Gastroesophageal Reflux Objectives Disease (GERD) · and treatment of GERD and H-Pylori Know...
Transcript of Gastroesophageal Reflux Objectives Disease (GERD) · and treatment of GERD and H-Pylori Know...
GastroesophagealGastroesophageal Reflux Reflux
Disease (GERD)Disease (GERD)
Greg W. Mennie,Greg W. Mennie,MSEdMSEd, PA, PA--CC
PIH Family Medicine ResidencyPIH Family Medicine Residency
Objectives
� Have working knowledge of the anatomy and physiological mechanisms that contribute to GERD
� Gain knowledge to develop a consistent format for identifying GERD risk factors
� Know the epidemiology of GERD as it relates to patients lifestyle and healthcare delivery
� Know the atypical symptoms associated with GERD
� Know the alarm symptoms associated with GERD
� Understand the relationship of H-Pylori and GERD
� Know the treatment modalities for GERD and H-Pylori
� Know the relevant laboratory testing guidelines for the diagnosis and treatment of GERD and H-Pylori
� Know indications for referral and invasive evaluation of GERD
� Know the lifestyle modification issues for reducing GERD symptoms
GERDGERD
PepticPeptic EsophagitisEsophagitis dates back to the dates back to the
mid 1930mid 1930’’s s –– WinkelsteinWinkelstein A. PepticA. Peptic esophagitisesophagitis: a new clinical : a new clinical
entity. JAMA 1935;104:906entity. JAMA 1935;104:906--909.909.
RefluxReflux EsophagitisEsophagitis introduced by introduced by
Allison in 1946Allison in 1946 -- Allison PR. Peptic ulcer of the esophagus. Allison PR. Peptic ulcer of the esophagus.
JJ Thorac SUrgThorac SUrg. 1946;15:308. 1946;15:308--317.317.
GERDGERD
Difficult to obtain accurate epidemiological Difficult to obtain accurate epidemiological information due to the lack of information due to the lack of standardized definition and diagnostic standardized definition and diagnostic goldgold--standard.standard.
Most epidemiological statistics assumeMost epidemiological statistics assume
Heartburn = GERDHeartburn = GERD
Spechler SJ. Epidemiology and natural history
of gastro-oesophageal reflux disease. Digestion 1992;51 suppl1:24-9
GERD GERD –– Gallup Poll 2000Gallup Poll 2000
Most common complaints among U.S. adults (18 y.o or older)
65% Heartburn – Daytime and Nocturnal
62% Gas
55% Burning Sensation in Chest
52% Burning Sensation in Throat
50% Acid Reflux
�� A description of a symptomatic A description of a symptomatic condition or pathological condition or pathological alteration resulting from alteration resulting from repeated episodes of gastric repeated episodes of gastric reflux.reflux.
�� A digestive disorder affectingA digestive disorder affecting
the LES.the LES.
�� Multiple symptoms with Multiple symptoms with esophageal andesophageal and extraesophagealextraesophagealmanifestations.manifestations.
GERD or GORDGERD or GORD
GERD GERD -- EpidemiologyEpidemiology
19931993--
““100 million adults suffer from heartburn100 million adults suffer from heartburn””
1995 1995 --
““17 17 ––40 million adults40 million adults””
2001 2001 --
““60 million adults60 million adults””
2525--40% experience GERD 40% experience GERD
77--10% daily10% daily
Herbella FA, Sweet MP, Tedesco P, Nipomnick I, Patti MG. Gastroesophageal reflux disease and obesity.Pathophysiology and implications for treatment. J Gastrointest Surg. Mar 2007;11(3):286-90
Difficult to obtain exact figures
GERD GERD -- EpidemiologyEpidemiology
EL-Serag H. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut
doi:10.1136/gutjnl-2012-304269
Increasing global presence of GERD
18%–28% in North America
ETHNICITYETHNICITY
White population White population 556/100,000556/100,000
AfricanAfrican--Americans Americans 288/100,000 288/100,000
Hispanics Hispanics 48/100,00048/100,000
Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The Burden of Gastrointestinal Diseases. The American
Gastroenterological Association 2001;1:1-86
AGE and GENDERAGE and GENDER
74% of all GERD cases occur in women74% of all GERD cases occur in women
Other studies have noted = prevalence but Other studies have noted = prevalence but higher amounts ofhigher amounts of esophagitisesophagitis in Men (2:1) in Men (2:1) andand BarretsBarrets in Men (10:1)*in Men (10:1)*
>90% of GERD sufferers >25 y.o.>90% of GERD sufferers >25 y.o.
Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The Burden of Gastrointestinal Diseases. The American Gastroenterological Association 2001;1:1-86
*Sleisenger and Fordtrans Textbook of Gatrointestinal and Liver Disease, Seventh Ed. 2002, Saunders.
216 percent increase
1998 - 995,402
2005 - 3,141,965
GERD DiagnosisGERD Diagnosis
Gastroesophageal Reflux Disease (GERD) Hospitalizations in 1998 and 2005 -
HCUP-US http://www.hcup-us.ahrq.gov/reports/statbriefs/sb44.jsp
� 122% rise in Yearly hospitalizations with obesity diagnoses 1996-2004
� Casual association with obesity and gerd
El-Serag H, The Association Between Obesity and GERD: A Review of the Epidemiological Evidence. Dig Dis Sci. Sep
2008; 53(9): 2307–2312.
ATYPICALATYPICAL
TYPICALTYPICAL
ALARMALARM
GERD GERD –– SymptomsSymptoms
ATYPICALChest Pain Voice changeDysphagia GlobusDyspepsia BronchitisAsthma Pneumonia
At least one atypical symptom was present in patients with typical symptoms
lOCKE, GR, et al. Prevalence and Clinical Spectrum of
Gastroesophageal Reflux: A population-Based Study in Olmstead County, Minnesota. Gastroenterology 1997;112:1448-56
GERD GERD –– SymptomsSymptoms
� TYPICAL
• Heartburn
• Acid Regurgitation
�Dysphagia
�Odynophagia
�Early Satiety
�Weight loss
�GI blood loss
�Anemia
�New age >45
�Non-cardiac "angina-like" chest pain
�Failure of 4 wk acid suppression trial
�Breakthrough sxs
Alarm SymptomsAlarm Symptoms
AsymptomaticAsymptomatic
• 1993 study pH monitoring
� Reported in Hospital Physician August 1999 Estimated 30% of patients with GERD have no symptoms.
COSTSCOSTS
GERD GERD ––COSTSCOSTS
DIRECTDIRECT -- 9.6 Billion dollars (Year 2000)
INDIRECT INDIRECT -- consumption of health care and the lost days of work
479 Million dollars (Year 1998)
Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The Burden of Gastrointestinal Diseases. The American
Gastroenterological Association 2001;1:1-86
Direct Cost of Gastroesophageal Reflux Disorder (in millions)
Drugs,
$5,892.20
Hospital
Inpatient,
$2,539.50
Office Visits,
$603.10
Hospital ER,
$77.50
Hospital OPD,
$212.90
Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The
Burden of Gastrointestinal Diseases. The American Gastroenterological Association 2001;1:1-86
““PLOPPLOP--PLOP PLOP
FIZZFIZZ--FIZZ FIZZ
OH WHAT A RELIEF OH WHAT A RELIEF
IT ISIT IS””
GERD GERD ––Direct COSTSDirect COSTS
GE
RD
9
.3
Ga
llb
lad
de
r 5
.8
CR
C 4
.9
PU
D 3
.1
Div
ert
icu
lar
2
.4
$0
$1
$2
$3
$4
$5
$6
$7
$8
$9
$10
Billion
57%
39%
27%
40%
48%
0%
10%
20%
30%
40%
50%
60%
Mo
od
So
cia
l
Sp
ou
se
's
Sle
ep
Wo
rk
Da
y-t
o-
Da
y
Severe
Moderate
Mild
Combined
Affects of Heartburn on Quality of Life
Gallup 2000
Clinical Diagnosis
vs Dyspepsia
“Tests” are not necessary in patients
with typical reflux symptoms
Trial of Therapy
GERD GERD --DiagnosisDiagnosis
No gold standard exists for the diagnosis of GERD
Endoscopy - appropriate first-line investigation
? Once in lifetime with chronic
symptoms (No ALARM)
24-hour pH monitoring reserved for atypical
symptoms or fail to respond to proton pump inhibitor
therapy.
