Care Initiative Gerd Chicago Meeting Slides PDF

8/14/2019 Care Initiative Gerd Chicago Meeting Slides PDF

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CARE Initiative on

ot ty sor ersin Primary Care:

ERD

11


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FACP, FAACHEmeritus Chief, Division of Gastroenterology

on e ore e ca en er anAlbert Einstein College of MedicineProfessor of Medicine and Sur erAlbert Einstein College of Medicine

New York, New York

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Faculty

John Allen, MD, MBA, AGAFMedical Director for QualityMinnesota GastroenterologyChair, AGAI Clinical Practice and Quality Management CommitteeClinical Councillor, AGA Governing Board

Peter J. Kahrilas, MD, AGAFGilbert H. Marquardt Professor of Medicine

Lead author of AGA guidelines

Stuart S echler MD AGAFChief, Division of Gastroenterology, Dallas VA Medical CenterProfessor of Medicine, Berta M. and Cecil O. Patterson Chair inGastroenterolo

33University of Texas Southwestern Medical Center at Dallas


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Accreditation and Funding

This activity has been planned and implemented in

accordance with the Essential Areas and Policies ofthe Accreditation Council for Continuing MedicalEducation (ACCME) through joint sponsorship of

,Associates LLC, Medikly, and PeerView AcademicNetwork. Albert Einstein College of Medicine isaccredited by the ACCME to provide continuing

medical education for physicians.

This activity is funded through an educational grantfrom Takeda Pharmaceuticals North America, Inc.

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S onsorshi

Co-sponsored by: Albert Einstein College of,Association, DIME, and PeerPoint MedicalEducation Institute, LLC

Jointly sponsored by: Albert Einstein College ofMedicine, Montefiore Medical Center, Gullapalli& Associates, LLC, Medikly, and PeerView

Academic Network

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Conflict of Interest Statement

The Conflict of Interest Disclosure Policy of Albert Einstein

College of Medicine requires that faculty participating in anyCME activity disclose to the audience any relationship(s) witha pharmaceutical, product, or device company. Anypresenter whose disclosed relationships prove to create a

conflict of interest with regard to their contribution to theactivity will not be permitted to present.

faculty participating in any CME activity disclose to the

audience when discussing any unlabeled or investigationaluse of an commercial roduct or device not et a roved foruse in the United States. The Albert Einstein College ofMedicine CCME staff has no conflicts of interest withcommercial interests related directl or indirectl to this

66educational activity.


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Facult DisclosuresJohn Allen, MD, MBA, AGAF

Sources of Funding for Research:NoneConsulting Agreements:Medtronic, Inc.

Speakers Bureau/Honorarium Agreements:None

Financial Interests/Stock Ownership:None

Discussion of Off-Label, Investigational, or Experimental Drug Use:None

Lawrence J. Brandt, MD, MACG, AGAF, FASGE, FACP, FAACH

Sources of Funding for Research:None

Consulting Agreements:NoneS eakers Bureau/Honorarium A reements:None



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Facult Disclosures contPeter J. Kahrilas, MD, AGAF

Sources of Funding for Research:National Institutes of HealthConsulting Agreements:AstraZeneca Pharmaceuticals LP; RevalesioCorporation; XenoPort, Inc.


Financial Interests/Stock Ownership:NoneDiscussion of Off-Label, Investigational, or Experimental Drug Use:None

Stuart Spechler, MD, AGAF

Sources of Funding for Research:AstraZeneca Pharmaceuticals LP;Takeda Pharmaceuticals; BARRX Medical, Inc.

Consulting Agreements:Procter & Gamble



88Discussion of Off-Label, Investigational, or Experimental Drug Use:None


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Plannin CommitteeRosalee Blumer, MA

DIME EditorConsulting Agreements:NoneSpeakers Bureau/Honorarium Agreements:None


CCME of Albert Einstein College of Medicine

Sources of Funding for Research:NoneConsultin A reements:Procter & GambleSpeakers Bureau/Honorarium Agreements:NoneFinancial Interests/Stock Ownership:Bioheart, Inc.; Chelsea Therapeutics, Inc.;Pharmacopeia, Inc.



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Plannin Committee contBonny McClain, MS, DC

Gullapalli & Associates EditorConsulting Agreements:NoneSpeakers Bureau/Honorarium Agreements:None


. ,The AGA Institute

Sources of Funding for Research:NoneConsultin A reements:Procter & GambleSpeakers Bureau/Honorarium Agreements:NoneFinancial Interests/Stock Ownership:NoneDiscussion of Off-Label, Investigational, or Experimental Drug Use:None


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The staff of CCME of Albert Einstein College of Medicine,The American Gastroenterological Association,

Gullapalli & Associates, and DIME have no conflictsof interests to report with commercial interests related

rec y or n rec y o s e uca ona ac v y.


