Prednisone and upper gi bleed. Short 'Bursts' of Oral Corticosteroids Are Associated With GI Bleeds, Other Adverse Events
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Prednisone and upper gi bleed.Corticosteroids and risk of gastrointestinal bleeding: a systematic review and meta-analysis
Prednisone and upper gi bleed.
It's a trade-off we are willing to make if the benefit is large enough and occurs often enough. Wallace and Waljee note that corticosteroids prescribed for acute flares of a chronic inflammatory conditions may fend off disability and maintain people's quality of life. Yao and his co-authors make similar points and call for prospective studies or clinical trials to determine the optimal use of corticosteroids by monitoring adverse events.
July 7, Peter Wehrwein. One must keep in mind that even though the overall incidence of GI bleeding appears small at 2. These findings should not only caution the clinician when considering steroids after SCI but also alert them to aggressively treat GI bleeds in cervical spine injured patients given the high demonstrated mortality rate. This association is particularly significant in patients with complete cervical spinal cord injuries and we recommend prompt diagnosis and treatment of any alimentary bleeding to avoid significant mortality in this population.
Increased susceptibility of patients with cervical cord lesions to peptic gastrointestinal complications. J Trauma ; 25 : — Gastrointestinal complications of spinal cord injury. Spine ; 6 : — Gastrointestinal bleeding in patients with acute spinal injuries. Injury ; 14 : — Article Google Scholar. Diagnosis of acute abdominal injuries in patients with spinal shock: Value of diagnostic peritoneal lavage.
J Trauma ; 20 : 55— Medicolegal aspects of post-traumatic gastroduodenal ulcers: a retrospective study. J Forensic Sci ; 54 : — The complications of high-dose corticosteroid therapy in neurosurgical patients: a prospective study. Ann Neurol ; 1 : — The incidence of peptic ulcer among patients on long term prednisone therapy. Gastroenterology ; 35 : — Double-blind study of the effects of dexamethasone on acute stroke. Neurology ; 22 : — Nonassociation of adrenocorticosteroid therapy and peptic ulcer.
N Engl J Med ; : — Adrenal glucocorticoids after 20 years: a review of the clinically relevant consequences. J Chron Dis ; 22 : — Gastrointestinal bleeding following head injury: a clinical study of cases.
J Trauma ; 17 : 44— New Engl J Med ; : — Gastrointestinal bleeding in patients with spinal cord trauma: Effects of steroids, cimetidine, and mini-dose heparin.
J Neurosurg ; 54 : 16— Gastrointestinal complications in spinal cord injury. Spine ; 16 : S—S Abdominal problems in patients with spinal cord lesions. Arch Phys Med Rehabil ; 56 : — CAS Google Scholar. The significance of hormonal factors in the pathogenesis of peptic ulcer. Gastroenterology ; 25 : One suggested a small but significant dose-dependent increased risk of peptic ulcers in the groups treated with steroids 18 , and another failed to find a difference between the steroid and placebo groups Regarding observational data, we found 11 previously published epidemiologic studies that included odds ratio estimates of serious upper gastrointestinal events associated with the use of steroids 4 — Results from individual studies were heterogeneous and often based on small numbers.
The pooled odds ratio estimate was 1. The risk of upper gastrointestinal complications has been shown to be higher when steroids are administered concomitantly with NSAIDs: Piper et al. It has been suggested that steroids may delay the healing of underlying erosive lesions caused by other factors such as NSAIDs, rather than causing ulcer de novo 4 , Potential limitations of all studies using computerized prescription data are the underascertainment of drugs obtained from other sources e.
However, it is probable that such misclassification expected to be small, because steroids are rarely purchased over-the-counter would be nondifferential, thus resulting in conservative odds ratio estimates. Because steroids are often indicated for patients with certain diseases, illness itself, and not the drugs, might be elevating the risk of upper gastrointestinal complications.
The drop in risk after treatment is stopped and the dose-response found suggest a drug effect. More directly, we reviewed the patient profiles and found little difference between the steroid indications for cases and controls. An elevated risk among steroid users might also be due to a preferential prescription of steroids, instead of other antiinflammatory drugs, to patients at higher risk of upper gastrointestinal complications. To control for this potential confounding, all estimates of risk were adjusted for antecedents of upper gastrointestinal disorders including dyspepsia , NSAIDs, aspirin, and several other risk factors for upper gastrointestinal complications.
However, unmeasured or inaccurately measured factors may lead to residual confounding. In conclusion, use of oral steroids and NSAIDs was associated with about twofold and fourfold increased risk of upper gastrointestinal complications, respectively.