DiagnosticsDiagnosticsGERD GERD –– Contributing FactorsContributing Factors
Dietary and lifestyle choices: certain foods, smoking, obesity
Pregnancy – Most common condition predisposing to GERD 50 – 80% of pregnant patients report heartburn*.
Genetics plays a role; a recent study indicates that a family member of someone with GERD is four times more likely to experience the disorder
Meds
Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The Burden of Gastrointestinal Diseases. The American Gastroenterological Association 2001;1:1-86
*Sleisenger and Fordtrans Textbook of Gatrointestinal and Liver Disease, Seventh Ed. 2002, Saunders.
MythsMyths
�� OccOcc reflux isnreflux isn’’t badt bad
�� Mint, milk will help soothe theMint, milk will help soothe the sxssxs�� +licorice (anise helps)+licorice (anise helps)
�� Avoid coffee, wine, juice, chocolateAvoid coffee, wine, juice, chocolate
�� Avoid spicy foodsAvoid spicy foods
FactFact
�� There is no evidence to show that any of the dietary There is no evidence to show that any of the dietary
restrictions usually recommended make a difference. restrictions usually recommended make a difference.
�� Evidence of a clear benefit from 2 lifestyle changesEvidence of a clear benefit from 2 lifestyle changes�� Weight loss Weight loss
�� raising the head of your bedraising the head of your bed
Kaltenbach T, Crockett S, Gerson L. Are Lifestyle Measures Effective in Patients With Gastroesophageal Reflux
Disease? Arch Intern Med. 2006;166:965-971
TreatmentTreatment
�� Head of bed Head of bed –– laryngeallaryngeal sxssxs, cough, , cough,
throat clearing,throat clearing, pharyngitispharyngitis avoidavoid
recumbancyrecumbancy
�� Small mealsSmall meals
�� Food restrictionsFood restrictions
STEPSTEP--UPUP
Proton pump
inhibitor therapy
Lifestyle modification + 8 week trial
b.i.d. H2RA
No relief with H2 at
2 weeks
Good response with H2
move to on- demand therapy
STEPSTEP--DOWNDOWN
H2receptor antagonist
or stop therapy
Proton pump
inhibitor therapy x
6-8 weeks
Step-down therapy has the merits of faster symptom relief,
faster healing and over all costs less.
GERDGERD
GERD GERD -- EpidemiologyEpidemiology
1998 Mortality Rate 0.48 deaths /100,000
-Centers for Disease Control
Isenberg Jl, Donowitz M, Association. TAG, Health Nlo. The
Burden of Gastrointestinal Diseases. The American Gastroenterological Association 2001;1:1-86
GERD GERD -- EpidemiologyEpidemiology
GERD GERD –– High Risk PatientHigh Risk Patient
Patient with Alarm symptom
Age of onset > 45 y.o. (> white males)
Significant ETOH of Tobacco use
Duration of symptomsweekly heartburn sxs > 5 years = 20-fold increased risk ofadenocarcinoma of the distal esophagus or gastric cardia
compared to non-heartburn patients.(NEJM)
GERD GERD -- EspohagitisEspohagitis
� Esophagitis – The squamous epithelium becomes altered secondary to excessive exposure of gastric juice from reflux.
