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Kahrilas PJ, Anastasiou F, Barrett K, Beh L, Chinzon D, Doerfler B, López-Pintor E, Maimin J, Mendive JM, Taft T, Hungin AP. Assessment and treatment of reflux-like symptoms in the community: a multidisciplinary perspective. Br J Gen Pract 2024; 74:232-235. [PMID: 38664044 PMCID: PMC11060810 DOI: 10.3399/bjgp24x737349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Affiliation(s)
- Peter J Kahrilas
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, US
| | - Foteini Anastasiou
- 24th Local Primary Care Team, Municipality Practice and Academic Practice of Heraklion, Crete, Greece
| | | | - Lovy Beh
- Malaysian Community Pharmacy Guild (MCPG), Malaysia
| | - Decio Chinzon
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Bethany Doerfler
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, US
| | - Elsa López-Pintor
- Department of Engineering, Area of Pharmacy and Pharmaceutical Technology, Universidad Miguel Hernández, Alicante, Spain; CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain
| | - Jacqueline Maimin
- Independent Community Pharmacy Association NPC, Cape Town, South Africa
| | - Juan M Mendive
- La Mina Primary Care Academic Centre, Catalan Health Institute, University of Barcelona, Spain
| | - Tiffany Taft
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, US
| | - A Pali Hungin
- Primary Care and General Practice, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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Kahrilas P, Anastasiou F, Bredenoord AJ, El Serag HB, Labenz J, Mendive J, Savarino EV, Sifrim D, Udrescu M, Yadlapati R, Hungin AP. Proton Pump Inhibitors: Rational Use and Use-Reduction - The Windsor Workshop. Dig Dis 2024; 42:211-220. [PMID: 38513623 DOI: 10.1159/000538399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Despite deprescribing initiatives to curb overutilization of proton pump inhibitors (PPIs), achieving meaningful reductions in PPI use is proving a challenge. SUMMARY An international group of primary care doctors and gastroenterologists examined the literature surrounding PPI use and use-reduction to clarify: (i) what constitutes rational PPI prescribing; (ii) when and in whom PPI use-reduction should be attempted; and (iii) what strategies to use when attempting PPI use-reduction. KEY MESSAGES Before starting a PPI for reflux-like symptoms, patients should be educated on potential causes and alternative approaches including dietary and lifestyle modification, weight loss, and relaxation strategies. When commencing a PPI, patients should understand the reason for treatment, planned duration, and review date. PPI use at hospital discharge should not be continued without a recognized indication for long-term treatment. Long-term PPI therapy should be reviewed at least annually. PPI use-reduction should be based on the lack of a rational indication for long-term PPI use, not concern for PPI-associated adverse events. PPI use-reduction strategies involving switching to on-demand PPI or dose tapering, with rescue therapy for rebound symptoms, are more likely to succeed than abrupt cessation.
