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Oral intolerance for esophagitis secondary to alendronic acid
Intolerancia oral por esofagitis secundaria a ácido alendrónico
Lucía Zabalza San Martína,
Corresponding author
luciazabalzasanmartin@gmail.com

Corresponding author.
, Cristina Saldaña Dueñasa, Marta Gómez Alonsoa, Gregorio Aisa Riberab
a Servicio de Aparato Digestivo, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
b Servicio de Anatomía Patológica, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Alendronate sodium &#40;Fosamax&#174;&#41; is an oral osteoclast inhibitor which reduces bone resorption and is indicated for the treatment of Paget&#39;s disease and osteoporosis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In 1996&#44; after the drug had been available on the market for only a year&#44; the United States Food and Drug Administration &#40;FDA&#41; put out an alert about the need for preventive measures when administering the drug to prevent oesophagogastric lesions&#44; in particular erosive or ulcerative oesophagitis&#46; The mechanism behind the injury is unknown&#44; but it has been suggested that direct contact with the mucosa may be involved&#46; Consequently&#44; those prescribed this drug should take it 30&#8239;min after their first meal of the day with plenty of water&#44; and remaining standing or sitting up for at least 30&#8239;min&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 62-year-old female smoker with osteoporosis who was admitted from the Accident and Emergency Department with a 24-h history of retrosternal pain&#44; odynophagia and dysphagia for solids and liquids&#46; She denied previous heartburn&#44; dysphagia and general adaptation syndrome&#46; She had been taking one 70-mg tablet of alendronic acid in an effervescent formulation every seven days for three weeks&#46; Physical examination revealed no findings of note&#44; with no crepitus of the neck or chest&#44; abdomen non-tender on palpation and no masses or organomegaly&#46; Blood testing showed leucocytosis of 15&#44;000 with a neutrophil count of 11&#44;600 and a C-reactive protein &#40;CRP&#41; level of 50&#46; The patient subsequently had a spike of fever at 38&#176;C&#44; with no microbiological isolation&#46; She was started on empirical treatment with intravenous analgesia and intravenous omeprazole 40&#8239;mg every 12&#8239;h&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Gastroscopy identified friable mucosa&#44; whitish exudate and ulceration covering the entire circumference in the distal segment of the oesophagus&#44; suggestive of severe oesophagitis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Biopsies were negative for cytomegalovirus &#40;CMV&#41; and for herpes simplex virus &#40;HSV&#41; types I and II&#46; Histology showed sheets of flat&#44; non-keratinised&#44; multi-layered epithelium particular to the oesophagus and remnants of ulcerated tissue with fibrin&#44; in addition to polymorphonuclear cells&#46; Periodic acid&#8211;Schiff &#40;PAS&#41; and GROCOTT staining were performed to rule out the presence of fungi&#44; with negative results&#46; Immunohistochemistry for CMV and HSV was also performed and also found to be negative&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient subsequently followed a good clinical course with oral omeprazole and sucralfate&#46; She regained suitable tolerance to an oral diet and so was discharged home with outpatient follow-up&#46; Gastroscopy one month later showed mucosal healing&#44; and biopsies were normal&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Oesophagitis associated with the use of alendronate is a type of drug-induced oesophagitis&#46; Its prevalence is at least 1&#46;5&#37;&#44; but can be much higher if preventive measures are not properly taken during drug administration&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It can present with odynophagia&#44; dysphagia for solids and liquids&#44; retrosternal pain&#44; epigastric pain&#44; fever and even haematemesis&#44; sometimes requiring hospital admission&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Oesophageal strictures may also occur at a later stage&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Symptoms can appear two to four weeks after starting treatment&#59; however&#44; in our case&#44; they occurred only four days later&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Characteristic endoscopic findings are large erosions with variable morphology and dense whitish exudate in the distal and medial segments&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">While there are no pathognomonic pathology findings for this condition&#44; in two published reviews&#44; one by Abraham et al&#46; and the other by Ribeiro et al&#46;&#44; histopathology findings generally consisted of granulation tissue and inflammatory exudate&#46; In addition&#44; it is common to find polarisable foreign material with a crystalline&#44; clear&#44; refractive appearance mixed with inflammatory exudates&#44; probably related to prolonged contact between the drug and the mucosa&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> Other possible findings are multinucleated giant cells with inflammatory exudate and reactive squamous cells close to the ulcers&#46; In our case&#44; no polarisable material was identified&#44; but inflammatory cells were&#46; These changes can be mistaken for HSV oesophagitis&#59; hence&#44; immunohistochemistry techniques are important for distinguishing between them&#46; In our case&#44; these tests were negative&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A thorough medical history&#44; upper gastrointestinal endoscopy and histology are essential for diagnosing this disorder&#46; Infectious oesophagitis&#44; mainly herpes or candida&#44; must be ruled out as it would require specific treatment&#59; candida is more common in immunosuppressed patients&#46; To conclude&#44; this disease is not to be overlooked&#44; as it can be prevented with hygiene and dietary measures when administering the drug&#46;</p></span>"
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Article information
ISSN: 24443824
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos