Wizhar SyamsuriWizhar SyamsuriThe ROLE OF PPI IN THE The ROLE OF PPI IN THE MANAGEMENT MANAGEMENT ofof GERDGERDDivision of Internal MedicinePutra Bahagia HospitalApa yang dimaksud Apa yang dimaksud GGastroastroEEsophageal sophageal RReflux eflux DDisease ?isease ?GERD adalah suatu keadaan dimana isi lambung /duodenum bergerak berbalik arah masuk ke esophagus (reflux) dan menimbulkan keluhan. Physiologic vs PathologicPhysiologic vs PathologicPhysiologic GERDPhysiologic GERDPostprandial PostprandialShort lived Short livedAsymptomatic AsymptomaticNo nocturnal sx No nocturnal sxPathologic GERDPathologic GERDSymptoms SymptomsMucosal injury Mucosal injuryNocturnal sx Nocturnal sxhe overall de!inition o! GERD and he overall de!inition o! GERD and its constituent syndromes its constituent syndromes "#igure $% "#igure $%&a'il N et al(Am ) Gastroenterol $**+, -*-. -/** 0 -/$*IncidenceIncidence1t is one o! the most common conditions 1t is one o! the most common conditions a!!ecting the gastrointestinal system(a!!ecting the gastrointestinal system(Any2here !rom 3+0445 o! people have symptoms o!Any2here !rom 3+0445 o! people have symptoms o! GERD "heart6urn7 regurgitation o! acid etc(% spreadGERD "heart6urn7 regurgitation o! acid etc(% spread e8ually 6et2een men and 2omen( e8ually 6et2een men and 2omen(45 have daily heart6urn45 have daily heart6urn-90$*5 have 2ee'ly heart6urn-90$*5 have 2ee'ly heart6urn-:0:*5 have monthly heart6urn-:0:*5 have monthly heart6urnEpidemiology GERD) Dent7 ; < El0Serag7 M0A =allander and S )ohansson $**:,:9,4-*04-4 Gut , a systematic revie2 Epidemiology o! gastro0oesophageal re!lux disease Mechanisms o! GERD "3%Mechanisms o! GERD "3%Delayed Gastric EmptyingIneffective Esophageal ClearanceDefective motilityDefects in salivaRecumbencyDefective Antireflux Barrier>ES ;ypotension?incompetence1ncreased ransient Relaxation;iatal ;erniaIntrinsic Mucosal AbnormalitiesA6normal esophageal gland secretion1mpaired mucosal resistanceSymptoms of Classic GERDSymptoms of Classic GERD;eart6urn "pyrosis%;eart6urn "pyrosis%Most common clinical mani!estation Most common clinical mani!estationesi mu'osa eso!agus yang 6ersi!at sir'um!erensial "mengelilingi seluruh lumen eso!agus%The LA Classifcation system for theThe LA Classifcation system for theendoscopic assessment of reu! endoscopic assessment of reu! esophagitisesophagitis0ne 'or more* mucosal brea&1 no longer than 2 mm1 that does not extend bet%een the tops of t%o mucosal foldsGrade A0ne 'or more* mucosal brea&1 more than 2 mm long1 that does not extend bet%een the tops of t%o mucosal foldsGrade B0ne 'or more* mucosal brea&that is continuous bet%een the topsof t%o or more mucosal folds1but %hich involves less than 324 of the circumferenceGrade C0ne 'or more* mucosal brea& that involves at least 324 of the esophageal circumferenceGrade D!undell et al 1999A. Esofagus normalB. Esofagitis ringan. Esofagitis se!angD. Esofagitis "eratE. Esofagus BarretA B D ETreatment of GERDTreatment of GERD"Colla#orate Cares$"Colla#orate Cares$Goal of (reatmentGoal of (reatmentEliminate symptomsEliminate symptoms;eal esophagitis;eal esophagitisManage or prevent complicationsManage or prevent complicationsMaintain remissionMaintain remission%ifestyle modifications &'(%ifestyle modifications &'(Aorner stone o! GERD therapy Aorner stone o! GERD therapyAvoid !actors that cause re!luxAvoid !actors that cause re!lux Stop smo'ing Stop smo'ing Avoid alcohol and ca!!eine Avoid alcohol and ca!!eine Avoid acidic !oods Avoid acidic !oodsModi!y