Peptic Ulcer Disease in Older Adults - letter

To the Editor:

Could the authors of the February 2007 article “Peptic Ulcer Disease in Older Adults” (Geriatrics Aging 2007;vol. 10, no. 2:77-83) please comment in a bit more detail on the evidence supporting the statement that “it would be prudent not only to switch to a COX-2 inhibitor but also to add a PPI” (p. 82, section on NSAIDs, last sentence).

Toronto Physician

Drs. Constantine A. Soulellis and Carlo A. Fallone respond:

To our knowledge, the issue of concurrent usage of COX-2 inhibitors and proton pump inhibitors (PPIs) has been explored in the literature only once before;1,2 this was a negative study that failed to demonstrate superiority of COX-2 inhibitors/PPIs over nonselective NSAIDs/PPIs in high-risk GI patients. However, we would like to disclose that we are privy to the results of a large retrospective cohort study conducted at McGill University and the University of Montreal that included over two million registered prescriptions for COX-2 inhibitors, nonselective NSAIDS, PPIs, and every combination thereof. The findings, to be published in an upcoming issue of Arthritis and Rheumatism (July 2007),3 demonstrate a clear reduction in the studied outcome (hospitalizations from perforated or bleeding ulcers) for COX-2 inhibitors plus PPIs compared to COX-2 inhibitors alone for ages greater than 75. COX-2 inhibitors and PPIs were also found to be superior to nonselective NSAIDs and PPIs for the same measured outcomes.

I hope this explanation is satisfactory for your readers. Again, thank you kindly for affording us the opportunity to contribute to Geriatrics & Aging.

Regards,
C. A. Fallone and C. A. Soulellis

References

1. Cryer B. A COX-2-specific inhibitor plus a proton-pump inhibitor: is this a reasonable approach to reduction in NSAIDs’ GI toxicity? Am J Gastroenterol 2006;101:711-3.
2. Scheiman JM, Yeomans ND, Talley NJ et al. Prevention of ulcers by esomeprazole in at-risk patients using non-selective NSAIDs and COX-2 inhibitors.  Am J Gastroenterol 2006;101:701-10.
3. Rahme E, Barkun AN, Toubouti Y, et al. Do proton pump inhibitors confer additional gastrointestinal protection in patients given celecoxib? Arthritis Rheum 2007;57. In press.