Current gastroenterology reports
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Curr Gastroenterol Rep · Jun 2013
ReviewProton pump inhibitors and potential interactions with clopidogrel: an update.
Clopidogrel, an antiplatelet agent, is increasingly prescribed for patients with recent stroke, myocardial infarction, acute coronary syndrome, and/or patients post-coronary stent insertion to prevent recurrent cardiovascular events. Since clopidogrel can increase the risk of gastrointestinal hemorrhage, co-administration of proton pump inhibitors (PPIs) has been recommended, particularly in patients at high risk. In 2009, the FDA issued warnings about potential interactions between clopidogrel and PPIs, given the fact that both drugs are metabolized via the cytochrome P450 pathway. ⋯ More importantly, the newer data demonstrated that PPI usage independently was a risk factor for adverse CV outcomes, since most PPI users were older patients who were more likely to have concomitant co-morbid conditions. Two updated reviews also concluded that the presence of confounding factors likely explained differences in results between studies, and that there were no significant differences in effects on clopidogrel between individual proton pump inhibitors. Overall, clinicians can assure their patients that combination therapy is safe when indicated in a patient at high risk of GI bleeding, but they should also stop PPI therapy if it is not clinically indicated.
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In recent years, many new agents have been evaluated for the treatment of inflammatory bowel disease. In this paper, we critically review recently published literature about these novel therapies, which have been the result of extensive research identifying molecular targets. ⋯ We discuss a number of them with specific focus on vedolizumab, a monoclonal antibody directed against the alpha4beta7 integrin on lymphocytes, ustekinumab, a monoclonal antibody against the p40 subunit of interleukin-12 and interleukin-23, and tofacitinib, a small molecule targeting Janus-activated kinase. Most likely, these three agents will find their way to the market and offer significant therapeutic alternatives for the management of Crohn's disease and/or ulcerative colitis.
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The colonic ecosystem differs from that in the proximal gut in several important respects. The colonic microbiota represents the largest population of microbes colonizing humans from birth. Constraints on bacterial numbers, composition, and interaction with the host involve not only the innate and acquired immune system, but also the colonic mucin structure. ⋯ In some instances, these findings have the potential to serve as new biomarkers of risk of disease. In this overview, recent advances are focused upon in relation to irritable bowel syndrome, inflammatory bowel disease, and colon cancer. The possibility that the therapeutic solution to some of these disorders may reside within the microbiota will also be addressed.
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A long-term follow-up of the landmark National Polyp Study recently showed that colonoscopy was associated with critical clinical benefit, including reduced overall death rate, colorectal cancer (CRC) death rate, and CRC incidence Zauber et al. (N Engl J Med 366(8):687-96, 2012). This and other recent studies emphasize the need for high-quality colonoscopy to realize maximal benefit. Adenoma detection has emerged as an important predictor of quality colonoscopy. ⋯ The specific methods associated with higher quality colonoscopy include careful inspection behind folds, washing the colon surface, adequate insufflation, and recognition of subtle flat polyps. Use of high-definition white light colonoscopy, chromoendoscopy, and cap-fitted colonoscopy has also been studied as potential methods for increasing adenoma detection. We will review these methods and techniques in this article.
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Curr Gastroenterol Rep · Aug 2012
ReviewWhen is irritable bowel syndrome not irritable bowel syndrome? Diagnosis and treatment of chronic functional abdominal pain.
Functional abdominal pain syndrome (FAPS) is a distinct chronic gastrointestinal (GI) pain disorder characterized by the presence of constant or frequently recurring abdominal pain that is not associated with eating, change in bowel habits, or menstrual periods. The pain experience in FAPS is predominantly centrally driven as compared to other chronic painful GI conditions such as inflammatory bowel disease and chronic pancreatitis where peripherally acting factors play a major role in driving the pain. ⋯ Treatment options are limited at best with most therapeutic regimens extrapolated from pain management of other functional GI disorders and chronic pain conditions. A comprehensive approach to management using a biopsychosocial construct and collaboration with pain specialists and psychiatry is most beneficial to the management of this disorder.