� Low Grade – seen histopathologically
� High Grade – seen endoscopically
� Less than half of all GERD patients have EE
� Mantynen, et al. The impact of GI endoscopy referral volume on the diagnosis of GERD and its complications: a 1-year cross-sectional study. Am J Gastro. 2002 Oct; 97 (10) 2524-29.
EndoscopyEndoscopy ScreenScreen
�� GERD symptoms that are persistent or progressive despite GERD symptoms that are persistent or progressive despite
appropriate medical therapyappropriate medical therapy
�� DysphagiaDysphagia oror odynophagiaodynophagia
�� Involuntary weight loss > 5%Involuntary weight loss > 5%
�� Evidence of GI bleeding or anemiaEvidence of GI bleeding or anemia
�� Finding of a mass, stricture, or ulcer on imaging studiesFinding of a mass, stricture, or ulcer on imaging studies
�� Evaluation of patients with suspected extraEvaluation of patients with suspected extra--esophagealesophageal
�� manifestations of GERDmanifestations of GERD
�� Screening for BE in selected patients (as clinicallyScreening for BE in selected patients (as clinically
�� Indicated Indicated –– if negative no further screening)if negative no further screening)
�� Persistent vomitingPersistent vomiting
�� Evaluation of patients with recurrent symptoms afterEvaluation of patients with recurrent symptoms after endoscopicendoscopic
or surgicalor surgical antirefluxantireflux proceduresprocedures
American Society for GI Endsocopy. Role of Endoscopy in the Management of GERD. Gastrointestinal
endoscopy journal. Volume 66, No. 2 : 2007
GERD GERD –– BarrettBarrett MetaplasiaMetaplasia
�� Severe outcome of chronic GERDSevere outcome of chronic GERD
•• MetaplasticMetaplastic columnar cells replace nativecolumnar cells replace native
squamoussquamous epithelium.epithelium.
� Prevalence rate of less than 20% in the GERD patient population with African Americans having a higher rate than caucasians.*
� Patients at highest risk for Barrett’s are Caucasian males
with long duration (>5yrs) of reflux symptoms.
GERD GERD -- EpidemiologyEpidemiology
*lOCKE, GR, et al. Prevalence and Clinical Spectrum of
Gastroesophageal Reflux: A population-Based Study in Olmstead County, Minnesota. Gastroenterology 1997;112:1448-56
EndoscopyEndoscopy SurveillanceSurveillance
The cost effectiveness for patients without dysplasia is controversial.
Appropriate for patients fit to undergo therapy.
Barret’s - Initial 2 screenings within one year.
�No dysplasia, after 2 consecutive examinations
• surveillance is every 3 years.
�LGD
• No specific protocol – consider f/u eval and bx in 6 mos from dx. If continued dysplasis consider yearly
eval
�HGD
• Q 3mos x 1 year with multiple large capacity bx obtained at 1 cm intervals.
• If Neg after 1 year for CA the interval may lengthen if no dysplastic changes are noted on 2 subsequent
endoscopies performed at 3-month intervals.
American Society for GI Endsocopy. ASGE guideline: the role of endoscopy in the surveillance
of premalignant conditions of the upper GI tract. Gastrointestinal Endoscopy Journal Volume 63, No. 4 : 2006
ROME III
The Rome criteria is a system developed to classify the functional gastrointestinal disorders (FGIDs), disorders of the digestive system in which symptoms cannot be explained by the presence of structural or tissue abnormality, based on clinical symptoms.
