Faculty Peer Reviewed
As Thanksgiving fast approaches and you enjoy the last stretch of fall weather, Primecuts is here to offer you the latest medical news making headlines.
Proton pump inhibitor (PPI) use in patients on anti-platelet therapy is again in the news. A new joint document released by the American College of Gastroenterology (ACG), American Heart Association (AHA) and the American College of Cardiology Foundation (ACCF) supports the use of PPIs in patients at risk for upper gastrointestinal (GI) bleeding who are on thienopyridines (e.g. clopidogrel). Since the release of a similar consensus document in 2008, several studies have raised concerns about potential interactions between the two classes of drugs and have prompted debate about optimal prescribing strategies in patients on anti-platelet therapy who are at risk for GI bleeding.  There is a theoretical concern that concomitant use of PPIs and clopidogrel may increase the risk of cardiovascular events through competitive inhibition of activation of clopidogrel by the enzyme CYP2C19, a member of the cytochrome P-450 system. Last month Primecuts featured the results of the COGENT Trial, a randomized study published in the New England Journal of Medicine that found significantly decreased upper gastrointestinal events and no difference in cardiovascular endpoints in patients taking a clopidogrel/omeprazole combination pill compared to clopidogrel alone. The authors of the latest consensus document admit combined use of PPIs and anti-platelet drugs must be individualized. However, they do outline recommendations to guide clinicians, including PPI use to decrease the risk of bleeding in patients with a history of GI bleeding or multiple risk factors for GI bleeding (H. pylori infection, advanced age, use of anticoagulants, and history of peptic ulcer disease). They also recommend against routine use in low-risk patients. Down the road, pharmacogenomic and platelet function testing could identify patients at higher risk for PPI and anti-platelet drug interactions and prove invaluable in deciding appropriate treatment in high-risk individuals.
Also making headlines this week is a Cochrane Review that shows probiotics may shorten the duration of symptoms associated with acute infectious diarrhea. The authors reviewed data from 63 randomized and quasi-randomized studies that compared probiotic agents to placebo or no probiotic in people suffering from acute diarrhea presumed or proven to be caused by an infectious agent. The average effect was a significant decrease in the duration of diarrheal symptoms (mean difference 24.76 hours; CI 15.9-33.6 hours) and diarrhea lasting greater than four days (risk ratio 0.41; CI 0.32-0.53). There were no adverse effects attributed to probiotic use. While considerable differences in probiotic regimens, study design, and patient characteristics are all limitations of the review, the study suggests probiotic regimens may be used as an adjuvant to rehydration therapy to shorten the duration of symptoms in patients with acute infectious diarrhea. Clearly, further studies evaluating probiotic regimens in specific patient populations are needed.
Finally, a new study may give people another reason to stay away from sugar-sweetened beverages. This week the Journal of the American Medical Association published data from the Nurses’ Health Study that shows fructose-rich beverages are associated with an increased risk of gout in women. The large prospective study used survey data from 78,000 women over 22 years of follow-up and identified cases of gout based on the American College of Rheumatology gout survey criteria (the primary endpoint was met if ≥ 6 out of 11 criteria were present). Compared to those who consumed < 1 serving of sugar-sweetened soda per month, women who drank one serving of soda per day had a significant increase in incident gout (relative risk 1.74, 95% CI 1.19-2.55) and an even higher risk if they drank ≥ 2 servings per day (relative risk 2.4, 95% CI 1.34-4.26). These associations were independent of risk factors for gout including age, diuretic use, and intake of dairy, meat and seafood. There was no increase in gout in women who drank diet soda. An earlier study had shown a similar increased risk of gout in men who consumed 5-6 servings of sugar-sweetened soft drinks per week compared to those who drank less than one serving per month. While there is a low incidence rate of gout in women, these studies may give people another reason to forgo the empty calories of sugary sweet soda.
Dr. Hormozdi is a 2nd-year internal medicine resident at NYU Langone Medical Center
Danise Schiliro is a contributing editor, Clinical Correlations.
1. Abraham S, Neena, Hlatky A, Mark, Antman M, Elliot, et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. J Am Coll Cardiol. doi:10.1016/j.jacc.2010.09.010 (Published online 8 November 2010). http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.09.010
2. Bhatt L, Deepak, Scheiman, James, Abraham S, Neena, et al. ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. J Am Coll Cardiol, 2008; 52:1502-1517. http://content.onlinejacc.org/cgi/content/full/52/18/1502?ijkey=16b2b3422ae0d889e470c517172c7ab5889bb413&keytype2=tf_ipsecsha – SEC7
3. Tzimas, Demetrios. Primecuts. October 18, 2010. http://www.clinicalcorrelations.org/?p=3309
4. Allen SJ, Martinez EG, Gregorio GV, et al. Probiotics for treating acute infectious diarrhea. Cochrane Database Syst Rev. 2010 Nov 10;11:CD003048. http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD003048/frame.html
5. Choi K, Hyon, Willet Walter, Curhan, Gary. Fructose-Rich Beverages and Risk of Gout in Women. JAMA. Published online November 10, 2010. doi:10.1001/jama.2010.1638. http://jama.ama-assn.org/cgi/content/full/jama.2010.1638
6. Choi HK, Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ. 2008;336(7639):309-312. http://www.bmj.com/content/336/7639/309.abstract?ijkey=c2d788cf6be09b9f693ff5fdfac10cc33207dc30&keytype2=tf_ipsecsha