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Effect of Ranitidine Intake on the Risk of Gastric Cancer Development

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Effect of Ranitidine Intake on the Risk of Gastric Cancer Development healthcare Article Effect of Ranitidine Intake on the Risk of Gastric Cancer Development SunMoon Kim 1,†, Suehyun Lee 2,†, JeeYoung Hong 3, Inseok Ko 2 , Jong-Yeup Kim 2,4,* and Dong-Kyu Kim 5,6,* 1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, Konyang University, Daejeon 35365, Korea; [email protected] 2 Department of Biomedical Informatics, College of Medicine, Konyang University, Daejeon 35365, Korea; [email protected] (S.L.); [email protected] (I.K.) 3 Biomedical Research Institute, Konyang University Hospital, Daejeon 35365, Korea; [email protected] 4 Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Konyang University, Daejeon 35365, Korea 5 Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Korea 6 Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon 24253, Korea * Correspondence: [email protected] (J.-Y.K.); [email protected] (D.-K.K.); Tel.: +82-33-240-5180 (J.-Y.K.); +82-42-600-8679 (D.-K.K.); Fax: +82-33-241-2909 (J.-Y.K.); +82-42-543-8959 (D.-K.K.) † These authors contributed equally to this work as first authors. Abstract: Gastric cancer is one of the most prevalent cancers globally, with high mortality, particularly in East Asia. Certain ranitidine products contain potentially carcinogenic N-nitrosodimethylamine. We investigated the potential association between gastric cancer risk and ranitidine intake using a nationwide cohort, extracted from the Korean National Health Insurance Service. In this longitudinal study, we employed a 1:1 propensity score matching according to sociodemographic factors. A total of 40,887 subjects were enrolled, of which 906 developed gastric cancer during the follow-up Citation: Kim, S.; Lee, S.; Hong, J.; Ko, I.; Kim, J.-Y.; Kim, D.-K. Effect of period. We investigated gastric cancer events during the follow-up period using the survival analysis, Ranitidine Intake on the Risk of Gastric log-rank test, and Cox proportional hazards regression models to estimate incidence, survival rate, Cancer Development. Healthcare 2021, and hazard ratio. The incidence of gastric cancer was 67,422; 67,470; and 67,444 person-years in the 9, 1071. https://doi.org/10.3390/ control, other histamine-2 blockers, and ranitidine groups, respectively. Because the adjusted hazard healthcare9081071 ratio of gastric cancer was 0.98 and 1.01 in the other histamine-2 blockers and ranitidine groups, respectively, we could not calculate the likelihood of gastric cancer development in the ranitidine Academic Editor: Pedram Sendi group. Ranitidine intake did not significantly increase the incidence of gastric cancer. Therefore, the relative risk of gastric cancer may be low in patients taking ranitidine products in South Korea. Received: 6 August 2021 Accepted: 17 August 2021 Keywords: East Asia; gastric cancer; histamine-2 blocker; N-nitrosodimethylamine; ranitidine Published: 20 August 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in 1. Introduction published maps and institutional affil- iations. Gastric cancer is one of the most common cancers worldwide; however, its incidence is relatively high in Eastern and Central Asia and Latin America [1–3]. The majority of gastric cancers are adenocarcinomas, whereas gastrointestinal stromal tumors and primary gastric lymphoma account for a relatively low proportion of all gastric cancers. To date, well-known risk factors of gastric cancer include Helicobacter pylori infection, smoking, Copyright: © 2021 by the authors. alcohol, and chemical exposure [4–8]. In addition, the findings of various studies support Licensee MDPI, Basel, Switzerland. This article is an open access article the hypothesis that the consumption of salted, smoked, and pickled foods containing high distributed under the terms and levels of nitrosamines might be associated with an increased risk of upper gastrointestinal conditions of the Creative Commons tract cancer [9–13]. Attribution (CC BY) license (https:// Nitrosamines are produced by the reaction of nitrates and nitrites to other proteins; creativecommons.org/licenses/by/ N-nitrosodimethylamine (NDMA) is one of the most frequently occurring nitrosamines 4.0/). Healthcare 2021, 9, 1071. https://doi.org/10.3390/healthcare9081071 https://www.mdpi.com/journal/healthcare Healthcare 2021, 9, 1071 2 of 9 in various foods [14,15]. High concentrations of nitrosamines in the diet are carcino- genic [16,17]. In 2019, the US Food and Drug Administration announced that certain ranitidine medications were recalled because the NDMA levels in them were higher than the acceptable intake limit [18,19]. Following this, the Ministry