Pantoprazole or Placebo for Stress Ulcer Prophylaxis?

Kishan Patel, Mercer University College of Pharmacy

Stress ulcer prophylaxis is recommended for adult ICU patients with coagulopathy or patients that require mechanical ventilation for more than 48 hours according to guidelines by the American Society of Health System Pharmacists (ASHP) and the Society for Critical Care Medicine. [1,2] However, there have only been two studies that compare the use of proton pump inhibitors (PPIs) with placebo for the prevention of gastrointestinal (GI) bleeding in adult patients in the ICU. Furthermore, neither study results provide robust evidence that supports the use of PPI in for stress ulcer prophylaxis. [3] Moreover, several other observational studies have seen a strong association between stress ulcer prophylaxis treatment and Clostridium difficile infections and ventilator-associated pneumonia. Therefore, some suggest that the use of PPIs for prophylaxis in critically ill patients may be causing more harm than benefit. [4,5]

Despite the limited evidence and potential harm, use of PPI for stress ulcer prophylaxis is a common practice. Therefore, the Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP) trial was designed as an exploratory study to evaluate whether the benefits of stress ulcer prophylaxis outweigh its potential harm. [3]

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Tezepelumab in Adults with Uncontrolled Asthma

Christopher Ling, Mercer University College of Pharmacy

Asthma is a prevalent disorder that affects approximately 300 million people worldwide and is projected to increase to 400 million by 2025. [1] While most patients can be managed on current recommended therapies (e.g. long-acting and short-acting beta agonists [LABAs/ SABAs], inhaled glucocorticoids, long-acting and short-acting muscarinic antagonists), some patients remain uncontrolled. [2] Thymic stromal lymphopoietin (TSLP) is a cytokine produced in response to environmental and proinflammatory stimuli with the ability to promote B cell and dendritic cell activation. [3]  Its expression is increased in patients with severe asthma and is suggested to be correlated with Th2 cytokine and chemokine expression. [4]

Tezepelumab is a human IgG2 monoclonal antibody that inhibits TSLP interactions with TSLP receptor complexes. One study showed that in mild, atopic asthmatic patients, tezepelumab inhibited both early and late asthmatic response and suppressed biomarkers of type 2 inflammation after inhaled allergen challenge. [5] To further explore the effectiveness of tezepelumab, the following study evaluated the effects of tezepelumab in patients with moderate-to-severe asthma who were uncontrolled with LABAs combined with medium-to-high doses of inhaled glucocorticoids. [6]

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Canagliflozin Effect on Cardiovascular and Renal Events in Type 2 Diabetes

Kishan Patel, Mercer University College of Pharmacy

Canagliflozin is a sodium-glucose cotransporter 2 (SGLT-2) inhibitor that allows for lower blood glucose in patients with type 2 diabetes (T2D) by increasing the urinary excretion of glucose. [1] There is a large amount of data that suggests T2D is an independent risk factor for cardiovascular disease.  Furthermore, cardiovascular disease is also the cause of death for the majority of patients with T2D. [2] Current evidence suggests that canagliflozin may be more effective than comparative options such as dipeptidyl peptidase-4 (DPP-4) inhibitors in lowering glycated hemoglobin (HbA1C), body weight, and blood pressure when used as an add-on therapy with metformin. Canagliflozin also appears to be superior when used in combination with metformin than sulfonylureas (SU) in regard to lowering body weight, blood pressure, and risk of hypoglycemia. However, direct evidence from comparative studies is only limited to sitagliptan (DPP-4 inhibitor) and glimepiride (SU) for their respective drug classes.  Therefore, conclusions for canagliflozin’s comparative effectiveness against other agents in the same class as DPP-4 inhibitors and sulfonylureas have been deduced from indirect evidence in network meta-analyses. [3] Continue reading

Is the Use of Low-Intensity Therapy Effective in Adults with Burkitt’s Lymphoma?

Tanya Huang, Mercer University College of Pharmacy

Burkitt’s lymphoma (BL) is a type of non-Hodgkin lymphoma that is most prevalent in equatorial Africa. [1] There are three epidemiological subtypes of BL: endemic (African), sporadic (non-endemic), and immunodeficiency-related. [2] Chemotherapy treatments for BL are usually intensive short-cycle regimens due to the highly proliferative nature of the disease. However, they are associated with severe side effects in patients with immunodeficiencies, such as human immunodeficiency virus (HIV).

Previous attempts to use a significantly reduced intensity for BL in adults have not been successful. However, researchers have hypothesized that BL may be sensitive to genotoxic stress, leading to the prediction that prolonged exposure, not increased dose, as the therapeutic strategy for maximizing tumor cell death. Based on the concept, a study was conducted to compare efficacy of two different low-intensity regimens composed of etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for sporadic or immunodeficiency-associated BL patients. [3] A summary is provided below. Continue reading

Early Exposure of Peanuts to Reduce Risk of Peanut Allergy

Christopher Ling, Mercer University College of Pharmacy

Peanut allergy is one of the most common food allergies, and is represented as nearly a quarter of all allergies in children. It is suggested the allergy is least likely to be outgrown, and is associated with more severe reactions in children. [1] Due to the prevalence and severity of reaction, some recommend introducing peanut-containing products as early as four months old in those at risk of developing a peanut allergy. Moreover, if the infant has severe eczema, egg allergy, or both, specific immunoglobulin E (sIgE) measurements, skin prick test (SPT), and/or oral food challenge (OFC) are recommended before the exposure. [2] This recommendation is based on the Learning Early About Peanut Allergy (LEAP) trial results that show higher risk of peanut allergy in infants with severe eczema and/or egg allergy. [3]

In a study analyzing the data from the LEAP trial, children that consumed peanut products early had less prevalence of a peanut allergy than those that avoided peanut products in both SPT negative (1.9% vs. 13.7%; p< 0.001)  and SPT positive (10.6% vs. 35.3%; p= 0.004) groups. [4] The same authors then did a follow up study (LEAP-ON) consisting of all the eligible patients from the LEAP trial. A summary of the study is provided below. [5]

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Bivalirudin vs. Heparin for Improving Clinical Outcomes in PCI patients

Akpan Anani, Mercer College of Pharmacy

For patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS), anticoagulant therapy is necessitated by risk of thrombotic events. [1] Angiomax® (bivalirudin) is a direct thrombin inhibitor indicated for patients undergoing PCI and concurrently using a glycoprotein IIb/IIIa inhibitor (GPI). [2] Bivalirudin has been shown in some studies to cause less major bleeding than Hep-Lock® (heparin) in myocardial infarction (MI) patients needing anticoagulation [1,3]; however, limited research exists comparing bivalirudin to heparin for assessment of repeat MI or all-cause mortality risk.

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Long-Term Effects of Repeated Injections of Local Anesthetic with or Without Corticosteroid for Lumbar Spinal Stenosis

Eku Oben, Mercer University College of Pharmacy

Lumbar spinal stenosis is the narrowing of the space around the spinal cord, most commonly caused by arthritis. [1] Guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, corticosteroid injections, anesthetic injections, physical therapy, or a lumbar brace for treatment of lumbar spinal stenosis. [2] Comparing lumbar spinal stenosis patient pain scores shows no difference between groups that received steroid injections after anesthesia and placebo groups at the first month (p= 0.793). [3]

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