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Proton Pump Inhibitors and the Risk of Clostridium difficile Associated Diarrhea: A Systematic Review and Meta-Analysis
Sa1040 The Association Between Colorectal Adenoma and Obesity: A Systematic Review and Meta-Analysis Using Full Colonoscopy Fumio Omata, Gautam A. Deshpande, Sachiko Ohde, Tetsuya Mine, Tsuguya Fukui
AGA Abstracts
BACKGROUND & AIMS: Colorectal adenoma is a precancerous lesion with several putative risk factors, some of which may be modifiable. Obesity has been reported to be one of these modifiable risk factors in some observational studies. However, this association remains controversial and study level meta-analyses are lacking. Recently, the proportion of studies involving full colonoscopy, rather than flexible sigmoidoscopy, as the diagnostic tool has been increasing and is critical to reduce information bias and accurately characterize this association. The aim of this study was to determine the quantitative pooled estimates of this association after full colonoscopic evaluation. METHODS: We performed a comprehensive literature review from 1966 to September 2009 using the following search term, “((BMI OR overweight OR obesity OR body mass index) AND (adenomatous polyps OR adenoma OR polyps) AND (colon OR colonic OR rectum OR colorectal OR colorectum OR colon rectum)) in EMBASE and this term plus “OR (“adenomatous polyps”[MeSH major topic] AND “epidemiologic studies”[MeSH terms])” in MDELINE. Three investigators selected target studies following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Inclusion criteria were full studies in English, those studies in which all subjects underwent full colonoscopy, body mass index (BMI) categorized using cut-off values of 22, 25 and 30, and the reporting of adjusted odds ratio (OR). We calculated pooled estimates using inverse-variance weighting. We used random effects model (REM) or fixed effects model (FEM) depending on heterogeneity evaluated by I2. Publication bias and small study effects were assessed by Egger's test. RESULTS: 118 full-text articles were reviewed after retrieving 1000 initial search results. Seven studies (case/non-case = 2200/10429) in which BMI was categorized into three groups by cut-off values of 25 and 30 and four studies (case/ non-case = 679/1659) in which BMI was categorized into three groups by cut-off values of 22 and 25 were selected. All selected studies were either cross-sectional or case-control studies. Pooled OR [95% CI] of BMI ≧ 25 and BMI ≧ 30 was 1.13 [0.93-1.37] (REM, I2= 46%) and 1.41 [1.12-1.77] (REM, I2=47%), respectively in the former seven studies. Pooled OR [95% CI] of BMI ≧ 22 and BMI ≧ 25 was 1.64 [0.98-2.76] (REM, I2=60%) and 1.92 [0.66-5.63] (REM, I2=89%), respectively in the latter four studies. Egger's test was only significant in meta-analysis of studies for BMI ≧ 30. CONCLUSIONS: Obesity, rather than overweight, is suggested as a significant risk factor for colorectal adenoma, although heterogeneity of this meta-analysis is not negligible. OR for colorectal adenoma increased as BMI increased. Additional well-designed observational studies and up-dated meta-analysis will further clarify this association. ns: non-significant CD: Crohn's disease UC: ulcerative colitis
Sa1041 Proton Pump Inhibitors and the Risk of Clostridium difficile Associated Diarrhea: A Systematic Review and Meta-Analysis Ashutosh Gupta, Bashar M. Attar, Rajender Agarwal
Sa1039 Current Use of Proton Pump Inhibitors is Associated With an Increased Risk of Osteoporotic Fractures: A Meta-Analysis Kelvin K. Tsoi, Siew C. Ng, Martin C. Wong, Hoyee W. Hirai, Thomas Lam, Francis K. L. Chan
BACKGROUND & AIMS: Clostridium difficile associated diarrhea (CDAD) is the most common cause of infectious diarrhea in healthcare settings and accounts for 20-30 % of antibiotic associated diarrhea. Due to their proven efficacy and documented safety the use of proton pump inhibitors (PPIs) has increased tremendously over the last decade. Given the rising incidence of CDAD, concerns have been raised about the association of acid suppression and CDAD. We performed a systematic review and meta-analysis to examine the potential association between PPIs and CDAD. METHODS: A search for controlled studies was conducted in MEDLINE and EMBASE using keywords and medical subject heading (MeSH) terms for PPIs and CDAD. Screening of titles and abstracts was followed by full text screening. We included all controlled trials examining the association between PPIs and CDAD. Data were extracted for the study population, details about PPI use and incidence of CDAD. Meta-analysis was performed using the random effect model. Q and I2 statistics were used to examine heterogeneity. Additionally, we used the Bradford Hill criteria to determine if the association was causal. RESULTS: Our literature search yielded a total of 620 articles and 26 articles were finally included for data extraction, of which 22 were used for the meta-analysis. We found a statistical significant association between PPI use and CDAD (pooled odds ratio 2.04; 95 % confidence interval 1.93-2.17). The Q and I2 statistics indicated significant heterogeneity. This association was also causal as it fulfilled all the criteria proposed by Bradford Hill. CONCLUSION: The current state of evidence suggests an association and potentially causal link between PPI use and CDAD. While PPI use, like antibiotic will remain an integral part of inpatient management, judicious use and even strict guidelines may be necessary to curb the epidemic of CDAD.