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Continuing Education Credit

Albert Einstein College of Medicine designates this

educational activity for a maximum of 4.0 AMA PRACategory 1 Credits. Physicians should only claimcredit commensurate with the extent of their participationin the activit .

Participants must complete and return the evaluationform at the conclusion of this activit to receive credit.

Certificates will be available online. Please visit. .receive your certificate.

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Primary Care Management of

OverviewMultidisciplinary, multi-interventional educational

program that provides relevant and concise,

validate, and address the gaps and barriersrelated to gastroesophageal reflux disease(GERD) care in the primary care setting

Multi le educational activitiesEducational outreach program; 3 regional

workshops; Performance Improvement activity;

1313e-monograp ; anwebsitewww.medikly.com/gerd


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On completion of this activity, participants should beable to:

Identif risk factors for GERD

Demonstrate multidisciplinary management of

referral and surgical options

management of patients at risk for or diagnosedwith GERD

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GERD Case Study 1: Carol

American Gastroenterological Association Institute (AGAI)2008 Guideline Recommendations

GERD Case Study 2: JimQuestion and Answer Session

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Audience Response System (ARS)

When instructed, press the number

button s that corres ond with our selectedanswer (you do not need to press Enter)

Individual res onses will be dis la ed in the

screen at the top of the keypad

If ou want to chan e our answer ressthe C keyto clear; you may enter a new

answer as long as voting is open Audience results will be displayed on your

main screen immediately after voting is


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GERD

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The Need for Performance Improvement

Performance Improvement (PI) is designed to measure

and demonstrate ractice rocess chan es that arelinked by evidence to improved patient outcomes

Selected activities will inte rate a continuous rocess b

which a provider or a practice environment participatesin the following:

ses e a es gu e nes or mprove pa en care

Improves providerpatient communication

Assesses baseline knowledge regarding the GERD guidelines

Learns about specific performance measures

Retrospectively assesses their clinical practice

useful interval and re-evaluates performance


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CARE Initiative on GI Motility Disorders in

a en -re a e arr ers

From the atients ers ective there are

challenges and barriers to meeting GERDdiagnosis and treatment needs:Lack of awareness about GERD

The psychological impact of GERDPolypharmacy

Poor adherence


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CARE Initiative on GI Motility Disorders

Provider-related barriers in the primary care of GERD Although many providers are involved in the management of

GERD, they experience barriers to optimal care for their

GERD patients, including: Burden of care assigned to PCPs

primary care

Patients psychological resistance to long-term treatment with

Difficulties in referral to gastroenterologists

Financial challenges


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How Can I Im rove Patient Outcomes?

To begin evaluating and potentially improvingpatient care:

1. Go to www.medikly.com/gerd

2. Fill out a brief baseline self-assessment survey3. Gather appropriate patient-level data (based on identified

per ormance measures re rospec ve y or prospec ve yon 10 GERD patients

.

HIPAA = Health Insurance Portability and Accountability Act


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Live support will be available throughout the initiative

All communication will be confidential

- ,

a quantitative report of the data you submitted

an article that will be submitted to a peer-reviewed

journal that focuses on improving patient carenat ona y

You will receive up to 20.0 AMA PRA Category 1

Credits for successful completion of the program*RegistrantsmustcompletetheentireprogramtoreceivethemaximumavailableCME/CNEcredit


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How interested would you be to participate in a

you to do the following for your practice?:

Assess your practice performance against nationally recognized measures.

Compare your practice performance to your peers on a local, regional and.

Compare your performance to other healthcare providers and specialists.(Receive up to 20 CME/CE credits)

Veryinterested

Interested,tell me more

Not at allinterested

1 2 3 4 5 6 7

0 / 100Cross-Tab Label


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Do you have additional questions?

Please speak to personnel on site

or call a PeerPointPerformance Im rovement

site coordinator:

800.777.5790


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Please turn off

cellphones and pagers whileparticipating in todays activity.

Please refrain from photography.

25

.

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Your Presenters for Today

Peter J. Kahrilas, MD, AGAF

.Northwestern University Feinberg School of MedicineLead author of AGA guidelines

Stuart Spechler, MD, AGAFChief Division of Gastroenterolo Dallas VA Medical CenterProfessor of Medicine, Berta M. and Cecil O. Patterson Chair

in Gastroenterology


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What is your specialty?1. Internal medicine

2. Family practice

3. General practitioner4. Physician assistant

5. Physical medicine

6. Gastroenterolo ist

7. Other


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Which of the following best describes your

1. Private (individual)

. r va e par ners p or group3. Hospital-based

4. HMO

5. VA6. Other


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ase u y : aro

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Case Study: Carol

Carol, a 37-year-old African American

,of heartburn and occasional regurgitationof food or fluids into her mouth

Ht 52, W 148 lbs, BMI 27 Cor: Re ular rh thm and normal rate

Labs: Normal, including hemoglobin 13/dL hemocrit 42%

Current meds: inhaler

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x s ng con ons: as ma, a a ern a


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On a scale of 1 to 5, with 1 being notconfident at all, and 5 being extremelyconfident, how would you rate your

con ence n rea ng aro1. Not at all confident

2. Somewhat confident

4. Very confident

3131

.


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Wh n ini i ll r in i n wi h m mof heartburn and regurgitation, which approach

i ll k ?

1. Recommend lifestyle modifications

-. , ,antagonists [H2RAs] and move up to proton pump

inhibitors (PPIs) if symptoms persist3. Step-down approach, ie, start with PPI therapy

4. None of the above

3232


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Clinical Practice Key Points

practice environment


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American Gastroenterological Associationnst tute

2008 Guideline Recommendations For patients with esophageal GERD syndromes, treatment

with antisecretor dru s is recommended for healin

esophagitis, symptomatic relief, and maintenance ofesophageal healing. In this setting, PPIs are moreeffective than H2RAs, which, in turn, are more effectivethan placebo

Grade A: strongly recommended based on goodevidence

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Kahrilas P et al. Gastroenterology. 2008; 135:1392-1413.


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Association Institute (AGAI)

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AGAI 2008 Guidelines

3636Kahrilas P, Shaheen N, Vaezi M. American Gastroenterological Association Institute Technical Review on theManagement of Gastroesophageal Reflux Disease. Gastroenterology. 2008;135:1392-1413.


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Standards of Care for Assessing Evidenceu e nes or

. .guidelines, ie, the US does not put a priority on whichguidelines to use

This process is being refined and may be part ofhealthcare reform, but we are not there yet

AGAI guidelines use US Preventive Services

Task Force (USPSTF) grades to assign strength ofev ence

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USPSTF Grades Usedin AGAI Guidelines

Grade A: strongly recommended based on good evidence that itimproves important health outcomes

important outcomesGrade C: balance of benefits and harm is too close to justify a

Grade D: recommend against; fair evidence that it is ineffective

or that harms outweigh benefits

Grade Insufficient: no recommendation; insufficient evidence torecommend for or against

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Kahrilas P, Shaheen N, Vaezi M. Gastroenterology. 2008;135:1392-1413.


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The Difficulty of Defining GERD

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Symptoms of Gastroesophageale ux sease

ass c symp omsHeartburn

egurg a on

Common symptomsChest pain (noncardiac)

Dysphagia

Source: US National Library of Medicine,National Institutes of Health

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GERD: The Montreal DefinitionGERD is a condition that develops when the reflux of stomach content

causes troublesome symptoms and/or complications

Esophageal syndromes Extra-esophageal syndromes

SymptomaticSyndromes Typical reflux

ProposedAssociation Sinusitis

Syndromes WithEsophageal Injury Reflux esophagitis

EstablishedAssociation Reflux cough

Reflux chestpain syndrome

Pulmonaryfibrosis

Pharyngitis

Recurrent otitis

Reflux stricture

Barrettsesophagus

Adenocarcinoma

Refluxlaryngitis

Reflux asthma

Reflux dentalmediaerosions

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Adapted from Vakil N et al. Am J Gastroenterol. 2006;101:1900-1920.


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What is the Distinction BetweenGERD and Episodic Heartburn?

In the absence of esophageal injury,heartburn of sufficient intensit to be

perceived as troublesome by the patient(after assurance of its benign nature)meets t e ontrea e n t on o a

symptomatic esophageal GERD syndrome

4242Kahrilas P et al. Gastroenterology. 2008; 135:1392-1413.Vakil N et al. Am J Gastroenterol. 2006;101:1900-1920.


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PCP Review of the Pathophsysiology of GERD

External factors

Diet

Tissue resistance Stratified squamous epithelium

Smoking Obesity

Esophageal clearance

Gastric emptying

Body position (gravity)

Antireflux barriers Crural diaphragm Hiatal hernia

Gastric refluxate Acid Pepsin

43434343


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u

What is/are your goal(s) whentreating a patient such as Carolwho has typical symptoms of

1. Relieve the symptoms

2. Prevent relapse and complications

3. Heal the eso ha us

4. All of the above

4444

.


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Goals of Treatment: AGAI Guidelines

Relieve s m toms Prevent relapse and complications

erosive esophagitis

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diagnosing Carol?

. nce- a y r a

2. Endoscopy

3. Manometry

4. H monitorin5. Refer to gastroenterologist

4646

.


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Diagnosis of Uncomplicated GERD:u e nes

PPI therapy is appropriate foratients with uncom licated

heartburn such as Carols,

need exists for endoscopy or

require immediate referral toa specialist)

4747

Kahrilas P et al. Gastroenterology. 2008;135:1392-1413.


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Diagnosis of Uncomplicated GERD:AGAI Guidelines (cont)

Although Carol hascoexistin conditions her

case qualifies asuncomplicated GERDbecause she has no

warning signs

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Which of the following would be a warningsign(s) that would warrant endoscopyand/or immediate referral to a specialist?

1. Weight loss2. GI bleedin

3. Loss of appetite

.

5. Dysphagia

49496. All of the above


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Carols Risk Factors for GERD

ARS Question

? Which of the following is/arerisk factor s for GERD?

1. Overweight

2. st ma

3. Hiatal hernia4. None of the above

5. 1 2 and 3

5050


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Participants perspectives on individual practice


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AR i n: ?Extraesophageal Syndromes

,classified as an extraesophageal syndrome, aswell as laryngitis. If Carol did present with adult-onset asthma or laryngitis concomitant with anycommon or uncommon symptoms of GERD,

1. Yes

. o

3. Depends on physical examination

52524. Not sure


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Treatment of Extraesophageal RefluxSyndromes: AGAI Guideline

Recommendations

Acute or maintenance thera with once- or twice-dailPPIs (or H2RAs) for patients with a suspectedextraesophageal GERD syndrome (laryngitis, asthma)with a concomitant esophageal GERD syndrome

Grade B: recommended with fair evidence that itimproves important outcomes

5353



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Treatment of Extraesophageal Refluxyn romes: u e ne

Recommendations (cont)

Once- or twice-daily PPIs (or H2RAs) for acuterea men o pa en s w po en a ex raesop agea

GERD syndromes (laryngitis, asthma) in the absenceof a concomitant esophageal GERD syndrome

Grade D: recommend against; fair evidence that itis ineffective or that harm outweighs benefits

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Treatment of Extraesophageal Refluxyn romes: u e ne

Recommendations (cont)

Once- or twice-daily PPIs for patients with suspectedre ux coug syn rome

Grade Insufficient: no recommendation; insufficientevidence to recommend for or against

5555



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ues on

Carols GERD symptoms?

.

2. OTC antihistamines

3. Change in diet

4. All of the above5. None of the above

5656


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Nonpharmacologic Approaches

5757


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Weight loss is advised for patients who are overweight

have esophageal GERD syndromes Grade B: recommended with fair evidence that it

5858



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BMI Associated With Symptoms of GERD in Normal

Association Between BMI and GERD Symptoms in Women

3

.

2.92 2.353.62

2.93 (2.243.85)

P


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GERD in both normal weight andoverwei ht women

Even moderate weight gain among

exacerbate symptoms of reflux

6060

Jacobson BC et al. N Engl J Med. 2006;354:2340-2348.


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precipitate refluxCoffee alcohol chocolate

fatty foods

precipitate heartburn

Red sauce tomatoes citruscarbonated drinks, spicy foods

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esophageal exposureAvoid late-ni ht meals and bedtime snacks

Raise the head of the bedSto smokin

Weight loss

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Except for weight loss, evidence for lifestylemo cat ons nc u ng smo ng s genera yweak

owever, mo ca ons a ore o eac pa en s

individual circumstances may sometimes beeffective

Elevating the head of the bed for selected patients whoare troubled with heartburn or regurgitation when

Other lifestyle modifications including, but not limited to,avoiding late meals, specific foods, or specific activities

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Contributing Conditions:

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What is the Role of Hiatal Hernia in GERD?

Promotes reflux of stomach contents (via its direct

and thus is associated with GERD

,

potential consequences of GERD: heartburn,esophagitis, Barretts esophagitis, and esophagealcancer

However, the role attributed to hiatal hernia isvariable and difficult to quantify

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Axial Hiatus Hernia is Commonly Associated, spec a y en evere

Type I hiatal hernia.In this example, the

evident at rest, aftercompletion of esophageal

6666Kahrilas, PJ, Pandolfino JE. Hiatus hernia. In: Castell DO, Richter JE, eds. The Esophagus. 4th ed.Philadel hia: Li incott Williams & Wilkins, 2004:389-407.