Patients using steroids concomitantly with high-dose NSAIDs had the highest risk of upper gastrointestinal complications. Reprint requests to Dr. The authors are indebted to the Boston Collaborative Drug Surveillance Program for providing access to the data.
They thank the general practitioners for their excellent collaboration. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. Ann Intern Med ; : — Arch Intern Med ; : —9. Non-steroidal anti-inflammatory drugs and ulcer complications: a risk factor analysis for clinical decision-making. Scand J Gastroenterol ; 31 : — Corticosteroid use and peptic ulcer disease: role of nonsteroidal anti-inflammatory drugs.
The association of non-steroidal anti-inflammatory drugs with upper gastrointestinal tract bleeding. Arch Intern Med ; : 85 —8. Toward an epidemiology of gastropathy associated with nonsteroidal antiinflammatory drug use.
Gastroenterology ; 96 : — Relation of upper gastrointestinal bleeding to non-steroidal anti-inflammatory drugs and aspirin: a case-control study. Gut ; 32 : —4. Keating J, Chandran H. Antiinflammatory drugs and emergency surgery for peptic ulcers in the Waikato.
Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal anti-inflammatory drugs. Lancet ; : — Nonsteroidal anti-inflammatory drugs and upper gastrointestinal bleeding, identifying high-risk groups by excess risk estimates.
Scand J Gastroenterol ; 30 : — Matikaienen M, Kangas E. Is there a relationship between the use of analgesics and non-steroidal anti-inflammatory drugs and acute upper gastrointestinal bleeding? A Finnish case-control prospective study. Individual nonsteroidal antiinflammatory drugs and other risk factors for upper gastrointestinal bleeding and perforation. Epidemiology ; 8 : 18 — Conclusions: Corticosteroid use was associated with increased risk of gastrointestinal bleeding and perforation.
The increased risk was statistically significant for hospitalised patients only. For patients in ambulatory care, the total occurrence of bleeding or perforation was very low, and the increased risk was not statistically significant.
Most antiinflammatory drugs have been associated with an increase in upper gastrointestinal complications. However, the literature on steroids is more limited than that on nonsteroidal antiinflammatory drugs NSAIDs. To estimate the risk of upper gastrointestinal complications associated with use of steroids alone and in combination, a nested case-control analysis was conducted on the General Practice Research Database from the United Kingdom.
The authors identified 2, cases of upper gastrointestinal complications and 11, controls between and The adjusted odds ratios associated with current use of oral steroids were 1. Simultaneous use of steroids with low-medium and high NSAID doses, respectively, produced odds ratios of 4. Whenever possible, antiinflammatory drugs should be given in monotherapy and at the lowest effective dose in order to reduce the risk of upper gastrointestinal complications.
The association between upper gastrointestinal complications and intake of nonsteroidal antiinflammatory drugs NSAIDs has been extensively evaluated and reviewed 12. In some studies, the use of corticosteroids has been suggested to reinforce the risk associated with NSAIDs 13. However, the literature on corticosteroids as an independent risk factor for upper gastrointestinal complications in the general population is limited 4and often we learn about them from secondary analyses included in research on NSAIDs 5 — We used data from an ongoing population-based study to assess the risk of upper gastrointestinal complications related to steroid treatment, as well as the potential interaction between steroids and NSAIDs.
Sincegeneral practitioners throughout the United Kingdom have been collecting information on their patients in the General Practice Research Database. Currently, around 1, practices representative of the UK population participate. The general practitioners systematically store in office computers clinical information on their patients including demographics, diagnoses and comments, referral information, and records of all prescriptions issued by them.
Data for research purposes are strictly anonymous. Since prescriptions, including dosage instructions, are generated directly from the computer, the information on all prescriptions written by the general practitioner is complete.
Since general practitioners in the United Kingdom are the gatekeeper to all health care delivered, the General Practice Research Database includes all referrals to specialists, hospital admissions, and the results from these visits The accuracy and completeness of these data have been validated in previous studies This study included the period between April and Octoberand it was an extension of a previous study in which the data collection ended in February 9.
From this population we considered persons aged 40—79 years who had been enrolled at least 2 years with the general practitioner and who were free of cancer, esophageal varices, Mallory-Weiss disease, liver disease, coagulopathies, and alcohol-related disorders at the start date. A total ofstudy members were followed until they met a case definition criterion, one of the above listed exclusion criteria, died, or the end of follow-up, whichever came first.
We identified patients with codes for upper gastrointestinal complications and manually reviewed the information in their computerized patient profiles.
To validate the cases we sent the general practitioners a questionnaire for a random sample of patients. We received information on 99 patients with only one patient not confirmed as a case of upper gastrointestinal complications.
Controls were frequency matched to cases by age interval of 1 year and gender, and a date was randomly selected from the eligible person-time so that the likelihood of being selected as a control was proportional to the person-time at risk.
