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Comparative efficacy of various anti-ulcer medications after gastric endoscopic submucosal dissection: a systematic review and network meta-analysis

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Abstract

Background

The comparative efficacy of various anti-ulcer medications after gastric endoscopic submucosal dissection (ESD) has not been fully evaluated. Recently, vonoprazan, a novel potassium-competitive acid blocker, has also been used in ulcer treatment after ESD.

Methods

We searched for all relevant randomized controlled trials examining the efficacy of anti-ulcer medications after gastric ESD, published through October 2017. Healing of iatrogenic ulcers was investigated at 4–8 weeks after ESD. A network meta-analysis was performed to calculate the network estimates.

Results

Twenty-one studies with 2005 patients were included. Concerning the comparative efficacy for ulcer healing at 4 weeks after ESD, no network inconsistency was identified (Cochran’s Q-test, df = 10, P = 0.13; I2 = 34%). A combination therapy of proton-pump inhibitor (PPI) and muco-protective agent was superior to PPI alone [risk ratio (RR) (95% confidence interval, CI) 1.69 (1.20–2.39)]. The combination therapy of PPI and muco-protective agents tended to be superior to vonoprazan [RR (95% CI) 1.98 (0.99–3.94)]. There was no difference of ulcer healing effect between PPI and vonoprazan [RR (95% CI) PPI vs. vonoprazan, 1.17 (0.64–2.12)]. Concerning the ulcer healing rate at 8 weeks after ESD, however, vonoprazan was superior to PPI [RR (95% CI) 1.27 (1.03–1.56)]. Additionally, vonoprazan tended to be superior to the combination therapy of PPI and muco-protective agent [RR (95% CI) 1.20 (0.96–1.51)].

Conclusions

A combination therapy of PPI and muco-protective agent was superior to PPI alone for ulcer healing at 4 weeks after ESD. In the ulcer healing effect at 8 weeks after ESD, vonoprazan was superior to PPI.

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Acknowledgements

This work was supported by the research fund of Hanyang University (HY-2017).

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Correspondence to Chan Hyuk Park.

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Eun Hye Kim, Se Woo Park, Eunwoo Nam, Jae Gon Lee, and Chan Hyuk Park have no conflicts of interest or financial ties to disclose.

Electronic supplementary material

Appendix: Detailed search strategy

Appendix: Detailed search strategy

MEDLINE

(ESD[Title/Abstract] OR endoscopic submucosal dissection[Title/Abstract] OR EMR[Title/Abstract] OR endoscopic mucosal resection[Title/Abstract] OR endoscopic resection[Title/Abstract] OR iatrogenic[Title/Abstract] OR artificial[Title/Abstract]) AND (ulcer*[Title/Abstract]) AND (vonoprazan[Title/Abstract] OR TAK-438[Title/Abstract] OR revaprazan[Title/Abstract] OR YH1885[Title/Abstract] OR (potassium[Title/Abstract] AND competitive[Title/Abstract]) OR potassium-competitive[Title/Abstract] OR ppi[Title/Abstract] OR proton pump inhibitor*[Title/Abstract] OR dexlansoprazole[Title/Abstract] or esomeprazole[Title/Abstract] OR ilaprazole[Title/Abstract] OR lansoprazole[Title/Abstract] OR omeprazole[Title/Abstract] OR pantoprazole[Title/Abstract] OR rabeprazole[Title/Abstract] OR ((histamine[Title/Abstract] OR histamine2[Title/Abstract] OR histamine-2[Title/Abstract] OR h2[Title/Abstract] OR h-2[Title/Abstract]) AND (antagonist*[Title/Abstract] OR blocker*[Title/Abstract])) OR h2ra[Title/Abstract] OR famotidine[Title/Abstract] OR cimetidine[Title/Abstract] OR ranitidine[Title/Abstract] OR nizatidine[Title/Abstract] OR lafutidine[Title/Abstract] OR misoprostol[Title/Abstract] OR rebamipide[Title/Abstract] OR ecabet[Title/Abstract] OR irsogladine[Title/Abstract] OR polaprezinc[Title/Abstract] OR muco-protective[Title/Abstract] OR mucoprotective[Title/Abstract]) AND (“1990/01/01”[Date—Publication] : “2017/10/31”[Date—Publication]).

EMBASE

(ESD:ab,ti OR ‘endoscopic submucosal dissection’:ab,ti OR EMR:ab,ti OR ‘endoscopic mucosal resection’:ab,ti OR ‘endoscopic resection’:ab,ti OR iatrogenic:ab,ti OR artificial:ab,ti) AND (ulcer*:ab,ti) AND (vonoprazan:ab,ti OR TAK-438:ab,ti OR revaprazan:ab,ti OR YH1885:ab,ti OR (potassium:ab,ti AND competitive:ab,ti) OR potassium-competitive:ab,ti OR ppi:ab,ti OR proton pump inhibitor*:ab,ti OR dexlansoprazole:ab,ti or esomeprazole:ab,ti OR ilaprazole:ab,ti OR lansoprazole:ab,ti OR omeprazole:ab,ti OR pantoprazole:ab,ti OR rabeprazole:ab,ti OR ((histamine:ab,ti OR histamine2:ab,ti OR histamine-2:ab,ti OR h2:ab,ti OR h-2:ab,ti) AND (antagonist*:ab,ti OR blocker*:ab,ti)) OR h2ra:ab,ti OR famotidine:ab,ti OR cimetidine:ab,ti OR ranitidine:ab,ti OR nizatidine:ab,ti OR lafutidine:ab,ti OR misoprostol:ab,ti OR rebamipide:ab,ti OR ecabet:ab,ti OR irsogladine:ab,ti OR polaprezinc:ab,ti OR muco-protective:ab,ti OR mucoprotective:ab,ti) AND [1990–2017]/py AND [embase]/lim.

Cochrane

  1. 1.

    ESD or “endoscopic submucosal dissection” or EMR or “endoscopic mucosal resection” or “endoscopic resection” or iatrogenic or artificial

  2. 2.

    ulcer*

  3. 3.

    vonoprazan or TAK-438 or revaprazan or YH1885

  4. 4.

    potassium and competitive

  5. 5.

    ppi or ‘proton pump inhibitor*’ or dexlansoprazole or esomeprazole or ilaprazole or lansoprazole or omeprazole or pantoprazole or rabeprazole

  6. 6.

    histamine or histamine2 or histamine-2 or h2 or h-2

  7. 7.

    antagonist* or blocker*

  8. 8.

    h2ra or famotidine or cimetidine or ranitidine or nazatidine or lafutidine

  9. 9.

    misoprostol or rebamipide or ecabet or irsogladine or polaprezinc or muco-protective or mucoprotective

  10. 10.

    #3 or #4

  11. 11.

    #6 and #7

  12. 12.

    #11 or #8

  13. 13.

    #10 or #5 or #12 or #9

  14. 14.

    #1 and #2 and #13 (Publication year from 1990 to 2017)

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Kim, E.H., Park, S.W., Nam, E. et al. Comparative efficacy of various anti-ulcer medications after gastric endoscopic submucosal dissection: a systematic review and network meta-analysis. Surg Endosc 33, 1271–1283 (2019). https://doi.org/10.1007/s00464-018-6409-4

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  • DOI: https://doi.org/10.1007/s00464-018-6409-4

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