Reconsidering Benzodiazepines and Z-Drug Prescriptions: Responsible Prescribing and Deprescribing

Benzodiazepines and sedative-hypnotic (Z-drugs), collectively termed hypnotic drugs, bind to γ-aminobutyric acid receptors, the primary inhibitory neurotransmitters in the brain. Hypnotic drugs are among the most prescribed medications worldwide, with primary care providers leading this prescribing trend, primarily for the management of insomnia and anxiety. There is no evidence to support the use of long-term hypnotics, and evidence regarding the risks associated with long-term use of hypnotics is growing. However, it is not too late to reverse this hazardous prescribing trend and incorporate responsible hypnotic prescribing and describing practices     

Endoscopic Submucosal Dissection in the Era of Proton Pump Inhibitors

Endoscopic submucosal dissection (ESD) has the advantage over endoscopic mucosa resection, permitting removal of gastrointestinal neoplasms en bloc, but is associated with relatively high risk of complications. Indications for early gastric cancer (EGC) are expanded: mucosal cancer without ulcer findings irrespective of tumor size; mucosal cancer with ulcer findings ≤3 cm in diameter; and minute submucosal invasive cancer ≤3 cm in size. The indications for early esophageal cancer (EEC) are the tumors confined to the two-third layer of the lamina propria. The EEC lesions spreading more than three-quarter of circumference of the esophagus are at frequent risk of stenosis. The procedures include marking, submucosal injection, circumferential mucosal incision and exforiation of the lesion along the submucosal layer. Complete ESD can achieve a large one-piece resection, allowing precise histological assessment to prevent recurrence. Clinical outcomes of gastric and esophageal ESD have been promising, and the prognosis of EGC patients treated by ESD is likely to be excellent, though further longer follow-up studies are warranted. Notification of perforation risk is essential in particular for esophageal ESD. Bleeding during ESD can be managed with coagulation forceps, and postoperative bleeding may be reduced with routine use of the stronger acid suppressant, proton pump inhibitors.     

The Effects of Concomitant Use of Proton Pump Inhibitors on Iron Supplements

Iron-deficiency anemia is a growing concern and administration of oral iron may be affected by proton pump inhibitors. This drug interaction is common and often overlooked. Iron absorption requires an acidic environment that may be lowered by concomitant use of proton pump inhibitors. Administration of acidic agents, such as vitamin C or orange juice, along with oral iron, may help improve absorption, avoid the use of acid suppression medications, or provide more oral iron availability in those with iron-deficiency anemia. Nurse practitioners are primary health care providers who can help recognize this common drug interaction and help to improve patient care.     

Proton Pump Inhibitors: Review of Emerging Concerns

First introduced in 1989, proton pump inhibitors (PPIs) are among the most widely utilized medications worldwide, both in the ambulatory and inpatient clinical settings. The PPIs are currently approved by the US Food and Drug Administration for the management of a variety of gastrointestinal disorders including symptomatic peptic ulcer disease, gastroesophageal reflux disease, and nonulcer dyspepsia as well as for prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy. PPIs inhibit gastric acid secretion, and the most commonly associated adverse effects include abdominal pain, diarrhea, and headache. Although PPIs have had an encouraging safety profile, recent studies regarding the long-term use of PPI medications have noted potential adverse effects, including risk of fractures, pneumonia, Clostridium difficile diarrhea, hypomagnesemia, vitamin B₁₂ deficiency, chronic kidney disease, and dementia. These emerging data have led to subsequent investigations to assess these potential risks in patients receiving long-term PPI therapy. However, most of the published evidence is inadequate to establish a definite association between PPI use and the risk for development of serious adverse effects. Hence, when clinically indicated, PPIs can be prescribed at the lowest effective dose for symptom control.     

2011—2013年北京某三甲综合性医院住院患者质子泵抑制剂应用分析

目的分析北京某三甲综合性医院2011—2013年住院患者质子泵抑制剂(proton pump inhibitor,PPI)的应用情况。方法对该院3年间住院患者应用PPI的品种、消耗金额、用药频度(DDDs)、日均费用(DDDc)等情况进行统计和分析。结果该院2011—2013年住院患者PPI全年总消耗金额呈增长趋势,且占年药品消耗金额比例逐年增加,由2011年的1.81%增长至2013年的2.31%,其中奥美拉唑的消耗金额始终排在前列,但年增长率有所下降。3年间埃索美拉唑口服剂使用频度较高,注射用奥美拉唑DDDs排序上升幅度较大,泮托拉唑、雷贝拉唑口服剂DDDs排序不断下降。以奥美拉唑和埃索美拉唑口服剂序号比值1的情况最为突出,大多数PPI的DDDc逐年下降。外科PPI使用率逐年升高。结论胃酸分泌相关性消化系统疾病发病率呈上升趋势,第一代PPI在临床用药中仍占主要地位,但是已有被第二代取代的趋势。该院PPI临床用药基本合理,但在外科应用中尚需进一步加强规范使用适应证。     