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Affiliation(s)
- Peter Kahrilas
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Foteini Anastasiou
- 4th Local Primary Care Team, Municipality Practice and Academic Practice of Heraklion, Crete, Greece
| | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Hashem B El Serag
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Joachim Labenz
- Department of Internal Medicine, Jung-Stilling-Hospital, Siegen, Germany
| | - Juan Mendive
- La Mina Primary Care Academic Centre, Catalan Health Institute, University of Barcelona, Barcelona, Spain
| | - Edoardo V Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | | | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - A Pali Hungin
- Faculty of Medical Sciences, Professor Emeritus, Primary Care and General Practice, Newcastle University, Newcastle upon Tyne, UK
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Hungin AP, Yadlapati R, Anastasiou F, Bredenoord AJ, El Serag H, Fracasso P, Mendive JM, Savarino EV, Sifrim D, Udrescu M, Kahrilas PJ. Management advice for patients with reflux-like symptoms: an evidence-based consensus. Eur J Gastroenterol Hepatol 2024; 36:13-25. [PMID: 38006602 PMCID: PMC10695341 DOI: 10.1097/meg.0000000000002682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/11/2023] [Indexed: 11/27/2023]
Abstract
Patients with reflux-like symptoms (heartburn and regurgitation) are often not well advised on implementing individualised strategies to help control their symptoms using dietary changes, lifestyle modifications, behavioural changes or fast-acting rescue therapies. One reason for this may be the lack of emphasis in management guidelines owing to 'low-quality' evidence and a paucity of interventional studies. Thus, a panel of 11 gastroenterologists and primary care doctors used the Delphi method to develop consolidated advice for patients based on expert consensus. A steering committee selected topics for literature searches using the PubMed database, and a modified Delphi process including two online meetings and two rounds of voting was conducted to generate consensus statements based on prespecified criteria (67% voting 'strongly agree' or 'agree with minor reservation'). After expert discussion and two rounds of voting, 21 consensus statements were generated, and assigned strength of evidence and Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) rating. Eleven statements achieved the strongest (100%) agreement: five are related to diet and include identification and avoidance of dietary triggers, limiting alcohol, coffee and carbonated beverages, and advising patients troubled by postprandial symptoms not to overeat; the remaining six statements concern advice around smoking cessation, weight loss, raising the head-of-the-bed, avoiding recumbency after meals, stress reduction and alginate use. The aim of developing the consensus statements is that they may serve as a foundation for tools and advice that can routinely help patients with reflux-like symptoms better understand the causes of their symptoms and manage their individual risk factors and triggers.
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Affiliation(s)
- A. Pali Hungin
- Professor Emeritus, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Foteini Anastasiou
- 4th Local Primary Care Team, Municipality Practice and Academic Practice of Heraklion; University of Crete, Crete, Greece
| | - Albert J. Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Hashem El Serag
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Pierluigi Fracasso
- Department of Gastroenterology and Digestive Endoscopy, Ospedale Sandro Pertini, Local Health Agency Roma 2, Rome, Italy
| | - Juan M Mendive
- La Mina Primary Care Academic Centre, Catalan Health Institute, University of Barcelona, Spain
| | - Edoardo V. Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | | | - Peter J Kahrilas
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Guadagnoli L, Geeraerts A, Geysen H, Pauwels A, Vanuytsel T, Tack J, Van Oudenhove L. Psychological Processes, Not Physiological Parameters, Are Most Important Contributors to Symptom Severity in Patients With Refractory Heartburn/Regurgitation Symptoms. Gastroenterology 2023; 165:848-860. [PMID: 37394015 DOI: 10.1053/j.gastro.2023.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 06/03/2023] [Accepted: 06/12/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND & AIMS Physiological and psychological factors have been found to influence esophageal symptom reporting. We aimed to evaluate which of these factors are associated with 3 reflux symptom severity outcomes (ie, Total Reflux, Heartburn, and Sleep Disturbance) through a traditional statistical and a complementary machine-learning approach. METHODS Consecutive adult patients with refractory heartburn/regurgitation symptoms underwent standard 24-hour pH-impedance monitoring and completed questionnaires assessing past and current gastrointestinal and psychological health. In the traditional statistical approach, hierarchical general linear models assessed relationships of psychological and physiological variables (eg, total number of reflux episodes) with reflux severity scores. Mediation analyses further assessed pathways between relevant variables. In the machine-learning approach, all psychological and physiological variables were entered into 11 different models and cross-validated model performance was compared among the different models to select the best model. RESULTS Three hundred ninety-three participants (mean [SD] age, 48.5 [14.1] years; 60% were female) were included. General psychological functioning emerged as an important variable in the traditional statistical approach, as it was significantly associated with all 3 outcomes and mediated the relationship between childhood trauma and both Total Reflux and Heartburn Severity. In the machine-learning analyses, general psychological variables (eg, depressive symptoms) were most important for Total Reflux and Sleep Disturbance outcomes, and symptom-specific variables, like visceral anxiety, were more influential for Heartburn Severity. Physiological variables were not significant contributors to reflux symptom severity outcomes in our sample across reflux classifications and statistical methodology. CONCLUSIONS Psychological processes, both general and symptom-specific, should be considered as another important factor within the multifactorial processes that impact reflux symptom severity reporting across the reflux spectrum.
