This document discusses the gastrointestinal (GI) and cardiovascular (CV) risks associated with nonsteroidal anti-inflammatory drug (NSAID) use. It outlines the mechanisms by which NSAIDs can cause GI adverse effects like gastric ulcers and bleeding. It also notes that NSAIDs are associated with increased CV risks. The document recommends prevention strategies for NSAID use based on assessing individual patient's GI and CV risk factors.
Dpp4i vs sglt2 inhibitors against the motionSujoy Majumdar
A debate showing why SGLT2 inhibitors have not have a major advantage over DPP4 inhibitors as the next add on drug after Metformin in the management of Type 2 Diabetes
Dpp4i vs sglt2 inhibitors against the motionSujoy Majumdar
A debate showing why SGLT2 inhibitors have not have a major advantage over DPP4 inhibitors as the next add on drug after Metformin in the management of Type 2 Diabetes
Atorvastatin: Statins in CVD management. Is just lipid lowering enough Dr Vivek Baliga
When it comes to management of cardiovascular diseases, are achieving lipid lowering targets sufficient. Here Dr Vivek Baliga, Consultant Internal medicine discusses the additional benefits of statins in CVD in India.
Marcellus Simadibrata Kolopaking MD PhD
Department of Medical Education
Division Gastroenterology Department of Internal Medicine
Faculty of Medicine University Indonesia
Dr.Cipto Mangunkusumo Hospital Jakarta
Atorvastatin: Statins in CVD management. Is just lipid lowering enough Dr Vivek Baliga
When it comes to management of cardiovascular diseases, are achieving lipid lowering targets sufficient. Here Dr Vivek Baliga, Consultant Internal medicine discusses the additional benefits of statins in CVD in India.
Marcellus Simadibrata Kolopaking MD PhD
Department of Medical Education
Division Gastroenterology Department of Internal Medicine
Faculty of Medicine University Indonesia
Dr.Cipto Mangunkusumo Hospital Jakarta
Journal Club about the Phase 2 study of Selonsertib in Diabetic Kidney Disease to Our Division on 12/9/19.
Also an intro about the Phase 3 study (MOSAIC) we will be launching before the end of the year
Statistical analysis of risk factors associated withanamjavaid13
Gallstones are crystal like collections that formed by merging of normal and abnormal gallbladder content. Usually there are two types of gallstones exist i.e. cholesterol stones & pigment stones. The current paper focuses on symptoms of the disease, major cause for the disease and on the treatments that majority of patients preferred. For this purpose, sample of size 170 data from different hospitals in Multan is collected by using convenience sampling. Main demographic factors involved in this study are Gender, Age group, marital status for patients of GSD. Frequency distribution has been formed for these different demographic and social factors and a bar chart is constructed for differentiating between gender as gender is also an important factor in GSD. For weight factor, paired t test is applied to see the difference between before and after weight after having treatment. Findings show that 67 percent people prefer govt. hospitals because of the people suffering from this disease were from backward areas or villages & their income not meet to pay the private hospitals expense.
Statistical analysis of risk factors associated withanamjavaid13
Gallstones are crystal like collections that formed by merging of normal and abnormal gallbladder content. Usually there are two types of gallstones exist i.e. cholesterol stones & pigment stones. The current paper focuses on symptoms of the disease, major cause for the disease and on the treatments that majority of patients preferred. For this purpose, sample of size 170 data from different hospitals in Multan is collected by using convenience sampling. Main demographic factors involved in this study are Gender, Age group, marital status for patients of GSD. Frequency distribution has been formed for these different demographic and social factors and a bar chart is constructed for differentiating between gender as gender is also an important factor in GSD. For weight factor, paired t test is applied to see the difference between before and after weight after having treatment. Findings show that 67 percent people prefer govt. hospitals because of the people suffering from this disease were from backward areas or villages & their income not meet to pay the private hospitals expense.
Androgens & Cardiovascular Diseases in Women: From Basic Research to Clinical...InsideScientific
Join Dr. Licy Yanes-Cardozo as she expands on her research exploring the role of androgens on cardiovascular physiology in cis and transgender patients.
Women have higher plasma concentrations of androgens than estrogens, yet the role of androgens in physiological processes and diseases is not completely understood. High levels of androgens in women are associated with a negative cardiometabolic profile, whereas in men, low levels of androgens are associated with an increased incidence of cardiovascular diseases.The biology behind androgens’ sex difference is not completely understood.
