February 5th, 2009
PPIs and Plavix: There Are No Simple Answers but Maybe a Simple Solution!
In response to my earlier post on PPIs and upper GI bleeding, Bahman N Shokouhi writes:
A recent article in the Canadian Medical Association Journal (published online Jan 28, 2009), suggests that this is not a class effect and that Pantoprazole does not seem to have an effect. It has been suggested that the cause of this is the effect of most PPIs on P450 2C19. Pantoprazole does not affect P450 2C19 and therefore according to the data does not reduce the effectiveness of clopidogrel. So, hopefully if we start using Pantoprazole instead of Omeprazole and other PPIs you can still continue with your calls!
However, we should remember that we do not know if any PPI clearly has a detrimental effect on Plavix’s action. Until we know whether this is a causal, class-wide effect, one easy solution would be to avoid administering Plavix and a PPI too closely together. Although both Plavix and PPIs have a sustained pharamcological and tissue effect, their serum half-lives are very short (less than a few hours). Thus any drug interaction that results in a deleterious clinical effect (if one actually occurs) would be obviated if one drug was taken in the AM and the other in the PM.
January 23rd, 2009
Ambulatory Endoscopy Centers: No Seniors Allowed!
Ambulatory endoscopy centers (AECs) have proven so successful in providing convenient, efficient, low-cost, high-quality endoscopy services to outpatients that they are now ubiquitous around the country. Given this success, you might assume that payers would steer business their way. However, that’s not the case with the Centers for Medicare & Medicaid Services (CMS). In fact, Medicare beneficiaries are now being priced out of AECs.
CMS recently announced that it is changing reimbursements to AECs so that they receive only 59% of what hospitals receive for doing the exact same endoscopic procedures. Although the proportion paid to AECs versus hospitals has been inching downward for years now, this latest change is really the tipping point — what AECs will now receive for reimbursement ($312) is less than what it actually costs them to do the procedure (~$365).
What does this mean for seniors who need screening colonoscopy, diagnostic colonoscopy, or upper endoscopy exams? Local, convenient, efficient, and high-quality AEC service will probably not be available to them, and they will instead be forced to have their procedure done in a hospital. Granted, they’ll still receive a high-quality exam there, but they won’t have had the same choices in their care.
This stinks. CMS is potentially making colon cancer screening a difficult decision for seniors. This abuse by our own government agencies must stop. If you agree, let your Senators and U.S. Representatives know.
And if you have ideas on how to remedy this problem, by all means, let me know!
January 16th, 2009
Beware of Plavix: Your Next On-Call Nightmare
I love being a gastroenterologist, but I hate being on call. If I could avoid “call,” I probably would never even contemplate retiring. Alas, call may be about to get worse for gastroenterologists, especially in light of new evidence that could curtail the common use of PPIs to prevent GI bleeding in patients taking clopidogrel (Plavix).
Clopidogrel, a life-saving antiplatelet drug prescribed for a widening variety of cardiovascular indications, is associated with increased risk for GI bleeding – one of our most common on-call calls. To reduce the incidence of clopidogrel-induced bleeding, PPIs such as omeprazole (Prilosec) are often prescribed, since these agents reduce the prevalence of ulcers and erosions, which tend to bleed more in patients taking clopidogrel.
Why the concern about PPIs? Well emerging data show that although omeprazole protects patients against clopidogrel’s adverse GI effects, it might also negate clopidogrel’s cardiac protection. If patients taking clopidogrel are told to avoid PPIs, we might soon see a marked rise in cases of clopidogrel-related GI bleeding during our nights and days on call. If you have thoughts on this issue or on how best to manage patients if the above scenario comes to pass, please let me know.
December 29th, 2008
What Should We Do with Barrett’s: Ignore It or Fry it?
The answer to the question “What to do with Barrett’s: Ignore it or fry it” is simple: It depends on whether we are talking about Barrett’s with or without dysplasia! We now have ample evidence that endoscopic interventions for dysplastic Barrett’s are effective in decreasing the incidence of cancer. As a matter of fact, the success of PDT, EMR and now RFA in treating dysplastic Barrett’s, makes routine use of surgery for Barrett’s with high-grade dysplasia inappropriate.
Is the same true for the majority of patients with Barrett’s that have no dysplasia and are at low risk for progression to dysplasia (life time risk <15%) or cancer (life time risk <5%)? Furthermore, how could an endoscopic intervention that is 1) expensive and 2) potentially harmful, benefit them in any way? I would answer these questions in this way: If eradicating Barrett’s metaplasia led to the “cure” of Barrett’s and thus obviated the need for further endoscopic surveillance, then an endoscopic intervention would be supportable and this response then requires answering two further questions: 1) Does endoscopic ablation lead to elimination of Barrett’s metaplasia and 2) can we eliminate surveillance endoscopy in those whose Barrett’s is eradicated?
