In June 2019, the FDA delivered a warning about the potential danger of transmitting drug-resistant E coli with fecal microbiota tranplantaion (FMT). (FDA Warning for FMT)
A report on this issue has now been published: Z DeFilipp et al. NEJM 381: 2043-50, editorial M Blaser pgs 264-6.
The authors describe two patients, a 69 year-old with cirrhosis and a 73 year-old sp stem cell transplantation, who developed bacteremia due to transmission of a drug-resistant (extended-spectrum beta-lactamase [ESBL]) E coli following FMT which was delivered by oral capsules. The latter patient died from sepsis. The two patients had a genomicly-identical strain isolated that was also found in the donated aliquot.
In the commentary, a couple of important points:
- “Up to now, the complications have been infrequent [from FMT], and for recurrent C difficile infection, the benefits of FMT clearly outweigh the risks; however, as the use of FMT is broadened and more compromised patients are treated, complications may be more frequently observed.”
- “In the short term, improved and uniform screening of FMT material is needed to reduce the risks.”
My take: Both of these patients who became developed bacteremia were at risk for more severe infections. However, we need to remain aware that severe complications can and do occur with FMT. In context, though, there are risks of severe complications from routine use of antibiotics as well.
Frontenac Hotel, Quebec City
A recent letter (Z Kassam et al. NEJM 2019; 381: 2070-2) describes the arduous process involved in being selected as a stool donor for fecal microbiota transplantation (FMT).
In a previous blog (2015), it appeared that 17% of donors were accepted for FMT: Rejected! Most Stool is Not Good Enough for FMT This current review of the donor program from a stool bank (OpenBiome) prospectively evaluated 15,317 donor candidates from 2014-2018.
- Only 3% (n=386) made it through all the steps to become donors
Reasons for exclusion:
Stage 1: common reasons for exclusion:
- geographical -living too far away to donate regularly
- BMI >30
- social history
- travel history
- not in age range
Stage 2: “failing” the 200-item clinical assessment –common reasons for exclusion:
- lost to followup
- allergic disorders/asthma
- receiving medications/supplements
- mental health concerns
- infectious disease history
- social history/sexual history/other reasons
Stage 3: “failing” the stool and nasal screening which included (in 2016) carbapenem-resistant Enterobacteriacea (CRE), extended-spectrum beta-lactamase-producing organisms (ESBL) and MRSA. –common reasons for exclusion:
- lost to followup
- infectious disorders (including C diff in 7 patients)
Stage 4: “failing” serological screening
- lost to followup
- abnormal LFTs, CBC or infection
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Island Ford, Sandy Springs, GA
A recent cross-sectional study (PP Stanich et al. Clin Gastroenterol Hepatol 2019; 17: 2008-15, editorial 1942-44) identified a high frequency of genetic mutations among adults with at least 10 colonic polyps (cumulative burden of either adenomatous or hamartomatous).
This study had 3789 subjects who underwent multigene panel testing (MGPT) from 2012-16.
- All subjects had at least 14 CRC-associated genes tested: APC, BMPR1A, CDH1, CHEK2, EPCAM, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, SMAD4, STK11, TP53
- A subset had 3 more newly recognized polyposis genes: GREM1, POLD1, and POLE
- A mutation in at least 1 gene was found in 13.7%
- In those with fewer than 20 cumulative adenomas, 7.6% had a disease-associated genetic mutation with the majority (5.3%) being nonpolyposis CRC genes
- Younger patients, 18-29, were more likely to have mutations in any gene. For example, among patients with 10-19 polyps, these younger patients had a mutation in one of these genes in 27.8%; this is more than double the rate in any other age group.
- Hamartomatous polyps, regardless of number, had a very high yield with genetic testing: 40% with 10-19 polyps and 72% with 20-99 polyps.
- There is a referral bias in that the population was derived from a testing laboratory (Ambry)
- In clinical practice, genetic testing frequently results in variants of unknown significance
My take: This study shows that genetic mutations are fairly frequent in patients with cumulative polyp burden of 10 or more, especially in younger age groups. The surprising finding is the high frequency of nonpolyposis CRC genes. Thus, in patients with adenomatous polyposis, testing beyond APC and MUTYH may be needed.
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Atlanta Botanical Garden
Full Text Link: A Conceptual Approach to Understanding Treatment Response in Eosinophilic Esophagitis
Also, related articles:
- D Bushyhead et al. Gastroenterology 2019; 157: 944-5. This practical teaching case report noted that oral immunotherapy (OIT) has been shown to trigger new onset EoE in 2.7% (AJ Lucendo et al. Ann Allergy Asthma Immunol 2014; 113: 624-9).
- R Alexander et al. Clin Gastroenterol Hepatol 2019; 17: 2371-3. This study compared eating behaviors of adults with active EoE (n=10), inactive EoE (n=10) and control patients (n=10). Not surprisingly, those with active EoE took longer to eat (18.3 min compared to 12.4 min, and 13.0 min respectively) and had more drinks after a single bite (11.6 compared with 5.1 and 2.5 respectively)
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A recent study (SJ Spechler et al. NEJM 2019; 381: 1513-23) on first glance appears to support surgery as more effective than medical treatment for refractory heartburn.