In this webinar, Dr. Yanes-Cardozo discusses two clinical situations that are associated with high levels of androgens. Polycystic Ovary Syndrome (PCOS), the most common endocrine disorder in reproductive-aged women, is associated with a modest elevation of plasma levels of androgens. In transmen individuals (female to male), plasma concentrations of androgens are elevated to achieve similar levels found in cisgender men and much higher than in PCOS women. The role that these two different plasma concentrations play in cardiovascular physiology and pathophysiology remains unclear. Gaps and opportunities in basic research and clinical practice are highlighted.
Key Topics Include:
- Review the key role of androgens in cardiovascular pathophysiology
- Discuss potential mechanisms by which androgens mediate a deleterious cardiometabolic profile in females
- Interpret gaps and opportunities in basic and clinical practice in conditions of androgen excess
LF Energy Webinar: Electrical Grid Modelling and Simulation Through PowSyBl -...DanBrown980551
Do you want to learn how to model and simulate an electrical network from scratch in under an hour?
Then welcome to this PowSyBl workshop, hosted by Rte, the French Transmission System Operator (TSO)!
During the webinar, you will discover the PowSyBl ecosystem as well as handle and study an electrical network through an interactive Python notebook.
PowSyBl is an open source project hosted by LF Energy, which offers a comprehensive set of features for electrical grid modelling and simulation. Among other advanced features, PowSyBl provides:
- A fully editable and extendable library for grid component modelling;
- Visualization tools to display your network;
- Grid simulation tools, such as power flows, security analyses (with or without remedial actions) and sensitivity analyses;
The framework is mostly written in Java, with a Python binding so that Python developers can access PowSyBl functionalities as well.
What you will learn during the webinar:
- For beginners: discover PowSyBl's functionalities through a quick general presentation and the notebook, without needing any expert coding skills;
- For advanced developers: master the skills to efficiently apply PowSyBl functionalities to your real-world scenarios.
The Art of the Pitch: WordPress Relationships and SalesLaura Byrne
Clients don’t know what they don’t know. What web solutions are right for them? How does WordPress come into the picture? How do you make sure you understand scope and timeline? What do you do if sometime changes?
All these questions and more will be explored as we talk about matching clients’ needs with what your agency offers without pulling teeth or pulling your hair out. Practical tips, and strategies for successful relationship building that leads to closing the deal.
Slack (or Teams) Automation for Bonterra Impact Management (fka Social Soluti...Jeffrey Haguewood
Sidekick Solutions uses Bonterra Impact Management (fka Social Solutions Apricot) and automation solutions to integrate data for business workflows.
We believe integration and automation are essential to user experience and the promise of efficient work through technology. Automation is the critical ingredient to realizing that full vision. We develop integration products and services for Bonterra Case Management software to support the deployment of automations for a variety of use cases.
This video focuses on the notifications, alerts, and approval requests using Slack for Bonterra Impact Management. The solutions covered in this webinar can also be deployed for Microsoft Teams.
Interested in deploying notification automations for Bonterra Impact Management? Contact us at sales@sidekicksolutionsllc.com to discuss next steps.
JMeter webinar - integration with InfluxDB and GrafanaRTTS
Watch this recorded webinar about real-time monitoring of application performance. See how to integrate Apache JMeter, the open-source leader in performance testing, with InfluxDB, the open-source time-series database, and Grafana, the open-source analytics and visualization application.
In this webinar, we will review the benefits of leveraging InfluxDB and Grafana when executing load tests and demonstrate how these tools are used to visualize performance metrics.
Length: 30 minutes
Session Overview
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During this webinar, we will cover the following topics while demonstrating the integrations of JMeter, InfluxDB and Grafana:
- What out-of-the-box solutions are available for real-time monitoring JMeter tests?
- What are the benefits of integrating InfluxDB and Grafana into the load testing stack?
- Which features are provided by Grafana?
- Demonstration of InfluxDB and Grafana using a practice web application
To view the webinar recording, go to:
https://www.rttsweb.com/jmeter-integration-webinar
Connector Corner: Automate dynamic content and events by pushing a buttonDianaGray10
Here is something new! In our next Connector Corner webinar, we will demonstrate how you can use a single workflow to:
Create a campaign using Mailchimp with merge tags/fields
Send an interactive Slack channel message (using buttons)
Have the message received by managers and peers along with a test email for review
But there’s more:
In a second workflow supporting the same use case, you’ll see:
Your campaign sent to target colleagues for approval
If the “Approve” button is clicked, a Jira/Zendesk ticket is created for the marketing design team
But—if the “Reject” button is pushed, colleagues will be alerted via Slack message
Join us to learn more about this new, human-in-the-loop capability, brought to you by Integration Service connectors.