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Two-Sphincter Model of the

LES relaxation Squamocolumnar junction

CD relaxation

CD incompetence?

Right

a a ern a


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Muscular Anatom of the EGJ

Slin

Spiral m.

Longitudinal m.

fibers

Claspfibers

6868PJ Kahrilas 2004.

The Flap Valve Concept of EGJ Disruption


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The Flap Valve Concept of EGJ DisruptionGrade IGrade I Grade IIGrade II Grade IIIGrade III Grade IVGrade IV

Normal ridge oftissue closely

Ridge is slightlyless well defined

Ridge is effacedand the hiatus is

Hiatus is wide open atall times and displaced

6969

Adapted from Hill LD et al. Gastrointest Endosc1996;44:541-547.

scopean opens w

respiration

pa u ous axially


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Radiographic Appearance of a Small SlidingHiatal Hernia Durin Swallowin

TubularEsophagus

EsophagealVestibule

Phrenic Ampulla

Sliding HiatalHernia

A ring

B ring

DiaphragmaticRugal Folds

Traversing Hiatus

7070

impression

Kahrilas PJ and Pandolfino JE. GI Motility Online. 2006;doi:10.1038/gimo48.


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Type I (Sliding) and Type II (Paraesophageal)Hiatus Hernia

EsophagusEsophagus

SquamocolumnarSquamocolumnarjunctionjunction

EsophagusEsophagus

HerniatedHerniatedstomachstomach

PhrenoPhreno--esophagealesophagealmembranemembrane

HerniatedHerniatedgastric fundusgastric fundus

HerniatedHerniatedparietalparietaleritoneumeritoneum

DiaphragmDiaphragm DiaphragmDiaphragmSquamocolumnarSquamocolumnar

junction (normal position)junction (normal position)

7171Modified from Jaffee BM, Surgery of the esophagus. In Orlando RC Ed. Atlas of EsophagealDiseases, Second Edition. 223242.


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Pharmacologic Treatments

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u According to AGAI guidelines, which one

of the following agents is never appropriatein the treatment of GERD?

1. OTC PPIs

2. Metoclo ramide

3. H2RAs

.

5. None of the above, they are all appropriate

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Available Treatments for GERD Promotility agents

Bethanechol

e oc opram e ac ox warn ng; see o ow ng s e orrecommendation)

Histamine2 receptor antagonists (H2RAs) me ne

Famotidine Nizatidine

Proton pump inhibitors (PPIs) Dexlansoprazole

someprazo e

Lansoprazole

Omeprazole

7474

Rabeprazole

Source: www.fda.gov. Accessed on August 20, 2009.


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Metoclopramide:AGAI Guideline Recommendation

Metoclopramide as monotherapy or adjunctive therapyin patients with esophageal or suspected

Grade D: recommend against; fair evidence that it isineffective or harms outweigh benefits

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PPIs and H2RAs:

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AGAI 2008Guideline Recommendation

Antisecretory drugs for the treatment of patients withesophageal GERD syndromes (healing esophagitis

In these uses, PPIs are more effective than H2RAs,which are more effective than placebo

Grade A: strongly recommended based on goodevidence

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ARS Question

c o e o ow ng agen s as emost rapid speed of healing?

1. H2RAs.

3. PPIs

. nset o act on s a out t e same or eac

8080


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Speed of Healing GERD: PPIs vs H2RAsSpeed of healing GERD expressed as the mean percentage ofhealing per week for each drug class at evaluation time points

Placebo

PPI

35

30Healed/week

225

20

(%)

10

5

02 4 6 8 12

Weeks

8181

, 2 ,

but the speed of healing falls off as fewer patients are left to be healedAdapted from Chiba N et al. Gastroenterology. 1997;112:1798-1810.


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ARS Question

ccor ng o e gu e nes, w cof the following agents heal(s) more

1. PPIs

2. H2RAs

3. Promotility agents

4. A and B are equal

8282


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Healing-time Curve: PPIs vs H2RAs vs Placebo100

80PPI

(3)(26)

(2)

60

H2RAlhealed

(4)(27)

(25)

(22)

40

20Placebo%

Tota

(2)

(23) (25)

(8)

(5)

(9)

0

2 4 6 8 12

By week 4, PPIs heal more atients than H RAs and continue to do so

Time in weeks

8383

even after 12 weeks of treatment (number of studies is shown in

parentheses)Adapted from Chiba N et al. Gastroenterology. 1997;112:1798-1810.