The answer to the first question is an unequivocal yes. How about the answer to the second question and how many of you are comfortable telling a patient that has had all apparent Barrett’s eliminated by an endoscopic ablative method that they no longer need surveillance? If you actually tell them they no longer need surveillance once Barrett’s has been eliminated, then I can support you doing endoscopic treatment of non-dysplastic Barrett’s right now. If you are not comfortable with telling them they are cured and do not halt any further surveillance (e.g., fire the patient), then you should not be doing these procedures on non-dysplastic Barrett’s patients!
How long should we wait before we tell patients that have undergone Barrett’s ablation they are cured and no longer need surveillance? There are no data relating to this but we do know the residual risk is very low. My personal feeling is that if they have two successive surveillance exams that demonstrate no endoscopic or histological Barrett’s (5-6 years out) I would recommend that they forego further surveillance as any benefit from surveillance is questionable anyway.
Either way, the answer to “What should we do with Barrett’s: Ignore it or fry it?” appears pretty simple to me: if they have dysplasia-“fry it”; if they do not have dysplasia, “fry it” if you are willing to discharge them from surveillance, otherwise don’t intervene!
December 22nd, 2008
Telling the Truth About Colonoscopy, Take II
This article in Annals of Internal Medicine neatly drives home the argument that I made below about colonoscopies missing some cancers. Glad to see that in its coverage, the Times at least correctly identified that the problem is with who does the procedure, not with the procedure itself.
December 3rd, 2008
Are We Telling Patients the Truth About Colonoscopy?
Last week I heard one of our really talented GI fellows talking with a patient before her open access colonoscopy, and she told the patient that this test prevents colon cancer. I was somewhat surprised at the definitive implication of that statement and later asked her how much protection from colon cancer does colonoscopy screening provide? What really shocked me was her response that the protective value of colonoscopy was nearly 100%!
Unfortunately, I think her estimate is both widespread and incorrect. Most recent estimates are that colonoscopy decreases the incidence of colorectal cancer by approximately 70% to 80%, a remarkable figure that substantiates that colonoscopy is by far the best cancer-prevention strategy of any currently practiced screening test, including mammography, PAP smears, and PSA screening. But it it does not provide the 100% protection assumed by gastroenterologists, other healthcare providers, and patients.
Why aren’t we able to achieve 100% protection with this test? There are many likely reasons including imperfect colonoscopy (we miss lesions) and biological behavior of colon neoplasms (microsatellite unstable lesions and the like) that allow for “interval” cancers to develop.
So why the discrepancy between reality (colonoscopy is a great cancer prevention test but not perfect) and perception (colonoscopy guarantees cancer prevention)? I think that it is not because we are being disingenuous but rather that we are being naïve and have not followed the literature very closely and that our patients are sometimes blinded by their hope and optimism. We really need to make sure that they understand the need for colon cancer prevention screening with colonoscopy but also that the test has limitations.
What do you tell your patients when you are referring them for colonoscopy or before you do perform the screening? How protective do you think the test is? Do you think it eventually will get better with improvements in technology? How can we reduce misperceptions–both our own and our patients’–about this test?
November 4th, 2008
Whither Gastroenterology?
What does it mean to be a gastroenterologist in 2008? Is our field moving in the right direction?
I suspect that most gastroenterologists were and are attracted to the specialty because it offered the opportunity to deal with multiple organs and diseases. My generation of gastroenterologists came of age along with the exciting and emerging ability to diagnose–and later manage–aspects of GI diseases with endoscopy. However, most of our days were still spent as consultants seeing patients in the clinics and inpatient units, ordering radiographic and laboratory studies, and occasionally performing endoscopy. Many of our patients belonged to us–they had IBD, chronic pancreatitis, peptic ulcer disease, peptic esophageal strictures, chronic liver disease, etc. We knew them and they knew us.
The world of medicine has changed, however, and with it the practice of gastroenterology. For many of us, most of our days are now spent “scoping” patients we have never met. Many of these patients don’t even have what would traditionally be thought of as a GI disorder. When we are not performing screening tests, we are often evaluating patients with chronic pain located somewhere in the abdomen. Many gastroenterologists no longer see patients with complex IBD or liver disease. For that matter, some of us don’t see hospital patients anymore, leaving this population to the newly arrived GI hospitalist. While these trends have invariably led to greater efficiency and more widespread cancer prevention screening they have also removed us from the primary care of patients with acute and chronic GI disorders.
I miss the old days! I think the new paradigm of open endoscopy, a one-time consult and then dismiss the patient back to the PCP, etc. has diminished our specialty. Endoscopy is an amazing and wonderful tool that has improved the health of our patients, but it also has become a barrier to the practice of gastroenterology. How do we take the best of modern technologies and efficiencies without losing the best of the old connection with our patients and our primary role in managing gastrointestinal diseases? My own take is that, as individuals, we need to re-embrace providing primary care to patients with GI diseases and convince our colleagues to see the value of the “old-fashioned” gastroenterologist and make it easier for us to be one again.
What do you think? Should gastroenterologists be more involved in patient care? How did we lose our way? How do we find it again? Are we gastroenterologists or just endoscopists? And primary care physicians, what role do you see for the gastroenterologist in the management of GI disease?
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
Biography | Disclosures | Summaries
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