And...
Speakers:
Akshay Agnihotri, Product Manager
Charlie Greenberg, Host
Epistemic Interaction - tuning interfaces to provide information for AI supportAlan Dix
Paper presented at SYNERGY workshop at AVI 2024, Genoa, Italy. 3rd June 2024
https://alandix.com/academic/papers/synergy2024-epistemic/
As machine learning integrates deeper into human-computer interactions, the concept of epistemic interaction emerges, aiming to refine these interactions to enhance system adaptability. This approach encourages minor, intentional adjustments in user behaviour to enrich the data available for system learning. This paper introduces epistemic interaction within the context of human-system communication, illustrating how deliberate interaction design can improve system understanding and adaptation. Through concrete examples, we demonstrate the potential of epistemic interaction to significantly advance human-computer interaction by leveraging intuitive human communication strategies to inform system design and functionality, offering a novel pathway for enriching user-system engagements.
Neuro-symbolic is not enough, we need neuro-*semantic*Frank van Harmelen
Neuro-symbolic (NeSy) AI is on the rise. However, simply machine learning on just any symbolic structure is not sufficient to really harvest the gains of NeSy. These will only be gained when the symbolic structures have an actual semantics. I give an operational definition of semantics as “predictable inference”.
All of this illustrated with link prediction over knowledge graphs, but the argument is general.
PHP Frameworks: I want to break free (IPC Berlin 2024)Ralf Eggert
In this presentation, we examine the challenges and limitations of relying too heavily on PHP frameworks in web development. We discuss the history of PHP and its frameworks to understand how this dependence has evolved. The focus will be on providing concrete tips and strategies to reduce reliance on these frameworks, based on real-world examples and practical considerations. The goal is to equip developers with the skills and knowledge to create more flexible and future-proof web applications. We'll explore the importance of maintaining autonomy in a rapidly changing tech landscape and how to make informed decisions in PHP development.
This talk is aimed at encouraging a more independent approach to using PHP frameworks, moving towards a more flexible and future-proof approach to PHP development.
DevOps and Testing slides at DASA ConnectKari Kakkonen
My and Rik Marselis slides at 30.5.2024 DASA Connect conference. We discuss about what is testing, then what is agile testing and finally what is Testing in DevOps. Finally we had lovely workshop with the participants trying to find out different ways to think about quality and testing in different parts of the DevOps infinity loop.
Builder.ai Founder Sachin Dev Duggal's Strategic Approach to Create an Innova...Ramesh Iyer
In today's fast-changing business world, Companies that adapt and embrace new ideas often need help to keep up with the competition. However, fostering a culture of innovation takes much work. It takes vision, leadership and willingness to take risks in the right proportion. Sachin Dev Duggal, co-founder of Builder.ai, has perfected the art of this balance, creating a company culture where creativity and growth are nurtured at each stage.
GDG Cloud Southlake #33: Boule & Rebala: Effective AppSec in SDLC using Deplo...James Anderson
Effective Application Security in Software Delivery lifecycle using Deployment Firewall and DBOM
The modern software delivery process (or the CI/CD process) includes many tools, distributed teams, open-source code, and cloud platforms. Constant focus on speed to release software to market, along with the traditional slow and manual security checks has caused gaps in continuous security as an important piece in the software supply chain. Today organizations feel more susceptible to external and internal cyber threats due to the vast attack surface in their applications supply chain and the lack of end-to-end governance and risk management.
The software team must secure its software delivery process to avoid vulnerability and security breaches. This needs to be achieved with existing tool chains and without extensive rework of the delivery processes. This talk will present strategies and techniques for providing visibility into the true risk of the existing vulnerabilities, preventing the introduction of security issues in the software, resolving vulnerabilities in production environments quickly, and capturing the deployment bill of materials (DBOM).
Speakers:
Bob Boule
Robert Boule is a technology enthusiast with PASSION for technology and making things work along with a knack for helping others understand how things work. He comes with around 20 years of solution engineering experience in application security, software continuous delivery, and SaaS platforms. He is known for his dynamic presentations in CI/CD and application security integrated in software delivery lifecycle.