质子泵抑制剂和重症患者的医院获得性肺炎之间的关系

目的研究质子泵抑制剂（PPI）是否为危重患者发生医院获得性肺炎的危险因素。方法收集2002年6月-2009年6月收治的198例重症患者资料,分为使用PPI组（96例）和未使用PPI组（102例）。采用logistic回归分析PPI使用情况和医院获得性肺炎的关系。结果使用PPI组肺炎的发生率较高（26.9%）,尤其是PPI使用时间超过7d者（37.5%）。在不同的多变量logistic回归模型中,分别用APACHEⅡ评分和入住重症监护室原因校正后,使用PPI以及使用天数均是医院获得性肺炎发生的危险因素（P=0.031,OR=2.230,95%CI：1.957～2.947;P=0.002,OR=1.824,95%CI：1.457～2.242）。结论长时间应用PPI可能是增加ICU患者发生医院获得性肺炎的一种风险因素。     

质子泵抑制剂在反流性食管炎维持治疗中的效果

目的研究质子泵抑制剂在反流性食管炎维持治疗的临床疗效。方法将2009年3月12月门诊及住院的121例反流性食管炎并胃镜证实病灶已愈合,且停药1周内症状又复发者,随机分为A、B、C3组,3组均选用兰索拉唑。A组为兰索拉唑15mg,1次/d,早餐前服;B组为兰索拉唑15mg,1次/d,晚餐前服;C组兰索拉唑15mg,2次/d,餐前服。3组疗程均为4周。疗程结束后进行临床症状疗效评定,并予复查胃镜,评价3组胃镜下总有效率,并观察3组不良反应。结果三种方案有效率分别为77.5%、95.0%、92.7%。结论晚餐前15mg1次/d的兰索拉唑为反流性食管炎较佳维持治疗方案。     

Prescribing Practices Amid the OxyContin Crisis: Examining the Effect of Print Media Coverage on Opioid Prescribing Among Physicians

The pain medication OxyContin (hereafter referred to as oxycodone extended release) has been the subject of sustained, and largely negative, media attention in recent years. We sought to determine whether media coverage of oxycodone extended release in North American newspapers has led to changes in prescribing of the drug in Nova Scotia, Canada. An interrupted time-series design examined the effect of media attention on physicians' monthly prescribing of opioids. The outcome measures were, for each physician, the monthly proportions of all opioids prescribed and the proportion of strong opioids prescribed that were for oxycodone extended release. The exposure of interest was media attention defined as the number of articles published each month in 27 North American newspapers. Variations in media effects by provider characteristics (specialty, prescribing volume, and region) were assessed. Within-provider changes in the prescribing of oxycodone extended release in Nova Scotia were observed, and they followed changes in media coverage. Oxycodone extended release prescribing rose steadily prior to receiving media attention. Following peak media attention in the United States, the prescribing of oxycodone extended release slowed. Likewise, following peak coverage in Canadian newspapers, the prescribing of oxycodone extended release declined. These patterns were observed across prescriber specialties and by prescriber volume, though the magnitude of change in prescribing varied.     

Changes in 12-Year First-Line Eradication Rate of Helicobacter pylori Based on Triple Therapy with Proton Pump Inhibitor,Amoxicillin and Clarithromycin

A triple therapy based on a proton pump inhibitor (PPI), amoxicillin (AMPC), and clarithromycin (CAM) is recommended as a first-line therapy for Helicobacter pylori (H. pylori) eradication and is widely used in Japan. However, a decline in eradication rate associated with an increase in prevalence of CAM resistance is viewed as a problem. We investigated CAM resistance and eradication rates over time retrospectively in 750 patients who had undergone the triple therapy as first-line eradication therapy at Nagoya City University Hospital from 1995 to 2008, divided into four terms (Term 1: 1997–2000, Term 2: 2001–2003, Term 3: 2004–2006, Term 4: 2007–2008). Primary resistance to CAM rose significantly over time from 8.7% to 23.5%, 26.7% and 34.5% while the eradication rate decreased significantly from 90.6% to 80.2%, 76.0% and 74.8%. Based on the PPI type, significant declines in eradication rates were observed with omeprazole or lansoprazole, but not with rabeprazole. A decrease in the H. pylori eradication rate after triple therapy using a PPI + AMPC + CAM has been acknowledged, and an increase in CAM resistance is considered to be a factor. From now on, a first-line eradication regimen that results in a higher eradication rate ought to be investigated.     