Only ~20% of enrolled patients were included in the reported outcomes!
Here’s what happened. Among a cohort of VA patients (n=360, mean age 48 years) who were reportedly refractory to PPI-treatment:
- 78 were excluded during prerandomization
- 42 had relief of their heartburn during a 2-week omeprazole lead-in (20 mg BID)
- 70 did not complete trial procedures
- 23 had non-GERD disorders
- 99 had functional heartburn
This left 78 patients who underwent randomization. All patients in this highly-selected group had undergone endoscopy with biopsy, impedance-pH testing, and esophageal manometry. 18 of 27 (67%) had treatment success with surgery compared to 7 of 25 patients treated with baclofen/PPI and 3 of 26 with control medical treatment (PPI alone).
- Careful evaluation is needed in any patient with refractory heartburn, especially if contemplating surgery. Most will either respond to PPI treatment or have a disorder other than reflux; the authors note that 122 patients (out of 360 patients) did NOT have reflux –99 had functional heartburn.
- Careful instruction in PPI use can be helpful. Omeprazole and similar agents should be taken 30 minutes before meals.
- The authors noted that in addition to reflux, that reflux hypersensitivity can “respond to fundoplication…treatment success was 71% among the 14 with reflux hypersensitivity and 62% among the 13 with abnormal acid reflux.”
Limitations: The VA population is not representative of the general population; this trial had a predominance of white males. Also, it is hard to exclude that some of the ‘success’ of the procedure could relate to a powerful placebo response.
My take: This trial reinforces the notion that reflux surgery is helpful in very few highly-selected patients.
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Briefly noted: GR D’Haens, C Jobin. Gastroenterol 2019; 157: 624-36. This review sums up the emerging evidence for use of fecal microbial transplantation for conditions besides recurrent Clostridium difficile infection.
Table 2 succinctly provides list of disease, types of study/evidence, and potential effect.
- Among gastrointestinal diseases, the authors note that there is an “overall positive” effect for ulcerative colitis, “suggestive” benefits for IBS, GVHD, post-antibiotic diarrhea, constipation, and hepatic encephalopathy. No effect has been evident with Crohn’s disease or pouchitis.
- Among nongastrointestinal diseases, the authors note a “suggestive” benefit in autism and metabolic syndrome and “unknown” effect with psoriasis and multiple sclerosis.
My take: The review indicates a need for more studies and the need to define which factors in fecal material mediate the therapeutic effects.
Related article: OC Aroniadis. Lancet Gastroenterology and Hepatology; 2019. https://doi.org/10.1016/S2468-1253(19)30198-0. In this double-blind, randomized, placebo-controlled crossover trial in patients aged 18–65 years with moderate-to-severe IBS-D with 48 patients, FMT (capsule study) was safe, but did not induce symptom relief at 12 weeks compared with placebo.
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Here’s the link: Talking to your patients about ranitidine Thanks to John Pohl for sharing this information.
Talking to your patients about ranitidine
The recent FDA safety alert might be causing concern among your patients about their heartburn treatment.
The FDA recently released several safety alerts on ranitidine formulations, including the brand-name drug Zantac, that were found to contain a nitrosamine impurity called N-nitrosodimethylamine (NDMA) at low levels. NDMA is classified as a probable human carcinogen (a substance that could cause cancer) based on results from laboratory tests and animal studies. NDMA is a known environmental contaminant and found in water and foods, including meats, dairy products, and vegetables. This contaminant is similar to was recently found in losartan, an angiotensin II receptor blocker used to treat hypertension, that was recalled by the FDA.
The FDA is continuing to test ranitidine products from multiple manufacturers and is assessing the potential impact on patients who have been taking ranitidine.
With the voluntary recall of 14 lots of prescription ranitidine capsules distributed by Sandoz Inc., as well as the voluntary recall of over-the-counter (OTC) ranitidine tablets (75 mg and 150 mg), labeled by Walgreens, Walmart, and Rite-Aid and manufactured by Apotex Corp, your patients might be asking a lot of questions about whether to continue to using their medicines and what alternatives are available.
TALKING TO YOUR PATIENTS
The FDA safety alerts have been covered by various media outlets since early September. This may cause your patients to question whether they should stay on or start using ranitidine products. When discussing the recall with your patients, let them know that:
- Ranitidine is an H2 blocker (antihistamine) — available OTC and in prescription strength — used to prevent and relieve heartburn associated with acid ingestion and sour stomach. It reduces stomach acid and works longer but not as quickly as antacids.
- Not all ranitidine medicines marketed in the U.S. are being recalled and the FDA is not recommending individuals stop taking all ranitidine medicines at this time.
- It might be prudent to hold off taking Zantac until a final FDA conclusion.
- Multiple drugs are approved for the same or similar uses as ranitidine. Other treatment options are available, both prescription and OTC, for patients who are concerned about ranitidine.
- Life-style modifications may reduce or eliminate the need for heartburn drugs for long-term use. These may include weight loss, avoiding tobacco or a change in eating patterns. Share AGA’s patient education content on gastroesophageal reflux disease (GERD) for more tips for your patients.
Related blog post: Preliminary Recommendations from NASPGHAN on Ranitidine Warnings