Gopinath Rebala
Gopinath Rebala is the CTO of OpsMx, where he has overall responsibility for the machine learning and data processing architectures for Secure Software Delivery. Gopi also has a strong connection with our customers, leading design and architecture for strategic implementations. Gopi is a frequent speaker and well-known leader in continuous delivery and integrating security into software delivery.
1. Practical Approach in Managing NSAID Risks: GI and CV Prof. Chutima Pramoolsinsap Division of Gastroenterology and Tropical Medicine Ramathibodi Hospital 1 st Emergency Medicine Update 2550 สมาคมเวชศาสตร์ฉุกเฉินแห่งประเทศไทย 1 September 2007
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4. Major Diseases Attributable to Disability-Adjusted Life Years (DALYs) Lost of Thai People by Sex, 2002 Bureau of Policy and Strategy. Burden of Disease and Injuries in Thailand, 2002
5. Death and Injury Rates from Road Traffic Accidents, Thailand, 1984-2002 Police Information System Centre, Royal Thai Police.
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7. Proportion of Thai elders with most common diseases/symptoms by age group,2002 Surveys on Elderly People in Thailand 2002, National Statistical Office. Age (yrs) 17.7 22.3 27.5 34.4 34.1 42.8 72.7 60-64 20.3 26.5 31.1 35.6 38.1 46.7 74.7 65-69 21.9 33.2 37.3 38.7 42.0 49.8 77.8 70-74 21.6 20.0 Hyper/ hypotension 45.2 29.8 Dementia 42.8 33.2 Eye diseases 41.2 36.8 Vertigo 44.9 38.7 Insomnia 54.9 47.5 Joint pain (degeneration) 77.3 75.1 Body ache, backache > 75 Total Disease/Symptom of Thai Elders
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9. Willow leaf extracts for musculoskeletal conditions Aspirin first synthesised NSAIDs – a Long History of Analgesia and Toxicity 4 00 B.C. Greek physician 1899 1938 1950 1970 1982 1992 1998 Hippocrates Non-selective NSAIDs identified and developed. COX-2 selective NSAIDs discovered First COX-2 selective NSAIDs approved first endoscopic evidence that aspirin caused gastric mucosal damage. Lancet 1938;ii:12225 M echanism of action for aspirin
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11. The 9 chemical groupings of NSAIDs http://www.fda.gov/cder/drug/infopage/COX2/NSAIDmedguide.htm
12. Range of COX-1 and COX-2 selectivity of NSAIDs COX = cyclooxy-genase; IC50 = concentration of NSAID that inhibits COX by 50%,
16. Gastric acid plays a central role in NSAID-associated gastroduodenal damage Acidic environment Bicarbonate layer Ionic gradient Gastric acid NSAIDs Pepsin Surface epithelial cells Mucus layer Neutral environment Mucosal blood supply Alkaline environment Prostaglandin production Bicarbonate production Mucus production NSAIDs normal gastric mucosa 16 minutes after administration of aspirin Direct effect
17. Gastric acid plays a central role in NSAID-associated gastroduodenal damage Acidic environment Bicarbonate layer Ionic gradient Gastric acid NSAIDs Pepsin Surface epithelial cells Mucus layer Neutral environment Mucosal blood supply Alkaline environment Prostaglandin production Bicarbonate production Mucus production NSAIDs Systemic effect
18. NSAIDs increase neutrophil – endothelial adhesion NSAIDs Decreased prostaglandin, increased tumour necrosis factor Increased neutrophil– endothelial adhesion Ischaemic/hypoxic cell injury Endothelial and epithelial injury Mucosal ulceration Wallace et al 1997 Neutrophil release of proteases and oxygen-derived free radicals Capillary obstruction
21. GI symptoms Endoscopic ulcers Clinical ulcers Serious GI events Relative severity Relative frequency NSAID-related GI Effects