Specifically, a random date within the study period was generated for each of the members of the study cohort. All persons with a random date included in their person-time period of observation from study entry to end of follow-up were eligible as controls. The same computer-based inclusion criteria as those for the cases were applied to all eligible controls, using each control's random date as his or her index date.
We included 2, cases and chose a fixed size of 11, for the control series slightly more than five times the number of cases. The general practitioners record in the computer the name, dose, frequency, and number of pills prescribed by them. We considered that a subject was exposed while the supply of the prescription lasted.
Cutoff values of daily dose for individual antiinflammatory drugs, United Kingdom General Practice Research Database, — Doses less than or equal to the cutoff value were grouped under low-medium doses, and doses greater than the cutoff value were grouped under high doses. Within our source population we performed a nested case-control analysis. Odds ratios of upper gastrointestinal complications and 95 percent confidence intervals were estimated for patients exposed versus not exposed to an anti-inflammatory drug, using unconditional logistic regression.
The odds ratios for concurrent exposure to more than one drug were examined by using a common reference group those exposed to neither drug. The associations presented below were adjusted, using multivariate models, for age, sex, calendar year, smoking, antecedents of upper gastrointestinal disorders, aspirin, and anticoagulant use. This study included 2, cases and 11, controls. Five percent of cases and 2 percent of controls were current steroid users.
The risk of upper gastrointestinal complications was 1. Among steroid users, the most common indications were arthritis 23 percent of controls and 26 percent of casesbronchitis 23 percent of controls and 17 percent of casesand asthma 13 percent of controls and 14 percent of cases. Adjusted for age, sex, calendar year, ulcer history, and smoking and also for anticoagulant, NSAID, steroid, and aspirin use.
The risk associated with the use of oral steroids tended to be greater for high doses than for low doses, although the difference was not statistically significant table 3. The risk for steroid doses equivalent to 10—30 mg of prednisone was equal to that for doses below 10 mg.
Users of inhaled and intramuscular steroids had odds ratios of 1. However, the latter odds ratio was based only on four exposed cases. These analyses include only current users of oral steroids. There were 15 subjects with missing values for oral steroid dose. Among the 2, cases identified, had lesions located in the stomach, 1, in the duodenum, and at an unspecified site. For duodenal lesions, the odds ratios associated with high and low doses were 1.
Notice that, when we stratified by site, the sample size for the analysis of steroids at high doses was small, yielding to broad confidence intervals. Regarding the type of lesion, 1, cases had suffered bleeding and had perforations. The odds ratio associated with current use of oral steroids was 1.
About 21 percent of the cases of upper gastrointestinal complications and 7 percent of the controls were current NSAID users, yielding an overall adjusted odds ratio of 4. The risk of upper gastrointestinal complications dropped 1 month after treatment was stopped. Compared with nonusers of either drug, the odds ratios were 4. We further analyzed the association between steroids and upper gastrointestinal complications when subjects were concomitantly exposed to either low or high NSAID doses.
Thus, we were not able to study the effect of using high steroid doses and NSAIDs simultaneously table 3. Current intake of systemic steroids increased 1.
Concomitant use of systemic steroids with high doses of NSAIDs was associated with a fold increased risk of upper gastrointestinal complications. Meta-analyses of early clinical trials showed conflicting results between them One suggested a small but significant dose-dependent increased risk of peptic ulcers in the groups treated with steroids 18and another failed to find a difference between the steroid and placebo groups Regarding observational data, we found 11 previously published epidemiologic studies that included odds ratio estimates of serious upper gastrointestinal events associated with the use of steroids 4 — Results from individual studies were heterogeneous and often based on small numbers.
The pooled odds ratio estimate was 1. The risk of upper gastrointestinal complications has been shown to be higher when steroids are administered concomitantly with NSAIDs: Piper et al.
It has been suggested that steroids may delay the healing of underlying erosive lesions caused by other factors such as NSAIDs, rather than causing ulcer de novo 4 Potential limitations of all studies using computerized prescription data are the underascertainment of drugs obtained from other sources e. However, it is probable that such misclassification expected to be small, because steroids are rarely purchased over-the-counter would be nondifferential, thus resulting in conservative odds ratio estimates.
Because steroids are often indicated for patients with certain diseases, illness itself, and not the drugs, might be elevating the risk of upper gastrointestinal complications. The drop in risk after treatment is stopped and the dose-response found suggest a drug effect. More directly, we reviewed the patient profiles and found little difference between the steroid indications for cases and controls. An elevated risk among steroid users might also be due to a preferential prescription of steroids, instead of other antiinflammatory drugs, to patients at higher risk of upper gastrointestinal complications.
