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Management of patients with ulcer bleeding

Authors Laine L , Jensen DM
Journal The American journal of gastroenterology
Year 2012
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This guideline presents recommendations for the step-wise management of patients with overt upper gastrointestinal bleeding. Hemodynamic status is first assessed, and resuscitation initiated as needed. Patients are risk-stratified based on features such as hemodynamic status, comorbidities, age, and laboratory tests. Pre-endoscopic erythromycin is considered to increase diagnostic yield at first endoscopy. Pre-endoscopic proton pump inhibitor (PPI) may be considered to decrease the need for endoscopic therapy but does not improve clinical outcomes. Upper endoscopy is generally performed within 24h. The endoscopic features of ulcers direct further management. Patients with active bleeding or non-bleeding visible vessels receive endoscopic therapy (e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) and those with an adherent clot may receive endoscopic therapy; these patients then receive intravenous PPI with a bolus followed by continuous infusion. Patients with flat spots or clean-based ulcers do not require endoscopic therapy or intensive PPI therapy. Recurrent bleeding after endoscopic therapy is treated with a second endoscopic treatment; if bleeding persists or recurs, treatment with surgery or interventional radiology is undertaken. Prevention of recurrent bleeding is based on the etiology of the bleeding ulcer. H. pylori is eradicated and after cure is documented anti-ulcer therapy is generally not given. Nonsteroidal anti-inflammatory drugs (NSAIDs) are stopped; if they must be resumed low-dose COX-2-selective NSAID plus PPI is used. Patients with established cardiovascular disease who require aspirin should start PPI and generally re-institute aspirin soon after bleeding ceases (within 7 days and ideally 1-3 days). Patients with idiopathic ulcers receive long-term anti-ulcer therapy. © 2012 by the American College of Gastroenterology.

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Analgesics for Osteoarthritis: An Update of the 2006 Comparative Effectiveness Review

Book AHRQ Comparative Effectiveness Reviews
Year 2011
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OBJECTIVES: To update a previous report on the comparative benefits and harms of oral non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, over-the-counter supplements (chondroitin and glucosamine), and topical agents (NSAIDs and rubefacients, including capsaicin) for osteoarthritis. DATA SOURCES: Ovid MEDLINE (1996–January 2011), the Cochrane Database (through fourth quarter 2010), and reference lists. REVIEW METHODS: We included randomized trials, cohort studies, case-control studies, and systematic reviews that met predefined inclusion criteria. For each study, investigators abstracted details about the study population, study design, data analysis, followup, and results, and they assessed quality using predefined criteria. We assessed the overall strength of each body of evidence using predefined criteria, which included the type and number of studies; risk of bias; consistency; and precision of estimates. Meta-analyses were not performed, though pooled estimates from previously published studies were reported. RESULTS: A total of 273 studies were included. Overall, we found no clear differences in efficacy for pain relief associated with different NSAIDs. Celecoxib was associated with a lower risk of ulcer complications (RR 0.23, 95% CI 0.07 to 0.76) compared to nonselective NSAIDs. Coprescribing of proton pump inhibitors, misoprostol, and H2-antagonists reduce the risk of endoscopically detected gastroduodenal ulcers compared to placebo in persons prescribed NSAIDs. Celecoxib and most nonselective, nonaspirin NSAIDs appeared to be associated with an increased risk of serious cardiovascular (CV) harms. There was no clear association between longer duration of NSAID use or higher doses and increased risk of serious CV harms. There were no clear differences between glucosamine or chondroitin and oral NSAIDs for pain or function, though evidence from a systematic review of higher-quality trials suggests that glucosamine had some very small benefits over placebo for pain. Head-to-head trials showed no difference between topical and oral NSAIDs for efficacy in patients with localized osteoarthritis, lower risk of gastrointestinal (GI) adverse events, and higher risk of dermatological adverse events, but serious GI and CV harms were not evaluated. No head-to-head trials compared topical salicylates or capsaicin to oral NSAIDs. CONCLUSIONS: Each of the analgesics evaluated in this report was associated with a unique set of risks and benefits. Choosing the optimal analgesic for an individual with osteoarthritis requires careful consideration and thorough discussion of the relevant tradeoffs.