine the adoption of emerging pharmacological and endoscopic technologies in the every day care of patients with upper GI bleeding: the RUGBE initiative Alan N. Barkun1, Naoki Chiba6, Rob Enns5, John Marshall2, David Armstrong2, Sandrine Sabbagh1, Jamie Gregor3, Richard Fedorak4, Norm Marcon8, Jonathan Love8, Raymond Lahale8, Alan Cockeram7 and all other RUGBE investigators8*. 1McGill University; 2McMaster University; 3University of Western Ontario; 4University of Alberta; 5 University of British Columbia; 6Guelph General Hospital; 7Saint John Regional Hospital; and 8all other participating institutions, Canada. Purpose: We used a national GI bleed registry to track the adoption of new therapies such as intravenous PPI’s, combined endoscopic therapy, and clipping devices across different health care settings and geographic areas. Methods: A Registry of patients presenting with acute Upper Gastrointestinal Bleeding and undergoing Endoscopy (RUGBE) was initiated 12 months ago. Data were abstracted from the records of randomly selected patients at 17 institutions across Canada in varying care settings. The information was denominalized, entered electronically using a common endoscopic database, and downloaded into a central repository monthly following extensive data validation procedures. Pre-set clinical variables were recorded. Results: To date, 1042 procedures (median:55 per site) have been performed on 767 patients (37% females, mean age 66 ⫾ 17 years, mean: 1.4 procedures per patient). Both cardiac (44%) and respiratory (22%) comorbid conditions were frequent. Medication use included ASA (41%), NSAIDs (22%), warfarin (11%), and steroids (8%). COX-2 selective inhibitors comprised 39% of all NSAID use. The first endoscopy was carried out within 24 hours of the onset of symptoms in 34%. A second endoscopy was performed in 27% of patients (for follow-up or “second look” (51%), and continued or re-bleeding (31%)). Relevant endoscopic lesions were noted in the esophagus (24%), stomach (40%), and duodenum (35%) with multiple lesions noted in 6% of patients. Acid-related causes predominated (70%) (esophagitis (10%), duodenal ulcers (28%), and gastric ulcers (20%)). 32% of lesions required endoscopic therapy according to their description which was actually performed in 37% (injection (51%), thermal treatment (30%), a combination thereof (29%), ligating/clipping devices (9%)). The first dose of pharmacotherapy was given within 10.7 ⫾ 16.7 hrs of presentation and included an oral or intravenous PPI in 81%. Bleeding stopped spontaneously in 56%. The mean duration of hospital stay was 6.4 ⫾ 7.6 days (1.1 ICU days). A mean of 2 units of blood were transfused in 52% of patients. Surgery was needed in 3%. The overall mortality was 6.1%. Conclusions: These effectiveness data seem to indicate rapid, widespread acceptance of the use of proton pump inhibition in this patient population. Further analyses are required to determine the appropriateness of therapeutic approaches and any regional variations in the care provided.
834 NSAID gastropathy OTC self treatment Bernard S. Bloom, Ph.D.1, Walter L. Straus, M.D.2, and Joseph Thomas, Ph.D.3 1University of Pennsylvania, Department of Medicine, Philadelphia, PA; 2West Point, PA; 3West Lafayette, IN. Purpose: To estimate use of OTC NSAIDS, GI side effects, and professional and self-care for these side effects. Methods: Random telephone survey of age-stratified US national probability sample of OTC NSAID users and nonusers. Population was 535 English-speaking persons ⱖ 40 years old, who used an OTC NSAID for 4 of the previous 7 days, and a comparison population of 1,068 persons who reported no NSAID use within the previous 30 days. Telephone survey asked about current OTC NSAID use, GI symptoms and treatment, and prescription and OTC GI medications. Results: Most commonly used OTC NSAID was aspirin (alone or in combination compounds). Prevention (of MI or stroke) was most common reason for use (43.2%), followed by all forms of pain relief (44.2%) and
Abstracts
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relief of arthritis symptoms (24.5%). NSAID users were twice as likely as nonusers to report GI side effects (19.6% vs. 9.5%, p ⫽ 0.0001), including ulcer and bleeding, and more than twice as likely to use an OTC GI medication when they had GI symptoms (46.7% vs. 20.8%, p ⫽ 0.001). Conclusion: Low dose OTC NSAIDs were associated with a 2-fold increase in GI side effects, similar to prescription NSAIDs. Physicians may be unaware that patients self-medicate with OTC NSAIDs and GI medications and, therefore should routinely ask every patient about all self-treatment.
