Letter from the Editor

Gary R. Lichtenstein, MD, AGAF, FACP, FACG

Medicine is a continually evolving field. Occasionally, we encounter advances in knowledge that are relatively straightforward: a gene is found that explains how and why a particular condition develops, a randomized controlled trial links a risk factor with a disease, or a new drug is shown to be effective for a disorder. Often, however, the progression of knowledge is a back-and-forth conversation in which definitive evidence is lacking, available data are inconsistent, and consensus is elusive. In these latter cases, we must work hard to stay abreast of the latest developments.

One question that has recently generated much discussion is whether proton pump inhibitors (PPIs) are associated with an increased risk of fractures. (This risk, as well as other safety issues associated with PPI use, is discussed in a clinical roundtable monograph included in this month’s issue.) Early epidemiologic studies found that PPI use was associated with an increased risk of hip
and/or spine fractures, and other studies suggested that the risk of fractures was higher in patients who used PPIs at higher doses and/or for longer durations. Although none of these data came from randomized controlled trials—which are still the gold standard in medicine, as in most areas of science—the US Food and Drug Administration (FDA) nonetheless issued a warning in May 2010 based on the available observational data. Specifically, the FDA required that labeling for both prescription-strength and over-the-counter PPIs include information about the risk of hip, spine, or wrist factures. Just as this issue of Gastroenterology & Hepatology was being prepared, however, the FDA revised its warning regarding over-the-counter PPIs. Because the highest risk of fractures is seen in patients who take prescription-strength PPIs and/or use these medications for more than 1 year, a Drug Safety Communication released on March 23, 2011 stated that over-the-counter PPIs no longer need to carry the osteoporosis and fracture warning. (See the updated Drug Safety Communication at http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htm.)

Where does this latest development leave a well-informed clinician? While PPIs are still associated with an increased risk of fractures, the available information now suggests that this risk is minimal in patients who use low-dose PPIs for limited durations. Of course, the risk-benefit ratio differs for every patient, so physicians must always consider all the relevant factors in a particular case. More broadly, this example also illustrates the need to remain aware of any changes that may impact how we practice medicine. Staying on the forefront of medicine means continually learning new things, reviewing previously mastered topics, and developing additional skills.

On that note, I hope you all will find valuable information and new insights in this month’s issue of Gastroenterology & Hepatology. We have 2 features—1 on the management of hepatic encephalopathy and the other on extraintestinal manifestations of inflammatory bowel disease—plus a case describing a Dieulafoy lesion in the afferent limb of a Billroth II reconstruction. This month’s columns address the clinical presentation and treatment of eosinophilic esophagitis in children, techniques for endoscopic mucosal resection of polyps, surgical risks associated with the use of inflammatory bowel disease medications, the diagnosis and treatment of immunoglobulin G4-associated autoimmune cholangiopathy, and management of pancreatic insufficiency due to chronic pancreatitis or pancreatic surgery.

As always, I hope you find these articles informative and interesting. In addition, I look forward to seeing many of you at the upcoming Digestive Disease Week. With a number of sessions, posters, and exhibitor displays, this meeting is a great way to stay abreast of the latest developments in gastroenterology and hepatology. And please remember to stop by the Gastroenterology & Hepatology booth to pick up extra copies of this issue and recent supplements, ask questions about the journal, or just say hello.

Millennium Medical Publishing, Inc