Normal in 25% of erosive esophagitis and 50% in NERD
Confirmation test
Esophageal manometry
NO ROLE
PPI test in typical GERD PPI test in typical GERD
Dosage
• Omeprazole 20 – 80 mg
• Lansoprazole 60 mg
• Rabeprazole 40 mg
• Esomeprazole 40 mg
Duration
7 – 28 days
Sensitivity 27 – 89 %
Specificity 35 – 73% Depend on dose, DurationAnd gold standard test (s)
11/19/2012
4
Inclusion
Consultation n = 31Advertisement n = 59
Eligible for inclusion N = 90
Unanalysable n = 16
Refused participation n = 2
Failed catheter insertion n = 1
Intolerance catheter n = 3
No symptoms during pH study n = 9Achlorhydria n = 1
PPI test n = 74
PPI test + n = 58
PPI test -n = 9
Missing n = 7
GERD n = 41
No GERD n = 17
GERD n = 5
No GERD n = 4
Annen MC. Aliment Pharmacol Ther 2006.1377-1384
Symptom scores and the prevalence of reflux Symptom scores and the prevalence of reflux symptoms at baseline symptoms at baseline
Annen MC. Aliment Pharmacol Ther 2006.1377-1384
Symptoms
prevalence (%)
Symptom score,
mean (95% CI)
Reflux symptoms
Heartburn
Regurgitation
Epigastric burning
Acid taste
Chest pain
Epigastric pain
Total
82
75
70
48
46
44
Total
10.1 (8.3 – 11.7)
5.6 (3.8 – 7.4)
8.4 (6.6 – 10.2)
5.3 (3.5 – 7.1)
4.7 (3.0 – 6.5)
7.7 (5.8 – 9.5)
CI, Confidence interval
Sensitivity and specificity of the symptoms scored at Sensitivity and specificity of the symptoms scored at baseline calculated with SAP as reference standard baseline calculated with SAP as reference standard
Reflux symptoms Sensitivity Specificity
(%) 95% CI (%) 95% CI
Heartburn
Regurgitation
Epigastric Burning
Acid taste
Chest pain
Epigastric pain
87
82
73
45
42
40
0.74 – 0.94
0.69 – 0.91
0.59 – 0.84
0.31 – 0.60
0.29 – 0.57
0.27 – 0.55
27
41
38
45
45
48
0.12 – 0.50
0.21 - 0.63
0.19 – 0.61
0.60 – 0.67
0.25 – 0.67
0.26 – 0.70
Annen MC. Aliment Pharmacol Ther 2006.1377-1384
Symptoms suggestive of GERDSymptoms suggestive of GERD
AlarmAlarm Yes
Typical Atypical
LSM plusStandard dose
PPI 4 wk
LSM plusDouble dose PPI 2 wk(consider 4-12 wks for
atypical GERD)
StopStopMaintain
for at least 4 wks
On-demand/Continuous Rx
EGD/ Re-evaluation
No
No improvement within 12 wks
symptom
persist
Symptom
persist
Symptom
persist
Alarm symptoms
Symptom
No
Symptoms free
Recurrent symptoms
• Dysphagia• Odynophagia• Frequent vomiting• GI bleed / anemia• Weight loss*Exclude other condition
Alarm features present Alarm features absent
PPI therapy 4 wks and review at 2 to 4 wks
Symptoms respond
Trial of stopping PPI
Relapse
Restart PPIOn demand therapy
Frequent relapses, or
Alarm features
Refer for EGD, 24 pH and H.pylori
test
Stop PPIat least
1 wk
Symptoms persist
2006 Asia Pacific Consensus on the Management of GERD
Algorithm Uninvestigated Typical Reflux Symptoms
GERD: Initial Management
Symptom-baseddiagnosis
Riskassessment
Empiricaltherapy
Labenz, Malfertheiner. World J Gastroenterol 2005
NERD
RE~35%
CRD~5%
~60%
Endoscopy
Alarmsymptoms
Reflux esophagitis
Complicated reflux disease
Non-erosive
reflux disease
~95% of patients
in primary care
Treatment failure
11/19/2012
5
Summary: Therapy of GERDSummary: Therapy of GERD
PPI PPI Initial Treatment Initial Treatment
4 4 weeksweeks
PPI PPI MaintenanceMaintenance
PPI PPI On demandOn demand
Uninvestigated,
Mild EE or NERD
Severe EE,
Frequent attacks
or Slow PPI response
Unsatisfactory response
Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture
Objective To determine the association between PPI therapy an d risk of
hip fracture
Design Setting, and Patients A nested case-control study was conducted using the General
Practice Research Database (1987-2003 in the United Kingdom
There were 13 556 hip fracture cases and 135 386 co ntrols
Yang YX. JAMA. 2006;296(24):2947-53.
Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture
Yang YX. JAMA. 2006;296(24):2947-53.
Summary: Long-term Proton Pump Inhibitor Therapy and Risk of Hip Fracture
- The adjusted odds ratio (AOR) for hip fracture ass ociated with more than 1 year of PPI therapy was 1.44 (95% CI).
- The risk of hip fracture was significantly increas ed among patients prescribed long-term high-dose PPIs (AOR, 2.65; 95% CI; P<.001).
- The strength of the association increased with inc reasing duration of PPI therapy
*AOR for 1 year, 1.22 (95% CI) 2 years, 1.41 (95% CI) 3 years, 1.54 (95% CI) 4 years, 1.59 (95% CI)
P<.001 for all comparisons
Yang YX. JAMA. 2006;296(24):2947-53.
PPI and risk of Community PPI and risk of Community ––acquired Pneumoniaacquired Pneumonia
• Population based study from Furen,Denmark
2000-2004.
• 7642 CAP and 34176 control subjects (age,sex
match)
• Diagnosis confirmed by x-ray and microbiological
samples
• Logistic regression analysis
Sinem Ezgi Gulmez et al. Arch Intern Med 2007;167:950-55
Association Between Exposure to Proton Pump Inhibit ors (PPIs) Association Between Exposure to Proton Pump Inhibit ors (PPIs)
or Histamineor Histamine 22--Receptor Antagonists (HReceptor Antagonists (H 22RAs) and CommunityRAs) and Community--
Acquired Pneumonia (CAP)Acquired Pneumonia (CAP)
Sinem Ezgi Gulmez et al. Arch Intern Med 2007;167:950-55
11/19/2012
6
Sinem Ezgi Gulmez et al. Arch Intern Med 2007;167:950-55
StratumStratum--Specific Odds Ratios (ORs) for the Associa tion Between Specific Odds Ratios (ORs) for the Association Betw een
Current Use of Proton Pump Inhibitors (PPIs) and Co mmunityCurrent Use of Proton Pump Inhibitors (PPIs) and Co mmunity--
Acquired Pneumonia (CAP)Acquired Pneumonia (CAP)
Association Between the Use of Proton Pump Inhibito rs (PPIs) and Community-Acquired Pneumonia (CAP), Subgroup An alysis
Within Modified End Points
Sinem Ezgi Gulmez et al. Arch Intern Med 2007;167:950-55
Subgroup of cases Cases, Exposed / Unexposed
X-Ray – positive CAP (n = 3942)
X-Ray – negative CAP (n = 3700)
Fatal CAP (n = 692)
Streptococcal CAP (n = 776)
Airborne pathogen demonstrated
(n = 1639)
No airborne pathogen demonstrated
(n = 6003)
432/3510
385/3315
129/563
51/725
91/1548
726/5277
Summary Summary
• The adjusted odds ratio (OR)
Associating PPI and CAP was
1.5(1.3-1.7).
• Association was strong for
younger group(<40 year-old)
:2.3(1.3-4.0)
• Recent treatment with PPI
<7 days had strong
correlation:5(2.1-11.7)
Sinem Ezgi Gulmez et al. Arch Intern Med 2007;167:950-55
0
1
2
3
4
5
6
0-7 8-14 15-28 29-56 57-84 >84
Ad
just
ed
OR
s
First – Ever PPI Prescription, Days before index date
Risk of Risk of C. C. difficiledifficile diarrhea among hospital in diarrhea among hospital in patients with PPIpatients with PPI
Sandra Dial et al CMAJ 2004;171(1)33-8
Relative risk of Clostridium difficile diarrhea in relation to use of PPIS in cohort of 1187 patients Who received antibiotics while in hospital
Variable
No. of cases of diarrhea / total no. with risk factor (%) RR (95% CI)