of Food and Drug Safety in South Korea also suspended the manufacture and sale of 269 ranitidine products after assessing their NDMA levels. According to the ministry, seven of these products had NDMA levels as high as 53.50 ppm, which significantly exceeds the provisional standard of 0.16 ppm, assuming that a patient takes the maximal dose of 600 mg daily for life. To date, several studies from other countries have noted that there is no demonstrable association between ranitidine long-term use and future gastric cancer [20–22]. However, other studies showed that NDMA-contaminated ranitidine could increase the risk of cancer [23,24]. Therefore, in this study, we investigated the association between the intake of ranitidine and the risk of gastric cancer development by comparing the incidence of gastric cancer in patients who were administered ranitidine versus that in patients who used other histamine-2 blockers or no treatment. For this analysis, we used a nationwide representative sample of 1,025,340 adults from the National Sample Cohort of the Korea National Health Insurance Service (KNHIS-NSC). 2. Experimental Section 2.1. Korea National Health Insurance Service This study adhered to the tenets of the Declaration of Helsinki and used data from the national health claims database collected by the KNHIS. It was approved by the Institutional Review Board of Hallym Medical University, Chuncheon Sacred Hospital (No. 2020-52), and the need for written informed consent was waived as the KNHIS-NSC dataset used in the study comprised de-identified secondary data. The KNIHS employs the Korean Classification of Diseases (KCD), which is similar to the International Classification of Diseases, as a system of diagnostic practice codes. Here, we used data from the KNHIS- NSC collected from 2002 to 2013, containing information of 1,025,340 representative random subjects and accounting for approximately 2.2% of the South Korean population in 2002 (46 million). Stratified random sampling was performed using 1476 strata with respect to age (18 groups), sex (2 groups), and income level (41 groups: 40 with health insurance and 1 medical aid beneficiary). 2.2. Study Population The patients in this study included all those who were prescribed ranitidine products (ranitidine and nizatidine) or other histamine-2 blockers (cimetidine, famotidine, roxatidine, and lafutidine) for more than 30 days between January 2002 and December 2008. Each patient was tracked until 2013, and patients diagnosed with gastric cancer (KCD C16) were identified. We excluded the following patients: (1) those under 20 years of age; (2) those who died as a result of any cause before 2009; (3) those diagnosed with any malignancy between 2002 and 2008; and (4) those diagnosed with other malignancies before the diagnosis of gastric cancer and several other gastric diseases (polyp, erosion, and ulcer: KCD D13.0, D13.1, D13.2, K25, and K26) since 2009. We also excluded patients who were prescribed proton-pump inhibitors (PPIs) because of their potential carcinogenicity in patients with gastric cancer arising from hypergastrinemia, gastric atrophy, and bacterial overgrowth in the stomach. 2.3. Predictor and Outcome Variables The details of patients, including age, sex, residence, household income, disability, nonsteroidal anti-inflammatory drug (NSAID) doses, and history of smoking and alcohol consumption were obtained from the database. The study population was divided into three age groups (<45, 45–64, and >65 years), three income groups (low: ≤30%, middle: 30.1–69.9%, and high: ≥70% of the median), three residential areas (Seoul, the largest metropolitan region in South Korea; other metropolitan cities in South Korea; and small Healthcare 2021, 9, 1071 3 of 9 cities and rural areas), and two disability-based groups (with and without). In addition, five groups were formed according to NSAID dose (none, ≤60 days, 61–120 days, 121–180 days, and >180 days) and three groups according to smoking history (never, former, and current) and alcohol use (rare; intermediate: 1–2 times per month/week and <3 shots of soju; heavy: ≥3 times per week and >7 shots of soju). Soju is a clear, colorless distilled beverage of Korean origin, and a shot of soju contains 11 g of alcohol. The operational definitions of the study endpoints were all-cause mortality or gastric cancer incidence. All patients who had no event and were alive until 31 December 2013 were censored after this time point. The risk of gastric cancer was compared between the ranitidine group, other histamine-2 blockers group, and the control group using person-years at risk, which was defined as the duration between the start of ranitidine or other histamine-2 blockers or 1 January 2009 (for the control)
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