Drossman D, The Functional Gastrointestinal Disorders and the Rome III Process. Gastroenterology 2006;130:1377–1390
My Tummy Hurts
FUNCTIONAL HEARTBURN
• Burning retrosternal discomfort
• Absence of evidence that gastroesophageal acid reflux is the cause of the symptom
• Absence of histopathology-based esophageal motility
disorders
� FUNCTIONAL DYSPEPSIA
• Bothersome postprandial fullness
• Early satiation
• Epigastric pain/burning
• No evidence of structural disease (including at upper
endoscopy)
3 mo sx onset 6 months prior to dx
HH--PyloriPylori
GERD may worsen or develop for the
first time after H pylori eradication.
�� No effect on EGJNo effect on EGJ
�� No effect on LESNo effect on LES
�� Unlikely effectsUnlikely effects esophesoph peristalsis or acid peristalsis or acid
clearanceclearance
�� IncreasesIncreases GastrinGastrin levels but decreased acid levels but decreased acid
secretion secretion –– cytokines inflammationcytokines inflammation
HH--PyloriPylori EpidemiolgyEpidemiolgy
�� 20% < age 4020% < age 40
�� 50% > age 60 50% > age 60
�� Uncommon in young children. Uncommon in young children.
�� > Low socio> Low socio--economic status economic status
�� Immigration is responsible for isolated Immigration is responsible for isolated
areas of high prevalence in some Western areas of high prevalence in some Western
countries. countries.
�� Lowering ratesLowering rates
HH-- PyloriPylori
�� No effect on EGJNo effect on EGJ
�� No effect on LESNo effect on LES
�� Unlikely effectsUnlikely effects esophesoph peristalsis or peristalsis or
acid clearanceacid clearance
�� IncreasesIncreases GastrinGastrin levels but levels but
decreased acid secretion decreased acid secretion –– cytokines inflammationcytokines inflammation
HH--Pylori and CancerPylori and Cancer
� ~ 6 fold risk of gastric cancer
� Mucosa associated lymphoid tissue (MALT)� ~90% are associated with H.pylori.
� ~50% cure for localized MALT after cure of H.pylori.
Eurogast Study Group
HH-- Pylori EradicationPylori Eradication
�� Increased risk of GERDIncreased risk of GERD
�� Increased severity ofIncreased severity of esophagitisesophagitis
�� Lower prevalence ofLower prevalence of barretsbarrets andand
esoph adenoesoph adeno –– gene dependentgene dependent
�� None of the above applicable in PUDNone of the above applicable in PUD
To Treat or not to TreatTo Treat or not to Treat
� H Pylori = 10 percent lifetime risk of developing peptic ulcer
disease and 2-3x’s increase of gastric adenocarcinoma.
• Corpus dominant or Pan gastritis mild worsen GERD sxs
Antral-dominant gastritis improvement of GERD sxs
• H Pylori and GERD� H. pylori improves the ability of proton pump inhibitors (PPIs) to suppress
acid.
• Chronic NSAID user� 61x’s more likely to develop ulcer with H-Pylori presence
Must TreatMust Treat
� Standard of care is to treat and test to cure:• Relatives of persons with gastric cancer
• Patients in whom intestinal metaplasia has been detected on gastric biopsy
• Infected spouses of patients who have beenreinfected with H.pylori a second or third time after initial antibiotic treatment.
• H Pylori and PUD � 60 to 100 percent annual ulcer recurrence rate compared to 10 percent after eradication.
� >85% Duodenal ulcers CagA strain
TestsTests
�� PYPY--TestTest
•• Carbon 13 or 14 Urea Breath TestsCarbon 13 or 14 Urea Breath Tests
�� Antibody testing*Antibody testing*•• IgmIgm -- uselessuseless
•• IggIgg -- best (+ up to 1 yr. negative could be toobest (+ up to 1 yr. negative could be too ealryealry assess assess
with either treatment or length ofwith either treatment or length of sxssxs))
�� Stool AntigenStool Antigen
�� EndoscopyEndoscopy with biopsywith biopsy
* She R. Evaluation of Helicobacter pylori Immunoglobulin G
(IgG), IgA, and IgM Serologic Testing Compared to Stool
Antigen Testing. Clin Vaccine Immunol
v.16(8); Aug 2009
HH--Pylori MedsPylori Meds
�� Antibiotics Antibiotics •• Amoxicillin,Amoxicillin, ClarithromycinClarithromycin,, MetronidazoleMetronidazole, Tetracycline , Tetracycline
�� H2H2--BlockersBlockers•• CimetidineCimetidine ((TagametTagamet),), FamotidineFamotidine ((PepcidPepcid),), NizatidineNizatidine((AxidAxid), Ranitidine (Zantac) ), Ranitidine (Zantac)
�� Proton Pump Inhibitors (Proton Pump Inhibitors (PPIsPPIs))•• EsomeprazoleEsomeprazole ((NexiumNexium),), LansoprazoleLansoprazole ((PrevacidPrevacid),),OmeprazoleOmeprazole ((PrilosecPrilosec),), PantoprazolePantoprazole ((ProtonixProtonix),),RabeprazoleRabeprazole ((AciphexAciphex))
�� CytoprotectiveCytoprotective Agents Agents •• BismuthBismuth subsalicylatesubsalicylate, bismuth, bismuth subcitratesubcitrate potassium,potassium,sucralfate sucralfate
�� Combination ProductsCombination Products•• HelidacHelidac,, PrevpacPrevpac,, PyleraPylera
Regimen Side Effect Rating Cure Rate
Two-Drug Regimens
Amoxicillin + PPI Low-Medium less than 70-80%
Clarithromycin + PPI Low-Medium greater than 70-90%
Three-Drug Regimens
Clarithromycin + Metronidazole + PPI Medium greater than 80 to greater than 90%
Clarithromycin + Amoxicillin + PPI Low-Medium greater than 80 to greater than 90%
Amoxicillin + Metronidazole + PPI Medium greater than 80-90%
Tetracycline + Metronidazole + Sucralfate Medium greater than 80-90%
Four-Drug Regimens
Bismuth + Metronidazole + Tetracycline + H2 Blocker
(H2Blocker needs to be taken for 4-6 weeks)Medium-High greater than 80 to greater than 90%
Bismuth + Metronidazole + Amoxicillin + PPI Medium-High greater than 70-90%
Bismuth + Metronidazole + Tetracycline + PPI Medium-High greater than 80 to greater than 90%
Bismuth + Metronidazole + Clarithromycin + PPI Medium-High greater than 80 to greater than 90%
Combination Products*
Helidac + H2 Blocker Medium-High up to 82%
Prevpac Low-Medium 81-92%
Pylera + PPI Low-Medium 84-94%
H-PYLORI TREATMENT REGIMENS
Omeprazole 40 mg QD + clarithromycin 500 mg TID x 2 wks,then omeprazole 20 mg QD x 2 wks
Ranitidine bismuth citrate (RBC) 400 mg BID +clarithromycin 500 mg TID x 2 wks, then RBC 400 mg BID x 2 wks
Bismuth subsalicylate (Pepto Bismol®) 525 mg QID + metronidazole 250 mg QID +
tetracycline500 mg QID* x 2 wks + H2 receptor antagonist therapy as directed x 4 wks
Lansoprazole 30 mg BID + amoxicillin 1 g BID + clarithromycin 500 mg TID x 10 days
Lansoprazole 30 mg TID + amoxicillin 1 g TID x 2wks**
Rantidine bismuth citrate 400 mg BID +clarithromycin 500 mg BID x 2 wks, then RBC 400
mg BID x 2 wks
Omeprazole 20 mg BID + clarithromycin 500 mg BID + amoxicillin 1 g BID x 10 days
Lansoprazole 30 mg BID + clarithromycin 500 mg BID + amoxicillin 1 g BID x 10 days
CDC treatmentCDC treatment
Sequential TreatmentSequential Treatment
�� 10 day treatment10 day treatment
•• PPI bid andPPI bid and AmoxAmox 1gm bid x 5 days1gm bid x 5 days