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23. MUCOSA CLASS VIGOR TARGET (N=4439) (N=3981) (N=4029) (N=9127) Arthritis RA OA(73%); RA OA RA (27%) NSAID (N) 10 specified Ibuprofen naproxen Ibuprofen NSAIDs diclofenac naproxen Low-dose aspirin Not stated 20% 0 24% Median follow-up 6 mo 9 mo 9 mo 12 mo Upper GI complications 1.5% 1.0% 1.4% 1.3% (annualized incidence) Upper GI clinical events 2.7% 2.8% 4.5% 2.8% (annualized incidence) Incidences of Upper GI Complications and Clinical Events (Complications plus Symptomatic Ulcers) From NSAID-only Arms of GI Outcome Studies J Cardiovasc Pharmacol 2006; 47(1):S60-6
24. Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) Trial Life-threatening or major bleeding 0 1 2 3 4 5 % of patients By aspirin dose, n=6293 <100 mg 1.9 n=990 100–150 mg 2.2 n=2857 151–300 mg 3.3 n=1385 >300 mg n=1061 3.8 Eur Heart J 2002;4:Suppl, 510
27. Risk of Hospitalization for Upper GI Bleeding with COXIBs 3.0 4.0 1.9 1 2 3 4 5 6 7 Adjusted Rate Ratio 0 Non-use celecoxib rofecoxib diclo+miso NSAIDs Mamdani et al. BMJ 2002;325(7365):624-7 1.0 1.0 >55% women Mean age >75 yrs >1% with Hx of GI bleed >16% Use of gastroprotective agent >12% Use of aspirin 100,000 (2.2)* 18,908 (3.6)* 14,583 (7.3)* 5,087 (9.6)* 5,391 (12.6)* *n (no. upper GI bleeds per 1000 person-yrs)
28. Risk Factors for NSAID-Induced Gastropathy Definite: • Age • Prior history of ulcer • Duration of NSAID therapy • Concomitant corticosteroid therapy • Concomitant warfarin therapy • Concomitant ASA / NSAID • NSAID dose • Serious systemic illness (CHF, RA, CAD, others) Possible: • Concomitant H. Pylori infection? • Smoking • Alcohol
29. Risk Factors for NSAID-Associate d GI Complications NSAIDs, nonsteroidal antiinflammatory drugs; SSRIs, selective serotonin reuptake inhibitors. Dalton SO, et al. Arch Intern Med. 2003;163:59–64. Gabriel SE, et al. Ann Intern Med. 1991;115:787–796; Garcia Rodriguez LA, et al. Lancet. 1994;343:769–772. Silverstein FE, et al. Ann Intern Med. 1995;123:241–249.
30. Distribution of Patients with GI Complications From NSAIDs by Age and Sex Am J Gastroenterol 2005;100:1685–93
31. Risk of UGI Complication for NSAID Users Impact of Ulcer History 20-60 60-69 70-79 >=80 Men complic ulcer +NSAID Men ulcer + NSAIDs Men No ulcer +NSAIDs Incidence per 1,000 person-years Based on Hemandez & Garcia-Rodriguez, BMC Medicine 2006;4:22.
32. Rates of symptomatic ulcers and ulcer complications with naproxen in patients with rheumatoid arthritis Bombadlar C et al. N Engl J Med 343;1520-8(2000): Lenas A. Gastroenterol Gastro 2007. Number events x 100 patient-years No NSAID use <65 65-74 >74 Ulcer Hx Ulcer complications >65+Hx Ulcer >65+Hx Ulcer+sterolds Age
33. Annualized Incidence % Ulcer Complications Symptomatic Ulcers and Ulcer Complications 49 / 1384 30 / 1441 11 / 1441 20 / 1384 p = 0.02 p = 0.09 All Patients 32 / 1101 16 / 1143 5 / 1143 14 / 1101 p = 0.02 p = 0.04 Patients Not Taking Aspirin 17 / 283 14/ 298 6 / 298 6 / 283 p = 0.49 p = 0.92 Patients Taking Aspirin CLASS Trial: Upper GI Complications Alone and With Symptomatic Ulcers Silverstein et al. JAMA 2000; 284:1247-1255 = celecoxib = NSAIDs (ibuprofen + diclofenac)
35. Cumulative Incidence (%) *P<0.001 vs placebo and vs aspirin ROF = Rofecoxib Gastroduodenal ulcers at 12 weeks in patients with OA Aspirin Negates the GI-sparing Effect of COX-2 Inhibitors Gastroenterology 2004; 127: 395-402. * * N=381 N=387 N=377 N=374 %