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Affiliation(s)
- Livia Guadagnoli
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Leuven Brain Institute, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Annelies Geeraerts
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Hannelore Geysen
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ans Pauwels
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Gastroenterology Division, University Hospitals Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Gastroenterology Division, University Hospitals Leuven, Leuven, Belgium
| | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium; Leuven Brain Institute, Katholieke Universiteit Leuven, Leuven, Belgium; Consultation-Liaison Psychiatry, University Psychiatric Centre Katholieke Universiteit Leuven Campus Gasthuisberg, Leuven, Belgium; Cognitive and Affective Neuroscience Laboratory, Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire
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Agwaonye S, Vasant DH. Optimising reflux symptom burden and patient compliance during PPI washout periods for oesophageal pH monitoring studies: should we be more proactive with alginate use? BMJ Open Gastroenterol 2023; 10:bmjgast-2022-001078. [PMID: 36746521 PMCID: PMC9906276 DOI: 10.1136/bmjgast-2022-001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/24/2023] [Indexed: 02/08/2023] Open
Affiliation(s)
- Sophia Agwaonye
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Dipesh H Vasant
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK .,Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
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Vaezi MF, Brunton S, Mark Fendrick A, Howden CW, Atkinson C, Pelletier C, Jacob R, Spechler SJ. Patient journey in erosive oesophagitis: real-world perspectives from US physicians and patients. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000941. [PMID: 35868653 PMCID: PMC9316025 DOI: 10.1136/bmjgast-2022-000941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/07/2022] [Indexed: 11/25/2022] Open
Abstract
Objective Management of erosive oesophagitis (EE) remains suboptimal, with many patients experiencing incomplete healing, ongoing symptoms, and relapse despite proton pump inhibitor (PPI) treatment. The Study of Acid-Related Disorders investigated patient burden of individuals with EE in a real-world setting. Design US gastroenterologists (GIs) or family physicians (FPs)/general practitioners (GPs) treating patients with EE completed a physician survey and enrolled up to four patients with EE for a patient survey, with prespecified data extracted from medical records. Results 102 GIs and 149 FPs/GPs completed the survey; data were available for 73 patients (mean age at diagnosis, 45.4 years). Omeprazole was healthcare professional (HCP)-preferred first-line treatment (60.8% GIs; 56.4% FPs/GPs), and pantoprazole preferred second line (29.4% and 32.9%, respectively). Price and insurance coverage (both 55.5% HCPs) and familiarity (47.9%) key drivers for omeprazole; insurance coverage (52.0%), price (50.0%), familiarity (48.0%), initial symptom relief (46.0%), and safety (44.0%) key drivers for pantoprazole. Only 49.3% patients took medication as instructed all the time; 56.8% independently increased medication frequency some of the time. Despite treatment, 57.5% patients experienced heartburn and 30.1% regurgitation; heartburn was the most bothersome symptom. 58.9% patients believed that their symptoms could be better controlled; only 28.3% HCPs were very satisfied with current treatment options. 83.6% patients wanted long-lasting treatment options. Fast symptom relief for patients was a top priority for 66.1% HCPs, while 56.6% would welcome alternatives to PPIs. Conclusion This real-world multicentre study highlights the need for new, rapidly acting treatments in EE that reduce symptom burden, offer durable healing and provide symptom control.
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Affiliation(s)
- Michael F Vaezi
- Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - A Mark Fendrick
- Department of Internal Medicine, University of Michigan Department of Internal Medicine, Ann Arbor, Michigan, USA
| | | | | | | | - Rinu Jacob
- Phathom Pharmaceuticals, New Jersey, New Jersey, USA
| | - Stuart J Spechler
- Division of Gastroenterology, Baylor University Medical Center at Dallas, Dallas, Texas, USA
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