To control for this potential confounding, all estimates of risk were adjusted for antecedents of upper gastrointestinal disorders including dyspepsiaNSAIDs, aspirin, and several other risk factors for upper gastrointestinal complications.
However, unmeasured or inaccurately measured factors may lead to residual confounding. In conclusion, use of oral steroids and NSAIDs was associated with about twofold and fourfold increased risk of upper gastrointestinal complications, respectively. Patients using steroids concomitantly with high-dose NSAIDs had the highest risk of upper gastrointestinal complications.
Reprint requests to Dr. The authors are indebted to the Boston Collaborative Drug Surveillance Program for providing access to the data. They thank the general practitioners for their excellent collaboration. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs.
Ann Intern Med ; : — Arch Intern Med ; : —9. Non-steroidal anti-inflammatory drugs and ulcer complications: a risk factor analysis for clinical decision-making. Scand J Gastroenterol ; 31 : — Corticosteroid use and peptic ulcer disease: role of nonsteroidal anti-inflammatory drugs. The association of non-steroidal anti-inflammatory drugs with upper gastrointestinal tract bleeding.
Arch Intern Med ; : 85 —8. Toward an epidemiology of gastropathy associated with nonsteroidal antiinflammatory drug use. Gastroenterology ; 96 : — Relation of upper gastrointestinal bleeding to non-steroidal anti-inflammatory drugs and aspirin: a case-control study. Gut ; 32 : —4. Keating J, Chandran H. Antiinflammatory drugs and emergency surgery for peptic ulcers in the Waikato.
Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal anti-inflammatory drugs. Lancet ; : — Nonsteroidal anti-inflammatory drugs and upper gastrointestinal bleeding, identifying high-risk groups by excess risk estimates. Scand J Gastroenterol ; 30 : — Matikaienen M, Kangas E.
Corticosteroid use was associated with increased risk of gastrointestinal bleeding and perforation. The increased risk was statistically. Current intake of systemic steroids increased times the risk of having a new episode of upper gastrointestinal bleeding or perforation. Concomitant use of. Short-term (7–28 days) exposure to glucocorticoids is significantly associated with peptic ulcer bleeding; this risk seems dose-dependent and is. Corticosteroids increased the risk of gastrointestinal bleeding or perforation by 40% (OR , 95% CI to ). The risk was increased for. Even short courses of oral corticosteroids such as prednisone and dexamethasone increase the risk gastrointestinal bleeding, sepsis. We further analyzed the association between steroids and upper gastrointestinal complications when subjects were concomitantly exposed to either low or high NSAID doses. The risk of upper gastrointestinal complications has been shown to be higher when steroids are administered concomitantly with NSAIDs: Piper et al. Article Navigation. The incidence and mortality from GIH were the primary outcome measures.The risk of long-term use of oral corticosteroids are well known. This research shows that short "bursts" of one to two weeks also carry some risk of adverse events. Even short courses of oral corticosteroids such as prednisone and dexamethasone increase the risk gastrointestinal bleeding, sepsis, and heart failure, according to results reported in this week's Annals of Internal Medicine.
The adverse effects of long-term use of corticosteroids are well characterized and common knowledge among physicians, nurses, and many other healthcare professionals. But short "corticosteroid bursts" of one to two weeks have been seen as being relatively safe and an effective way to quell inflammation, particularly for people experiencing a flare-up of a chronic inflammatory conditions.
And dexamethasone has been in the news lately because researchers have reported that it substantially cuts the mortality risk of people who are seriously ill from COVID But this report in the Annals puts corticosteroid bursts in a different light, one in which the benefits are attended by some risk of adverse events, and with the recognition of the drawback the suggestion that they be prescribed only when necessary.
T sung-Chieh Yao , M. Of the roughly For most of their analysis, Yao and his colleagues winnowed that 4 million down to 2. When Yao et al. The accompanying editorial by Beth Wallace , M. Yao and his colleagues noted how common prescriptions for corticosteroid bursts are in Taiwan a quarter of the people in the database had received a prescription and that they are prescribed most often for common skin disorders, such as contact dermatitis and eczema, and upper respiratory tract infections.
Short-term use of corticosteroids is not confined to Taiwan problem; the researchers referenced a U. As Wallace and Waljee point out, the chance of an adverse event can be outweighed by a medication's benefit.
It's a trade-off we are willing to make if the benefit is large enough and occurs often enough. Wallace and Waljee note that corticosteroids prescribed for acute flares of a chronic inflammatory conditions may fend off disability and maintain people's quality of life. Yao and his co-authors make similar points and call for prospective studies or clinical trials to determine the optimal use of corticosteroids by monitoring adverse events.
July 7, Peter Wehrwein.
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