36. Low-Dose Aspirin Combined with NSAID or Coxib Drug R.R 95% CI Aspirin only 3.6 2.9-4.3 NSAID only 5.0 4.3-5.9 Combined 10.2 6.2-16.7 Aspirin only 3.3 2.8-4.0 Coxib only 1.1 0.7-1.9 Combined 9.5 2.5-36.2 Lanas et al. Gut 2006
37. Risk of UGI Complication for NSAID Users Impact of ASA use 20-60 60-69 70-79 >=80 Incidence per 1,000 person-years Based on Hermandez & Garcla-Rodriguez. BMC Medicine 2006;4:22
38. Non-aspirin antiplatelet agents combined with NSAIDs Drug R.R 95% CI Aspirin only 3.6 2.9-4.3 NSAID only 5.0 4.3-5.9 Combined 10.2 6.2-16.7 Clopidogrel/Ticlid only 3.1 2.2-4.4 NSAID only 5.0 4.3-5.8 Combined 15.5 4.7-50.4 Lanas et al. Gut 2006
39. NSAID-Induced Small Bowel Lesions Endoscopic photograph of terminal ileum, demonstrating inflamed diaphragm in patient receiving long-term NSAIDs
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43. Mortality Rate Attributed to NSAID/Aspirin-Associated GI Complications Am J Gastroenterol 2005;100:1685–93 Mortality rate per 1 million people Entire country population NSAID/aspirin users
47. Serious Thromboembolic Cardiovascular Adverse Events in Nonaspirin Users 1. Silverstein FE, et al. JAMA. 2000;284:1247–1255. 2. Bombardier C, et al. N Engl J Med. 2000;343:1520–1528.
48. APPROVe Trial: Confirmed Thrombotic Cardiovascular Events Over Time Bresalier RS, et al. N Engl J Med. 2005; 352: 1092-1102 . September 2004 , Vioxx (rofecoxib) withdrawal from worldwide market
49. April 7, 2005 , Bextra (valdecoxib) withdrawal Parecoxib/Valdecoxib: Cardiovascular Complications After Cardiac Surgery
50. Cardiovascular Risks in NSAID Users This black box warning statement now appears in the package insert (July 2005) for celecoxib
51. Black box warning for COX-2–selective drugs. This black box warning statement now appears in the package insert (July 2005 ) for celecoxib
52. APC Trial: Concomitant Aspirin Use Does Not Decrease Cardiovascular Risk of COX-2 Selective Inhibitors
53. MEDAL Program: Confirmed Thrombotic Cardiovascular Events Over Time Cannon CP, et al; MEDAL Steering Committee. Lancet. 2006;368:1771–1781.
74. Risk of adverse upper G.I. events associated with NSAIDs according to use of ulcer healing drugs. UK study: 9407 incident cases and 88,867 matched controls. BMJ 2005;331;1310-1316 Values are adjusted odds ratios* Not prescribed Prescribed Drug prescribed < 90 ulcer healing ulcer healing Interaction ratio ‡ P value for Days before index drugs in past drugs in past (95% Cl) interaction date † 90 days 90 days Celecoxib 1.44 1.06 0.73 (0.46 to 1.16) 0.18 Rofecoxib 2.33 1.06 0.45 (0.32 to 0.65) <0.001 Other selective 2.40 1.29 0.54 (0.36 to 0.81) <0.001 NSAIDs Ibuprofen 1.65 0.90 0.55 (0.43 to 0.70) <0.001 Diclofenac 2.17 1.49 0.69 (0.56 to 0.84) <0.001 Naproxen 2.73 0.83 0.31 (0.19 to 0.49) <0.001 Other non selective 2.03 1.16 0.57 (0.42 to 0.77) <0.001 NSAIDs Aspirin 1.87 0.81 0.43 (0.38 to 0.49) <0.001
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76. Prevention of NSAID-induced ulcer Endoscopic remission rates for patients with endoscopically normal or hyperaemic gastric mucosa at baseline [a subset of patients with grade 0 of Lanza classification, who were treated with either pantoprazole 40 mg od or placebo for up to 12 weeks 0 4 8 12 P=0.036 92% 82% 75% 55% BIanchi Parro G, et a. Digest Liver Dis 2000 Endoscopic remission rate (%) Time (wks)
77. Efficacy of pantoprazole in the primary prevention of NSAID-induced gastroduodenal damage Patient population Treatment Treatment n Remission rate (%) duration Rheumatic 6 months Pantoprazole 20 mg od 257 89 disease; Continuous NSAID; Misoprostol 200 mg bid 258 70 high risk (p<0.001) Rheumatic 6 months Pantoprazole 20 mg od 196 90 Disease; Continuous NSAID; Pantoprazole 40 mg od 199 93 high risk Omeprazole 20 mg o.d. 200 89 (NS) SINGH, G. Int J Clin Pract 2005