835 Outcome of flexible sigmoidoscopy performed by physician assistants: impact of family history and prior screening on findings and analysis of polyp detection and insertion depth as compared to physicians Thomas J Byrne, M.D.1 and Williamson B Strum, M.D.1* 1 Gastroenterology and Hepatology, Scripps Clinic, La Jolla, California, United States. Purpose: We sought to determine the outcome of screening flexible sigmoidoscopy (FS) performed by physician assistants (PAs) regarding 1) the impact of family history of colorectal cancer (CRC), 2) the impact of prior screening, and 3) the rate of neoplasia detection and depth of insertion as compared to gastroenterologists (GEs). Methods: We reviewed the findings and pertinent histories of all patients who underwent screening FS performed by PAs at our institution between 9/1/99 and 4/3/00. 3 PAs participated. Patients undergoing FS for reasons other than screening and those in whom screening was performed by non-PAs were excluded. A positive family history was defined as having one or more first degree relatives with CRC. We compared the findings to a similar cohort of patients who had screening FS performed previously by GEs. Results: 1,937 of 3,214 patients (60.3%) met full entry criteria. 53.6% were male. Mean age was 61.8 years. Polyps were found in 232 patients (12.0%) and advanced polyps, defined as ⱖ1 cm or containing villous or dysplastic features on pathology, were found in 76 (3.9%). No cancers were found. 144 patients had a positive family history. Polyps were detected in 10.4% of these and in 12.1% of other patients. Advanced polyps were found in 5.5% and 3.8% of patients with and without a positive family history, respectively. These differences were not statistically significant. 838 study patients had undergone FS ⱖ5 years previously, 209 patients had FS within 5 years and 890 had never undergone FS. Polyps were detected in 92/838 (11.0%), 24/209 (11.5%) and 116/890 (13.0%), respectively. Advanced polyps were found in 28/838 (3.3%), 4/209 (1.9%) and 44/890 (4.9%), respectively. None of these differences were statistically significant. Data from screening FS performed previously by GEs in a similar cohort of 3,611 patients were used to compare neoplasia detection and insertion depth between PAs and GEs. Polyps and advanced polyps were found by PAs in 12.0% and 3.9% of patients, respectively, compared to 9.1% and 2.6% by GEs. Mean insertion depth using identical patient preparation and equipment was 57cm in PAs and 53cm in GEs. One complication of diverticulitis, treated medically, occurred in the PA group. Conclusions: A positive family history of CRC as defined for this study is not associated with increased polyp detection on FS. Previous FS within 5 years does not preclude discovery of advanced neoplasia. PAs perform as well or better than GEs in detection of neoplasia and depth of insertion at FS.
836 Cost-effectiveness of empiric PPI therapy vs. test and treat in uninvestigated dyspepsia: impact of decreasing H. pylori prevalence and increasing non-H. pylori ulcers William D Chey, MD, FACG, Uri Ladabaum, MD, A Mark Fendrick, MD, FACG and James M Scheiman, MD, FACG*. 1Internal MedicineGI, University of Michigan Health System, Ann Arbor, MI, United States; 2Internal Medicine-GI, UCSF, San Francisco, CA, United States; 3 Internal Medicine-General Medicine, University of Michigan Health System, Ann Arbor, MI, United States; and 4Internal Medicine-GI, University of Michigan Health System, Ann Arbor, MI, United States.