Proton Pump Inhibitors and the Risk for Hospital-Acquired Clostridium difficile Infection

ObjectiveTo examine the relationship between proton pump inhibitor (PPI) usage and nosocomial Clostridium difficile infection (CDI) and determine the duration of therapy at which CDI risk increases.Patients and MethodsThis retrospective case-control study included consecutive adult patients in whom nosocomial CDI developed after hospitalization for 3 or more days at one of 2 affiliated hospitals between June 1, 2010, and October 31, 2011. These patients were matched to patients hospitalized within 6 months who did not have CDI development in a 1:2 ratio using age, sex, and antibiotic usage. Potential risk factors for CDI, including PPI use and duration, were evaluated. Multivariate analysis was performed to control for confounding variables and identify risk factors.ResultsA total of 201 patients were evaluated, 67 with CDI and 134 matched controls. Patients in whom CDI developed were more likely to have received a PPI (76% vs 39%; P<.001) and had a longer duration of PPI therapy (median [range], 5 [0-20] days vs 0 [0-11] days; P<.001) than those who did not have CDI development. After controlling for prior hospital admission, intensive care unit admission, admission from a skilled nursing facility, immunosuppression, number of antibiotics received, PPI duration, and time to event via multivariate analysis, PPI duration was found to be a risk factor for CDI (odds ratio, 1.14; 95% CI, 1.02-1.27; P=.018). The probability for CDI was higher when PPI use exceeded 2 days in patients without a prior hospital admission and 1 day in patients with a prior admission.ConclusionThe duration of PPI therapy is significantly associated with CDI. Clinicians should strongly consider restricting PPI use given the short exposure time associated with this increased risk.     

碳酸氢盐血液透析副反应的观察分析

碳酸氢盐透析液是临床上应用最广泛的一种透析液,因其副反应较少,目前已取代醋酸盐透析液,但对碳酸氢盐透析液的副反应文献报道并不一致。我科2004年改为碳酸氢盐透析液,对其副反应进行了观察,现总结报告如下。     

纳洛酮治疗双硫醒反应的临床观察及护理

目的 探讨纳洛酮对双硫醒反应的治疗效果.方法 将48例双硫醒反应伴低血压患者随机分为治疗组(NLX)26例,对照组22例.两组均给予吸氧、静脉输液、补充能量、止吐等常规治疗,NLX组在常规治疗基础上静注纳洛酮.结果 NLX组早期BP、HR、R 等基本生命体征恢复明显优于对照组(P＜0.01),48h后心肌酶的升高明显低于对照组(P＜0.01).结论 纳洛酮可作为特效药用于双硫醒反应伴低血压患者,并有显著保护心肌作用.     

氯吡格雷与质子泵抑制剂联用治疗冠心病安全性的系统评价

目的 对冠心病患者单用氯吡格雷和联合使用氯吡格雷质子泵抑制剂(PPI)的安全性(心血管事件、死亡或胃肠道出血等)进行系统评价.方法 计算机检索Cochrane图书馆、PubMed,EMbase,SSCI,VIP,CNKI及CBM数据库,检索时间均从建库至2010年9月,并追踪已获文献的参考文献:,由2名研究者独立进行质...     

Successful Thrombolysis of Right Atrial and Ventricle Thrombi Encircling a Temporary Pacemaker Lead in a Patient with Heparin-Induced Thrombocytopenia Type II

Only few reports exist addressing the problem of temporary pacemaker leads associated with thromboembolic disease. We report the case of a 67-year-old patient who required a temporary transfemoral pacemaker due to AV block grade III. The patient developed extensive right atrial and ventricle thrombus formation attached to the pacing wire, as well as venous thrombosis at the insertion site due to heparin-induced thrombocytopenia type II (HIT type II). After short-term thrombolysis with 1 mg rt-PA/kg b.w. complete resolution of all clots could be shown by B-mode sonography and transthoracic, as well as transesophageal echocardiography.     

Association of Proton Pump Inhibitors With Higher Risk of Cardiovascular Disease and Heart Failure

ObjectiveTo examine associations of cumulative exposure to proton pump inhibitors (PPIs) with total cardiovascular disease (CVD; composed of stroke, coronary heart disease, and heart failure [HF]) and HF alone in a cohort study of White and African American participants of the Atherosclerosis Risk in Communities (ARIC) study.MethodsUse of PPIs was assessed by pill bottle inspection at visit 1 (January 1, 1987 to 1989) and up to 10 additional times before baseline (visit 5; 2011 to 2013). We calculated cumulative exposure to PPIs as days of use from visit 1 to baseline. Participants (n=4346 free of total CVD at visit 5; mean age, 75 years) were observed for incident total CVD and HF events through December 31, 2016. We used Cox regression to measure associations of PPIs with total CVD and HF.ResultsAfter adjustment for potential confounding variables, participants with a cumulative exposure to PPIs of more than 5.1 years had a 2.02-fold higher risk of total CVD (95% CI, 1.50 to 2.72) and a 2.21-fold higher risk of HF (95% CI, 1.51 to 3.23) than nonusers.ConclusionLong-term PPI use was associated with twice the risk of total CVD and HF compared with nonusers. Our findings are in concordance with other research and suggest another reason to be cautious of PPI overuse.