diet Modi!y diet Eat more !re8uent 6ut smaller meals Eat more !re8uent 6ut smaller meals Avoid !atty?!ried !ood7 peppermint7Avoid !atty?!ried !ood7 peppermint7 chocolate7 alcohol7chocolate7 alcohol7 car6onated 6everages7 co!!ee and tea car6onated 6everages7 co!!ee and teaStress reduction techni8ues Stress reduction techni8ues=eight reduction7 i! appropriate =eight reduction7 i! appropriateSmall !re8uent meals Small !re8uent mealsElevate ;o< 3* Elevate ;o< 3*oo "90+ inches% "90+ inches%Do not lie do2n !or $ to 3 hours a!terDo not lie do2n !or $ to 3 hours a!ter eating eatingAvoid late0night eating "$03 hs o! 6edtime% Avoid late0night eating "$03 hs o! 6edtime%Evaluate e!!ectiveness o! medications Evaluate e!!ectiveness o! medicationsE6serve !or side e!!ects o! medications E6serve !or side e!!ects o! medicationsDrug )herapy &*(Drug )herapy &*(2o approaches2o approaches-( -( Step up Step upStart 2ith antacids and EA ; Start 2ith antacids and EA ;$ $R 6loc'ers andR 6loc'ers and progress toprogress to prescription ; prescription ;$ $R 6loc'ers and !inally PP1sR 6loc'ers and !inally PP1s $( $( Step do2n Step do2nStart 2ith PP1 and titrate do2n to prescription ; Start 2ith PP1 and titrate do2n to prescription ;$ $R 6loc'ersR 6loc'ers and !inally EA ; and !inally EA ;$ $R 6loc'ers and antacids R 6loc'ers and antacidsPP1 " standard dose %;$RA " standar dose %;$RA " anti0re!lux dose %Step0up ApproachesStep0do2n ApproachesProton pump inhiitors &PP+(Proton pump inhiitors &PP+(Decrease gastric ;Al acid secretion Decrease gastric ;Al acid secretionPromote esophageal healing in H*5 to /*5 o!Promote esophageal healing in H*5 to /*5 o! patients patientsMay 6e 6ene!icial inMay 6e 6ene!icial in I esophageal strictures I esophageal strictures;eadache. Most common side e!!ect ;eadache. Most common side e!!ect$reatment$reatment;$RAs vs PP1s;$RAs vs PP1s-$ 2ee' !reedom !rom symptoms-$ 2ee' !reedom !rom symptoms9H5 vs 445 9H5 vs 445-$ 2ee' healing rate-$ 2ee' healing rate:$5 vs H95 :$5 vs H95Speed o! healingSpeed o! healing+5?2' vs -$5?2' +5?2' vs -$5?2'Proton Pump +nhiitorsProton Pump +nhiitorsomepraJole7 lansopraJole7 pantopraJole7omepraJole7 lansopraJole7 pantopraJole7 rabepra5olerabepra5ole '!ariet*'!ariet*7 7 esomepraJole "Nexium%( esomepraJole "Nexium%(Symptom relie! in /*5 Symptom relie! in /*5;ealing H*0/*5 ;ealing H*0/*5Maintenance o! remission 4*0/:5 Maintenance o! remission 4*0/:5E8ually e!!ective in G/*5 o! individuals E8ually e!!ective in G/*5 o! individuals>ong term sa!ety issues resolved >ong term sa!ety issues resolvedMore cost e!!ective than ;$RAs in complicated orMore cost e!!ective than ;$RAs in complicated or moderate to severe disease moderate to severe disease,aintenance )herapy for GERD,aintenance )herapy for GERD#or patients 2ith complicated disease #or patients 2ith complicated disease$:09*5 maintained in remission 2ith ;$RAs vs( H*0/*5$:09*5 maintained in remission 2ith ;$RAs vs( H*0/*5 2ith PP1Cs 2ith PP1Cs9*0:*5 o! patients re8uire PP1Cs !or maintenance o!9*0:*5 o! patients re8uire PP1Cs !or maintenance o! remission remissionhe lo2est e!!ective dose is therapeutic goal he lo2est e!!ective dose is therapeutic goalAost e!!ectiveness is determined 6y e!!icacy not price o!Aost e!!ectiveness is determined 6y e!!icacy not price o! drug drugE#e$ti%eness of Me!i$al E#e$ti%eness of Me!i$al Thera&ies for GERDThera&ies for GERD$reatment$reatmentResponseResponse%ifestyle modifi#ations/anta#ids%ifestyle modifi#ations/anta#ids&' (&' ())& &*re#eptor antagonists*re#eptor