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Percentage of Symptom-Free Patientsfor PPIs and H2RAs

Heartburn-PPI

40

30(%)

20

12 34 68

10

Time in Weeks

With longer therapy, PPIs continue to relieve heartburn faster thanH RAs but the s eed of s m tom relief falls off as fewer atients

8484

Adapted from Chiba N et al. Gastroenterology. 1997;112:1798-1810.

remain symptom-free


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Proton Pump Inhibitors-GERD Omeprazole Esomeprazole Lansoprazole Rabeprazole DexlansoprazolePantoprazole

Symptomaticrelief 20 mg daily

X 4 weeks

20 mg daily

X 4 weeks

15 mg daily

X 8 weeks

20 mg daily

X 48

20 mg daily

X 48 weeks

40 mg daily

X 48

Healing of

wee swee s

ulcerativeesophagitis

X 48 weeks

daily X 48weeks

X 816weeks

X 48weeks

daily X 48weeks

X 816weeks

Maintenanceof healing orerosive or

20 mg daily 20 mg daily 15 mg daily 20 mg daily 30 mg daily40 mg daily

8585

Source: www.fda.gov. Accessed on August 22, 2009.

esophagitis


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H2RAs- pprove n cat ons or t e reatment o

Cimetidine Famotidine Nizatidine Ranitidine

Treatment of

GERD

800 mg at night,

or in divideddoses, for up to12 weeks

20 mg bid for up

to 6 weeks

150 mg bid for

up to 12 weeks150 mg bid

Maintenanceof healing or

erosive or

800 mg at night,or in divided

doses for u to

20 or 40 mg bidfor up to 12

150 mg bid forup to 12 weeks

150 mg up to 4xper day

ulcerativeesophagitis

12 weeks

8686

Source: www.fda.gov. Accessed on September 2, 2009.


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Nocturnal Breakthrough Symptoms

8787

C S d 1 C l


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Case Stud 1: Carol

After 4 weeks of once-daily

PPI therapy, Carol returnsto your office

Her symptoms haveimproved somewhat,especially during the day;however, she wakes upa ou n g s a wee wheartburn and regurgitation

8888


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u How would you proceed with your

management of Carols symptoms?

1. Endosco

2. pH monitoring. -

4. Increase PPI to twice a day

5. Refer for surgical consultation


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AGAI guidelines recommend endoscopy to evaluatepatients with a suspected esophageal GERD syndrome

-daily PPI therapy

Grade B: recommended with fair evidence that itmproves mpor an ou comes

9191



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level


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Nocturnal Breakthrou h S m toms: AGAI2008 Guideline Recommendation

There is no evidence of improved long-term efficacy byadding a nocturnal dose of an H2RAs to twice-daily PPI

Grade Insufficient: no recommendation; insufficientevidence to recommend for or against

9393


ARS Question ?


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ARS Question ? Carols symptoms are successfully

managed after 3 weeks on twice-daily

PPI therapy. How would you approachmaintenance therapy?

. on nue ong- erm erapy a e same

dosage2. Continue lon -term thera and titrate down

to the lowest effective dose on the basis ofsymptom control

. discontinue until symptoms reappear

4. All of the above



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u t sc p nary anagement

Appropriate Referrals

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Case Stud : Jim


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Case Stud : Jim 63 years old

stent, arthritis, GERD

, ,

Meds: clopidogrel, low-dose,

Smoker, drinks a 6-pack of beer

Presenting symptoms: on twice-dail PPI but re orts ersistent

9696heartburn


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Because Jims presenting symptom is

,proceed?

.

2. Perform diagnostic tests to rule out cardiac-

3. Prescribe an antacid trial to see if it relieves

4. Refer him to a cardiologist

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Which of the following

closely monitored if Jim isrescribed PPI thera ?

1. Clopidogrel. e a oc ers

3. Low-dose aspirin

4. All of the above

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Are PPIs Contraindicated in Patients


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Are PPIs Contraindicated in Patientsa ng op ogre

Retrospective cohort study of 8205 patients with

acute coronary syndrome (ACS) taking clopidogrelafter discharge from 127 Veterans Affairs hospitals

, ,

Conclusion: Concomitant use of clopidogrel and PPI

a higher risk of adverse outcomes than use ofclopidogrel without PPI, suggesting that use of PPI

may e assoc a e w a enua on o ene s oclopidogrel after ACS

100100

Ho PM et al. JAMA. 2009;301:937-944.

Cumulative Hazard for Death or ACS


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Cumulative Hazard for Death or ACS0.6

0

eathsor

ACS

.40

rtion

of

ecurrent

Prop

0.2

0

None

Clop

0.0

0Clop+PPI

DaysSinceDischargeAdapted from Ho PM et al. JAMA. 2009;301:937-944.