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84. Effect of PPIs,H2-RA and nitrates on the RR of ulcer bleeding in patients taking Low-dose ASA or Clopidogrel 0 0.5 1 2 3 4 5 6 7 8 9 10 27 Adjusted RR (95% IC) Low dose ASA 3.6 +PPI 0.32 +H2-RA 0.40 +Nitrate 0.69 Clopidogrel 3.1 +PPI 0.19 +H2-RA 0.83 +Nitrate 0.88 Lanas et al. AJG 2007
85. PPI plus COX-2 inhibitor Ulcer incidence at 6 months by NSAID type ** P <.01, *** P <.001, **** P <.0001 vs . placebo. ** *** *** **** 134 141 125 318 326 334 n= Scheiman et al. DDW 2004
86. Coxibs versus standard-NSAIDs : Effect on serious upper GI events Adjusted relative risk (95% IC) 0 0.5 1 2 3 4 5 Type of event 51% reduction Symptomatic 0.49 (0.38-0.62) Ulcers Upper GI 45% reduction Complications 0.55 (0.38-0.80) Hooper L et al. BMJ 320:948-58 (2004)
90. High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer Fail Antisecretory therapy Refer Guideline of UGIB Management Endoscopy available Yes No Others Variceal bleeding Ulcer bleeding Pharmacological therapy and monitoring Rebleed Re-endoscopy Fail
91. Endoscopic Stigmata of Ulcer Hemorrhage Active arterial bleeding Visible Vessel Adherent clot Flat spot Clean base ulcer
92. Endoscopic Stigmata of Ulcer Hemorrhage: Prevalence, Risks of R ebleeding and Reduced Risk of Rebleeding following Endoscopic Therapy Endoscopy 1997; 29 : 827-33 Not available 3 32 Clean base ulcer Not available 7 10 Flat spot Not available 10 14 Oozong without stigmata 5 33 10 Adherent clot 15-30 50 22 Visible Vessel 15-30 90 12 Active arterial bleeding Rebleed Rate with Endoscopic treatment (%) Rebleed Rate Prevalence (%) Endoscopic Appearance
93. High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer Fail Antisecretory therapy Refer Guideline of UGIB Management Endoscopy available Yes No Others Variceal bleeding Ulcer bleeding Pharmacological therapy and monitoring Rebleed Re-endoscopy Fail
94.
95. High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer Fail Antisecretory therapy Refer Guideline of UGIB Management Endoscopy available Yes No Others Variceal bleeding Ulcer bleeding Pharmacological therapy and monitoring Rebleed Re-endoscopy Fail
98. 0 8 6 4 2 0 8 16 24 32 40 48 Median Intragastric pH Time [h] Van Rensburg, et al. Gastroenterology 1997. (Abstract) 80 mg bolus then 8 mg/hour n = 14; median pH 6.3, 68% range IV Pantoprazole In Patients With UGI B After Endoscopic Hemostasis
99.
100. High risk Low risk Pharmacologic therapy Endoscopy feasible Yes Endoscopic Hemostasis Success No Consult surgeon or refer Fail Antisecretory therapy Refer Guideline of UGIB Management Endoscopy available Yes No Others Variceal bleeding Ulcer bleeding Pharmacological therapy and monitoring Rebleed Re-endoscopy Fail
103. H.pylori , NSAID Use and the Risk of PU Bleeding Prevalence (%) PU bleeding + - + - + - OR 1.79 95% CI; 0.97-3.32 OR 4.85 95% CI; 3.77-6.23 OR 6.13 95% CI; 3.93-9.56 Lancet 2002 HP+ NSAID uses HP+ NSAID use HP- No NSAID H pylori and NSAIDs independently and significantly increase risk of PU bleeding
115. NSAID required? High risk Low risk - No prophylaxis -Monitor clinical signs and symptoms -Use non-NSAIDs analgesic -Use low dose, short acting NSAIDs -Limit duration of therapy -Avoid using combination of NSAIDs -Avoid to combine with corticosteriod or anticoagulant Risk assessment for NSAID-induced ulcer -Cotherapy with Gastroprotective drugs -Selective COX-2 inhibitors Yes