Background: The association between the use of proton pump inhibitors (PPIs) and the risk of osteoporotic fractures has been inconsistently presented in the existing literatures. Aim: We performed a meta-analysis to evaluate the association between PPI use and the risk of osteoporotic fractures. Methods: Full publications of cohort studies and case-control studies were identified in Ovid databases from 1950 to 2010. Two reviewers independently extracted the data. The reported relative risks (RR) of osteoporotic fractures were pooled by metaanalysis. Random-effects model was used to handle heterogeneous data. Outcome measures included the incidence of (i) hip fractures, (ii) spine fractures and (iii) overall fractures, amongst current PPI users and non-PPI users. Subgroup analyses on the patients received PPI over 1 year and over 3 years were performed. Results: Four cohort studies and 7 casecontrol studies that fulfilled search criteria were identified. Among 1,534,487 subjects (mean age 59.6 years; 62.9% female) recruited in these studies, 334,259 were current PPI-users and 1,200,228 were non-PPI users. Current use of PPI was associated with an increased risk of hip fractures (RR 1.16, 95% CI 1.07-1.27), spine fractures (RR 1.07, 95% CI 1.011.14), and overall fractures (RR 1.14, 95% CI 1.06-1.24) (Figure 1). The combined effects in the cohort studies (RR 1.21, 95% CI 1.12-1.32) were larger than that in case-control studies (RR: 1.10, 95% CI 0.99-1.24). In the subgroup analysis, the risks of overall fractures were increased among patients received longer duration of PPI (Current use of PPI over a year: RR: 1.15, 95% CI 1.01-1.31 and over three year: RR: 1.18, 95% CI 1.09-1.27). Conclusion: The current use of PPIs is associated with an increased risk of osteoporotic fractures. Further investigation on the causal relationship between PPI use and bone mineral density loss is required. The present data suggest that PPI therapy should be cautiously prescribed in patients with lower bone mineral density.
Forest plot showing the pooled Odds Ratio
AGA Abstracts
S-210
AGA Abstracts
BACKGROUND & AIMS: Colorectal adenoma is a precancerous lesion with several putative risk factors, some of which may be modifiable. Obesity has been reported to be one of these modifiable risk factors in some observational studies. However, this association remains controversial and study level meta-analyses are lacking. Recently, the proportion of studies involving full colonoscopy, rather than flexible sigmoidoscopy, as the diagnostic tool has been increasing and is critical to reduce information bias and accurately characterize this association. The aim of this study was to determine the quantitative pooled estimates of this association after full colonoscopic evaluation. METHODS: We performed a comprehensive literature review from 1966 to September 2009 using the following search term, “((BMI OR overweight OR obesity OR body mass index) AND (adenomatous polyps OR adenoma OR polyps) AND (colon OR colonic OR rectum OR colorectal OR colorectum OR colon rectum)) in EMBASE and this term plus “OR (“adenomatous polyps”[MeSH major topic] AND “epidemiologic studies”[MeSH terms])” in MDELINE. Three investigators selected target studies following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Inclusion criteria were full studies in English, those studies in which all subjects underwent full colonoscopy, body mass index (BMI) categorized using cut-off values of 22, 25 and 30, and the reporting of adjusted odds ratio (OR). We calculated pooled estimates using inverse-variance weighting. We used random effects model (REM) or fixed effects model (FEM) depending on heterogeneity evaluated by I2. Publication bias and small study effects were assessed by Egger's test. RESULTS: 118 full-text articles were reviewed after retrieving 1000 initial search results. Seven studies (case/non-case = 2200/10429) in which BMI was categorized into three groups by cut-off values of 25 and 30 and four studies (case/ non-case = 679/1659) in which BMI was categorized into three groups by cut-off values of 22 and 25 were selected. All selected studies were either cross-sectional or case-control studies. Pooled OR [95% CI] of BMI ≧ 25 and BMI ≧ 30 was 1.13 [0.93-1.37] (REM, I2= 46%) and 1.41 [1.12-1.77] (REM, I2=47%), respectively in the former seven studies. Pooled OR [95% CI] of BMI ≧ 22 and BMI ≧ 25 was 1.64 [0.98-2.76] (REM, I2=60%) and 1.92 [0.66-5.63] (REM, I2=89%), respectively in the latter four studies. Egger's test was only significant in meta-analysis of studies for BMI ≧ 30. CONCLUSIONS: Obesity, rather than overweight, is suggested as a significant risk factor for colorectal adenoma, although heterogeneity of this meta-analysis is not negligible. OR for colorectal adenoma increased as BMI increased. Additional well-designed observational studies and up-dated meta-analysis will further clarify this association. ns: non-significant CD: Crohn's disease UC: ulcerative colitis