PPIs Clo ido rel and Cardiovascular


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PPIs, Clo ido rel, and CardiovascularEvents: Expert Consensus Statement

In 2008, the American College of CardiologyFoundation, the American College of

,Association recommended that all patients who arereceiving NSAIDs, aspirin, dual antiplatelet therapy,or concom an an coagu an erapy an w o areat risk for gastrointestinal injury should receive

ro h lactic treatment with a PPI to reduce the riskof ulcer complications and GI bleeding

Bhatt D et al. J Am Coll Cardiol. 2008;52:1502-1517.

Conflicting Results


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Conflicting Results Several recent publications have reported

outcomes of patients concurrently takingclo ido rel and a PPI vs clo ido rel alone

Also, it is unclear if an interaction between

clinically meaningful adverse outcomes

Rude MK, Chey WD. Gastroenterology. 2009;137:1168-1171.

: im n ?


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: im n ? How would you proceed with

Jims treatment?1. Consider surgery

2. Recommend endoscopy

3. Order impedance pH monitoring

4. Switch to a different PPI

5. First ensure that he is taking his

twice-daily PPI therapy at theappropriate time

104104

AGAI 2008


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AGAI 2008u e ne ecommen a on

patients with a suspected esophageal GERD syndromewho have not responded to an empirical trial of twice-

Biopsies should target any area of suspectedmetaplasia, dysplasia, or malignancy

Grade B: recommended with fair evidence that itimproves important outcomes

105105



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Jim reports that he is taking his PPI

medication one-half hour before

breakfast and one-half hour beforedinner

How would you proceed?

1. Endoscopy with or without biopsy

2. Upper GI series

3. Esophageal manometry

4. Ambulatory pH monitoring

5. Impedance-pH monitoring

106106

6. Other


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Which of the following

characteristics put Jim athigh risk for Barrettsesop agus

1. Over 50 years of age

2. White man

.4. All of the above

107107


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Barretts Eso ha us: Risk Factors


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Barrett s Eso ha us: Risk FactorsGroup at Highest Risk

Age >50 years

ObeseGERD symptoms Early age of onset

Longer duration ( >510 years)

109109

Adapted from Katz PO et al. Curbside Consultation: 49 Clinical Questions. Thorofare, NJ: SLACK Inc., 2008.

m s agnos s


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m s agnos s

Jim is sent for anendoscopy

Results show Barrettseso ha us with hi h-grade dysplasia

110110


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What are the treatment options for patients

'1. Do nothing

2. Surveillance

3. Antireflux sur er

4. Mucosal ablation

. epen s on ex s ence an eve o ysp as a

6. I do not know

111111


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What are the next steps

1. Referral to agas roen ero og s e

isnt seeing one already.

3. Antireflux surgery

4. Mucosal ablation

5. De ends on existence

113113

and level of dysplasia


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Barretts Eso ha us

114114

Barretts Esophagus


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p g

115115

Shaheen NJ. Gastroenterology. 2000;119:333..


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Barretts Esophagus andAdenocarcinoma


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Adenocarcinoma

Patients with Barrett's esophagus have anincreased risk of developing esophageala enocarc noma

The incidence of esophagealadenocarcinoma is 0.3%0.5% per patientyear

However, lifetime incidence in anindividual atient ma be 10%11%

117117Reid BL et al. Annu Rev Med. 1987;38:477-492.Eisen GM. Gastrointest Endosc. 2003;58:760-769.


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Pr v l n f B rr E h

in the General Population of Sweden


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in the General Population of Sweden

1000 persons had endoscopy

.

9 (56%) had symptoms of GERD

119119

Ronkainen J. Gastroenterology. 2005;129:1825.

Metaplasia: Response to Chronic InflammationOne adult cell type replaces another


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One adult cell type replaces another

Stratified SquamousEpithelium

Specialized IntestinalMeta lasia

120120

(Normal Esophagus) (Barretts Esophagus)

Histological Features of Dysplasia


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Nuclei showenlargement,

pleomorphism,hyperchromatism,stratification,

Villiform surfacesand tubules showcrowding

121121

No Dysplasia Dysplasia

Estimates of Annual Cancer Incidence for


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. Shaheen. Gastroenterology. 2000;119:333.

Low-Grade Dysplasia: 0.6% Sharma. Clin Gastroenterol Hepatol. 2006;4:566.

- Spechler. Am J Gastroenterol. 2005;100:927. Rastogi. Gastrointest Endosc. 2008;67:399.