antagonists+' (+' (!ingle*dose ,,- !ingle*dose ,,- .' (.' (-n#reased*dose ,,--n#reased*dose ,,-up to /'' (up to /'' (Ahi6a et al( Gastroenterology -//45 esophagitis cases healed*$*9*+*H*-**$ 9 + H -*=ee's o! treatment-$PP1s;$RAsPlace6op F *(***: %%&s are the most e'ecti(e drugs %%&s are the most e'ecti(e drugs for the initial treatment of GERDfor the initial treatment of GERDSurgical )herapySurgical )herapySurgical therapy Surgical therapyReduce re!lux o! gastric contents 6y enhancing integrity o! >ES Reduce re!lux o! gastric contents 6y enhancing integrity o! >ESMost per!ormed laparoscopically Most per!ormed laparoscopicallySurgical therapy Surgical therapyNecessary i! Necessary i!Aonservative therapy !ails Aonservative therapy !ails;iatal hernia present ;iatal hernia presentEsophageal stricture and stenosis Esophageal stricture and stenosisAhronic esophagitis Ahronic esophagitisong0term use o! PP1s !or the treatment o! patients 2ith esophagitis once they have proven clinically e!!ective( >ong0term therapy should 6e titrated do2n to the lo2estproven clinically e!!ective( >ong0term therapy should 6e titrated do2n to the lo2est e!!ective dose 6ased on symptom control e!!ective dose 6ased on symptom control3( 3( =hen antire!lux surgery L PP1 therapy are judged to o!!er similar e!!ectiveness in a=hen antire!lux surgery L PP1 therapy are judged to o!!er similar e!!ectiveness in a patient 2ith an esophageal GERD syndrome7 PP1 therapy should 6e recommendedpatient 2ith an esophageal GERD syndrome7 PP1 therapy should 6e recommended as initial therapy 6ecause o! superior sa!ety as initial therapy 6ecause o! superior sa!ety9( 9( =hen a patient 2ith an esophageal GERD syndrome is responsive to7 6ut=hen a patient 2ith an esophageal GERD syndrome is responsive to7 6ut intolerant o!7 acid suppressive therapy7 antire!lux surgery should 6e recommendedintolerant o!7 acid suppressive therapy7 antire!lux surgery should 6e recommended as an alternative as an alternative:( :( 2ice0daily PP1 therapy as an empirical trial !or patients 2ith suspected re!lux chest2ice0daily PP1 therapy as an empirical trial !or patients 2ith suspected re!lux chest pain syndrome a!ter a cardiac etiology has 6een care!ully considered pain syndrome a!ter a cardiac etiology has 6een care!ully consideredMahrilas P) et al(Gastroenterology $**H, -3:. -3H3 0 -3/-* U.S. Preventive Services Task Force Grades - Grade A recommendations (strongly recommended based on good evidence that it improves important health otcomes!AGA American Gastroenterological Association, TR Technical Review, MPS Medical Position Statement, PPIs Proton Pump Inhibitors, H2RAs Histamine Receptor Antagonistserapi Empiriserapi EmpirisDinama'an juga PP1 testDinama'an juga PP1 testDosis ganda PP1Dosis ganda PP1-0$ minggu-0$ mingguPositi!, 6ila 'eluhan hilang 4:5 Positi!, 6ila 'eluhan hilang 4:5 dalam - minggudalam - mingguMonsensus GERD PG17 $**9reatment option in GERDreatment option in GERD6ontinuous7aintenan#e(month* year)! !-ntermittent 6ourses("eeks)!! ! ! !1n*demand(days)! 8 symptom re#urren#eP$ -yt.er/ 0 1$ %$ -lum29 Rationale and proposed algorithms for symptom*based proton pump inhibitor therapy for gastro*oesophageal reflux disease 1limentary Pharmacology 0 )herapeutics9 :olume &' ,age 5.;* August &''ollo"*up proto#ols P$ -yt.er/ 0 1$ %$ -lum29 Rationale and proposed algorithms for symptom*based proton pump inhibitor therapy for gastro*oesophageal reflux disease 1limentary Pharmacology 0 )herapeutics9 :olume &' ,age 5.;* August &''