Sa1041 Proton Pump Inhibitors and the Risk of Clostridium difficile Associated Diarrhea: A Systematic Review and Meta-Analysis Ashutosh Gupta, Bashar M. Attar, Rajender Agarwal
Sa1039 Current Use of Proton Pump Inhibitors is Associated With an Increased Risk of Osteoporotic Fractures: A Meta-Analysis Kelvin K. Tsoi, Siew C. Ng, Martin C. Wong, Hoyee W. Hirai, Thomas Lam, Francis K. L. Chan
BACKGROUND & AIMS: Clostridium difficile associated diarrhea (CDAD) is the most common cause of infectious diarrhea in healthcare settings and accounts for 20-30 % of antibiotic associated diarrhea. Due to their proven efficacy and documented safety the use of proton pump inhibitors (PPIs) has increased tremendously over the last decade. Given the rising incidence of CDAD, concerns have been raised about the association of acid suppression and CDAD. We performed a systematic review and meta-analysis to examine the potential association between PPIs and CDAD. METHODS: A search for controlled studies was conducted in MEDLINE and EMBASE using keywords and medical subject heading (MeSH) terms for PPIs and CDAD. Screening of titles and abstracts was followed by full text screening. We included all controlled trials examining the association between PPIs and CDAD. Data were extracted for the study population, details about PPI use and incidence of CDAD. Meta-analysis was performed using the random effect model. Q and I2 statistics were used to examine heterogeneity. Additionally, we used the Bradford Hill criteria to determine if the association was causal. RESULTS: Our literature search yielded a total of 620 articles and 26 articles were finally included for data extraction, of which 22 were used for the meta-analysis. We found a statistical significant association between PPI use and CDAD (pooled odds ratio 2.04; 95 % confidence interval 1.93-2.17). The Q and I2 statistics indicated significant heterogeneity. This association was also causal as it fulfilled all the criteria proposed by Bradford Hill. CONCLUSION: The current state of evidence suggests an association and potentially causal link between PPI use and CDAD. While PPI use, like antibiotic will remain an integral part of inpatient management, judicious use and even strict guidelines may be necessary to curb the epidemic of CDAD.
Background: The association between the use of proton pump inhibitors (PPIs) and the risk of osteoporotic fractures has been inconsistently presented in the existing literatures. Aim: We performed a meta-analysis to evaluate the association between PPI use and the risk of osteoporotic fractures. Methods: Full publications of cohort studies and case-control studies were identified in Ovid databases from 1950 to 2010. Two reviewers independently extracted the data. The reported relative risks (RR) of osteoporotic fractures were pooled by metaanalysis. Random-effects model was used to handle heterogeneous data. Outcome measures included the incidence of (i) hip fractures, (ii) spine fractures and (iii) overall fractures, amongst current PPI users and non-PPI users. Subgroup analyses on the patients received PPI over 1 year and over 3 years were performed. Results: Four cohort studies and 7 casecontrol studies that fulfilled search criteria were identified. Among 1,534,487 subjects (mean age 59.6 years; 62.9% female) recruited in these studies, 334,259 were current PPI-users and 1,200,228 were non-PPI users. Current use of PPI was associated with an increased risk of hip fractures (RR 1.16, 95% CI 1.07-1.27), spine fractures (RR 1.07, 95% CI 1.011.14), and overall fractures (RR 1.14, 95% CI 1.06-1.24) (Figure 1). The combined effects in the cohort studies (RR 1.21, 95% CI 1.12-1.32) were larger than that in case-control studies (RR: 1.10, 95% CI 0.99-1.24). In the subgroup analysis, the risks of overall fractures were increased among patients received longer duration of PPI (Current use of PPI over a year: RR: 1.15, 95% CI 1.01-1.31 and over three year: RR: 1.18, 95% CI 1.09-1.27). Conclusion: The current use of PPIs is associated with an increased risk of osteoporotic fractures. Further investigation on the causal relationship between PPI use and bone mineral density loss is required. The present data suggest that PPI therapy should be cautiously prescribed in patients with lower bone mineral density.
Forest plot showing the pooled Odds Ratio
AGA Abstracts
S-210