�� Then Then --
•• ClarithromycinClarithromycin 500mg bid500mg bid
•• TindazoleTindazole 500mg bid 500mg bid
Vakil, N. Sequential Therapy for Heliobacter Pylori JAMA, 2008;300(11)
Potential proton pump inhibitor safety concerns
Safety concern
PPI studied Duration of studies Evidence
Gastric carcinoidsOmeprazole, lansoprazole,
pantoprazole,
rabeprazole
1–8 years No increased risk1-5
Gastricmetaplasia/adenocarcinoma
Omeprazole 1–5 years No increased risk1-3,5
Enteric infections Omeprazole 1 year No increased risk6
Mineral malabsorption Omeprazole 6 months–2 years No increased risk1,3
B12 malabsorption Omeprazole 10 yearsDecreased B12 levels with
high-dose therapy1,2
Laine L, Ahnen D, McClain C, Solcia E, Walsh JH. Review article: potential gastrointestinal effects of long-term acid suppression with proton pump inhibitors. Aliment Pharmacol Ther 2000;14:651–668. Garnett WR. Considerations for long-term use of protonpump inhibitors. Am J Health Syst Pharm 1998;55:2268–2279.Freston JW. Long-term acid control and proton pump inhibitors: interactions and safety issues in perspective. Am JGastroenterol 1997;92(4 Suppl):51S–57S.Freston JW, Rose PA, Heller CA, Haber M, Jennings D. Safety profile of Lansoprazole: the US clinical trial experience. DrugSaf 1999;20:195–205.Thjodleifsson B, Rindi G, Fiocca R, et al. A randomized double-blind trial of the efficacy and safety of 10 or 20 mg rabeprazolecompared with 20 mg omeprazole in the maintenance of gastro-oesophageal reflux disease over 5 years. Aliment Pharmacol Ther 2003;17:343–351. Garcia Rodriguez LA, Ruigomez A. Gastric acid, acid-sup-pressing drugs, and bacterial gastroenteritis: how much of a risk? Epidemiology 1997;8:571–574.
PPIPPI’’ss and Hipsand Hips
�� 10,834 hip fractures among nonusers of acid 10,834 hip fractures among nonusers of acid suppression agents and 2,722 hip fractures suppression agents and 2,722 hip fractures among PPI users. among PPI users.
�� Patients usingPatients using PPIsPPIs for longer than one year for longer than one year were estimated to have a hip fracture rate were estimated to have a hip fracture rate of 4.0 per 1,000 personof 4.0 per 1,000 person--years compared years compared with 1.8 per 1,000 personwith 1.8 per 1,000 person--years in acid years in acid suppression nonusers. suppression nonusers.
�� Higher doses and longer use ofHigher doses and longer use of PPIsPPIs were were associated with higher fracture risk. The associated with higher fracture risk. The association also was stronger in men than in association also was stronger in men than in women.women.
Yang YX, et al. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA December 27, 2006;296:2947-53
Summary Summary
� Difficult to obtain accurate epidemiological information due to the lack of standardized definition and diagnostic gold-standard.
� More prevalent in Whites
� Studies suggest may be more Prevalent in Women
� More prevalent in adults over 25
GERD GERD -- EpidemiologyEpidemiology
Summary Summary
� May present with multiple symptoms, however Heartburn and Acid regurgitation considered most prevalent and synonymous with GERD.
� 50% state nighttime symptoms affect them more than daytime symptoms
GERD GERD -- EpidemiologyEpidemiology
Summary Summary
� One of the top five prevalent and costly conditions affecting adults.
� 9.6 Billion Dollars in Direct Costs
� 5.9 billion dollars spent on GERD medications.
� Low Mortality Rate
� Significant disruption in life activities
GERD GERD -- EpidemiologyEpidemiology