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Do Calcium Channel Blockers and Antimuscarinics Protect

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Do Calcium Channel Blockers and Antimuscarinics Protect 1734 COLON Gut: first published as 10.1136/gut.52.12.1734 on 21 November 2003. Downloaded from Do calcium channel blockers and antimuscarinics protect against perforated colonic diverticular disease? A case control study C R Morris, I M Harvey, W S L Stebbings, C T M Speakman, H J Kennedy, A R Hart ............................................................................................................................... Gut 2003;52:1734–1737 Background: The aetiology of perforated colonic diverticular disease (PCDD) remains largely unknown. Perforation may result from a combination of high intracolonic pressures, secondary to excessive colonic segmentation, and impairment of the mucosal barrier. Calcium channel blockers and antimuscarinic drugs, which reduce colonic contractility and tone, could potentially protect against perforation. The aim of See end of article for this study was to test this hypothesis using a case control design. authors’ affiliations Methods: All cases of acute PCDD were identified over a five year period in two hospitals in Norfolk, UK. ....................... Each case was matched for age, sex, and date of admission to two controls groups: (1) patients Correspondence to: undergoing cataract surgery and (2) patients with basal cell carcinoma. Data on drug use prior to hospital C R Morris, Research admission were obtained from medical and nursing records and compared between cases and controls. Fellow, School of Medicine Results: A total of 120 cases of PCDD were identified and matched to 240 controls in each group. A Health Policy and Practice, statistically significant protective association was seen between calcium channel blocker use and PCDD Elizabeth Fry Building, University of East Anglia, using both control groups. The odds ratios were 0.41 (95% confidence interval (CI) 0.18–0.93) using the Norwich NR4 7TJ, UK; ophthalmology control group and 0.36 (95% CI 0.16–0.82) using the dermatology control group. [email protected] Conclusions: This study has shown for the first time that a protective association exists between calcium Accepted for publication channel blockers and PCDD. The validity of this association is supported by the consistent finding in both 23 July 2003 control groups and the plausible biological mechanisms. Further studies are required to confirm this ....................... association but calcium channel blockers may represent a potential preventive therapy in PCDD. erforation of a colonic diverticulum is a serious condition hypertension, their smooth muscle relaxant properties have with case fatality rates of between 12% and 36%.12The been used to treat patients with irritable bowel syndrome,15 Pillness also results in considerable morbidity with many oesophageal spasm,16 and anal fissures.17 However, no study http://gut.bmj.com/ patients requiring multiple operations and the formation of a has examined their role in the treatment of colonic stoma. In the UK, it has been estimated that approximately diverticular disease or in preventing perforation. A second 2000 people each year will suffer from an abscess or group of drugs that might protect against perforation are generalised peritonitis secondary to diverticular perforation.3 those with antimuscarinic properties which reduce gastro- The incidence of these severe complications rises with age3 so intestinal tone18 and eliminate the prolonged postprandial that an increasing number of people are likely to be affected colonic activity seen in diverticular disease.19 Antimuscarinic in the future, requiring substantial extra resources from medications are commonly prescribed for depression, psy- on September 27, 2021 by guest. Protected copyright. healthcare services. Currently, the aetiology of diverticular choses, Parkinson’s disease, bladder instability, and respira- perforation is largely unknown and therefore prevention is tory conditions. Their gastrointestinal relaxant properties impossible. have also been used to treat patients with irritable bowel Two factors are likely to be important in the mechanism of syndrome but no study has investigated whether they may diverticular perforation. Firstly, excessive colonic segmenta- protect against diverticular perforation. The aim of this case tion may increase intracolonic pressures leading to mechan- control study was to test, for the first time in an ical weakening of the thin diverticular wall.4–6 Secondly, epidemiological study, the hypotheses that both calcium impairment of the mucosal barrier of the diverticulum, channel blockers and antimuscarinic drugs protect against through alterations in mucus secretion, microbial colonisa- perforated colonic diverticular disease (PCDD). tion, or epithelial cell function,7 may lead to further weakening. Therefore, drugs that reduce intracolonic pres- METHODS sures or protect the colonic mucosa may help to prevent Identification and confirmation of case group perforation. To date, the only medications found to be Hospital inpatient data were used to identify patients with associated with diverticular perforation are non-steroidal PCDD admitted to two hospitals, which serve a population of 8–10 anti-inflammatory drugs (NSAIDs) which may cause this approximately 750 000 people (Norfolk and Norwich 11 complication by impairing the integrity of the mucosa. University Hospital NHS Trust, Norwich and James Paget Calcium channel blockers are a group of drugs that could Hospital, Great Yarmouth, Norfolk, UK). A computer search potentially protect against perforation. They relax gastro- of the international classification of disease (ICD-10) codes intestinal smooth muscle and reduce the frequency of high was used to identify patients admitted to hospital between pressure waves in the colon.12 Furthermore, nifedipine has been shown to increase gastrointestinal mucosal blood flow and protect against immunosuppressant induced intestinal ................................................................ 13 14 injury. Although calcium channel blockers are most Abbreviations: PCDD, perforated colonic diverticular disease; NSAIDs, commonly prescribed for ischaemic heart disease and non-steroidal anti-inflammatory drugs www.gutjnl.com Perforated colonic diverticular disease 1735 1 April 1995 and 27 February 2000. These codes were K57.2 not taking that drug. These odds ratios were adjusted for the (perforation, abscess, or peritonitis of large intestinal confounding effect of NSAID medication, the only known diverticula); K57.4 (perforation, abscess, peritonitis, of both risk factor for this condition. Primary analyses were under- Gut: first published as 10.1136/gut.52.12.1734 on 21 November 2003. Downloaded from the small and large bowel diverticula); and K57.8 (perfora- taken for all calcium channel blockers and antimuscrainics. tion, abscess, or peritonitis of either the small or large bowel Further analyses were performed for short acting and diverticula). modified release calcium channel blockers and tricyclic The hospital records of all potential cases were reviewed by antidepressants, which accounted for the majority of anti- the principal investigator (CRM) to confirm the diagnoses. A muscarinics. The use of cardiovascular medication and patient was included in the case group if there was evidence prevalence of cardiovascular comorbidity were also compared of a macroscopic colonic diverticular perforation at either using conditional logistic regression. Differences in the laparotomy or post mortem. In the absence of a macroscopic number of medications taken by cases and controls were perforation, patients were included if there was evidence of compared using the Wilcoxon signed rank test. extracolonic pus or faeces, in the presence of an inflamed diverticulum, and with no other intra-abdominal pathology RESULTS (implying a sealed perforation). Finally, patients who did not Case group characteristics undergo laparotomy were included if there was radiological A total of 120 consecutive patients with confirmed PCDD evidence (computed tomography, ultrasound, or contrast were identified during the study period. The case group enema) of a colonic diverticular abscess. Patients with the consisted of 39 (32.5%) men and 81 (67.5%) women with a chronic sequelae of perforation such as colonic stricture and median age of 74 years (range 30–95). Prior to hospital fistulae were excluded. These complications may be present admission, 46 people (38%) were known to have colonic for some time before admission to hospital, presenting diverticular disease from previous radiological or endoscopic difficulties in determining whether drug exposures occurred investigations. However, only 16 (13%) had previously been before the onset of the illness. admitted to hospital with a complication of diverticular disease. The clinical management was surgical in 107 (89%) Selection of the control groups cases, the most frequent operative finding being purulent Two control groups were used, with each case matched for peritonitis (43%) followed by abscess (23%) and faecal age (within one year), sex, and hospital of admission to two peritonitis (22%). The overall mortality rate was 26%, ranging patients from each control group. The first control group were from 14% in patients with an abscess to 48% in those with patients admitted for cataract surgery within three months of faecal peritonitis. It was possible to accurately match case the case admission (ophthalmology control group). The group patients so that the age and sex characteristics of cases second control group
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