122122

Endoscopic Screening and Surveillancefor Barretts Esophagus: Pros


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p g

arre s w cancer s ncreas ng nfrequency

Computer models suggest benefit

No study shows physical harm

123123

for Barretts Esophagus: Cons


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for Barrett s Esophagus: Cons

Endoscopy is expensive

No proof that these procedures improvesurvival

No roof likel in the near future

124124

ARS Question ? As previously noted, Jim has beendi d i h B h d


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?diagnosed with Barretts esophagus and

- . , ,dysplasia is found on 2 endoscopies within1 year, which would be the appropriate nextstep

1. Surveillance endoscopy every year

2. Surveillance endoscopy every 6 months

every 3 years

4. No future surveillance endosco

125125

Wang KK et al. ACG Practice Parameters Committee. Am J Gastroenterol. 2008;103:788.

needed


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If Jim had low-grade dysplasia, how

1. When dysplasia is first noted,

within 6 months

. expert pathologist

. dysplasia is seen on 2consecutive endoscopies

1261264. All of the above

Wang KK et al. ACG Practice Parameters Committee. Am J Gastroenterol. 2008;103:788.

ARS Question ? Which of the following would bei t t ( ) i th


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?an appropriate step(s) in the

-dysplasia?

. an expert pathologist

. months

surveillance (Q 3 months),EMR, endoscopic ablation,

127127

esop agec omy

4. All of the above


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Appropriate Management of High-Grade


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Have diagnosis confirmed by an expert pathologist

Repeat endoscopy within 3 months;4- uadrant bio sies at 1-cm intervalsmucosal irregularity should have EMR

ons er op ons o n ens ve surve ance mon s ;EMR; endoscopic ablation; esophagectomy

Individualize treatment

129129

Wang KK. ACG Practice Parameters Committee. Am J Gastroenterol. 2008;103:788.

Jim experiences hoarseness which may


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Jim experiences hoarseness, which may

GERD. Which of the following is nota

GERD?

.

2. Neck pain

3. Chronic cough

4. Halitosis

130130

Extraeso ha eal S m toms of GERD


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Hoarseness

Chronic cough

Laryngitis

Sinusitis

Dental erosions

Halitosis

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Maintenance Thera

f


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Typical esophageal reflux syndrome

(with or without esophagitis)

(asthma, laryngitis, cough)

decreased or discontinued?

132132

Under what condition(s) should antisecretory


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Under what condition(s) should antisecretory

1. Patient reports likely adverse effect (headache,

2. Patient has been taking PPIs for a prolonged-

3. It is unclear why the patient is taking PPIs

4. The patient was started on twice-daily PPI beforeonce-daily dosage was tried

133133

5. All of the above


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Once PPIs have proven to be clinically effective for thetreatment of patients with esophagitis, therapy should be

-effective dose on the basis of symptom control

Grade A: strongly recommended based on good evidence

134134


Clinical Conse uencesof Long-term Acid Inhibition


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Screening for potential adverse effects

Calcium supplementation?H. pyloriscreening?

135135

Clinical Conse uencesof Long-term Acid Inhibition (cont)


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Dependency?

with PPIs for 8 weeks may induce rebound

acid-related symptoms upon discontinuanceo e

136136

Reimer C et al. Gastroenterology. 2009;137:80-87.

ARS Question ?Role of Endoscopy in the Long-termM t f GERD


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Mana ement of GERD

When should endoscopy be used as a tool forevaluating treatment failure or risk management?

1. Every 5 years

2. When a patient reports occasional breakthrough,

3. When the patient reports the new sensation of foodsticking in his esophagus

4. Every 10 years

5. When the patient was begun on empiric PPI therapy and

137137

has 80% resolution of heartburn after 2 weeks of therapy

Case Study: JimAntireflux Surgery

ARS Question ?


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ARS Question ? Under what conditions should

antireflux surgery be recommended

1. Never2. If Jim has worsening symptoms

3. After 2 years of PPI therapy,

because it is safer4. If Jim cannot tolerate acid

138138

suppress ve t erapy, even t s

effective



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Surgery vs Acid-Suppressive Therapy:u e nes


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patient with esophageal GERD syndrome cannottolerate acid-suppressive therapy, even if pharmacology

When treatment with antireflux surgery or PPIs isthought to be similarly effective in a patient withesophageal GERD syndrome, PPI therapy is consideredsafer and is therefore preferred as initial treatment

Grade A: stron l recommended based on ood

evidence

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Kahrilas P et al. Gastroenterology. 2008; 135:1392-1413.


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Question and Answeress on

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