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Jung HK, Tae CH, Song KH, Kang SJ, Park JK, Gong EJ, Shin JE, Lim HC, Lee SK, Jung DH, Choi YJ, Seo SI, Kim JS, Lee JM, Kim BJ, Kang SH, Park CH, Choi SC, Kwon JG, Park KS, Park MI, Lee TH, Kim SY, Cho YS, Lee HH, Jung KW, Kim DH, Moon HS, Miwa H, Chen CL, Gonlachanvit S, Ghoshal UC, Wu JCY, Siah KTH, Hou X, Oshima T, Choi MY, Lee KJ. 2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease. J Neurogastroenterol Motil 2021; 27:453-481. [PMID: 34642267 PMCID: PMC8521465 DOI: 10.5056/jnm21077] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis. Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.
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Affiliation(s)
- Hye-Kyung Jung
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Kyung Ho Song
- Division of Gastroenterology, Department of Internal Medicine, CHA Ilsan Medical Center, CHA University School of Medicine, Ilsan, Jeollabuk-do, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Gangnam Center, Seoul, Korea
| | - Jong Kyu Park
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Chungcheongnam-do, Korea
| | - Hyun Chul Lim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Jin Choi
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung In Seo
- Division of Gastroenterology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jung Min Lee
- Digestive Disease Center, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sun Hyung Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Gyeonggi-do, Korea
| | - Suck Chei Choi
- Department of Internal Medicine and Digestive Disease Research Institute, Wonkwang University School of Medicine, Iksan, Jeollabuk-do, Korea
| | - Joong Goo Kwon
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Tae Hee Lee
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Seung Young Kim
- Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Young Sin Cho
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University Cheonan, Hospital, Cheonan, Chungcheongnamdo, Korea
| | - Han Hong Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hirota Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Chien-Lin Chen
- Institute of Medical Sciences, Tzu Chi University, and Department of Public Health, College of Medicine, Tzu Chi University, Hualien City, Taiwan
| | - Sutep Gonlachanvit
- Center of Excellence on Neurogastroenterology and Motility, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Uday C Ghoshal
- Departments of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, India
| | - Justin C Y Wu
- Institute of Digestive Disease, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, China
| | - Kewin T H Siah
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Gastroenterology and Hepatology, University Medicine Cluster, National University Hospital, Singapore
| | - Xiaohua Hou
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Tadayuki Oshima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Mi-Young Choi
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
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Min YW, Shin YW, Cheon GJ, Park KS, Kim HS, Sohn CI, Kim TN, Moon HC, Rhee PL. Recurrence and Its Impact on the Health-related Quality of Life in Patients with Gastroesophageal Reflux Disease: A Prospective Follow-up Analysis. J Neurogastroenterol Motil 2015; 22:86-93. [PMID: 26486229 PMCID: PMC4699725 DOI: 10.5056/jnm15124] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/03/2015] [Accepted: 09/07/2015] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Limited data exist on the outcome of gastroesophageal reflux disease (GERD) treatment and its impact on the health-related quality of life (HRQoL) in the Asian population. This study aims to evaluate the treatment outcomes, to investigate the factors associated with recurrence, and to evaluate the impact of the treatment outcome on the HRQoL in a Korean GERD population. Methods This was a prospective, multicenter study involving a total of 824 GERD patients. The response to treatment was assessed at week 4 (or week 8 for the patients who did not achieve complete resolution [CR] at week 4). The EQ-5D questionnaire was used at baseline, end of treatment, and first recurrence to assess the HRQoL. To assess GERD symptoms, contact of patients by phone at 1, 6, and 12 months following treatment was carried out. Results CR was achieved in 65.6% and recurrence was observed in 47.8% following treatment. CR and recurrence rates did not differ by the presence of esophagitis. Multivariate analysis revealed that acid regurgitation (odds ratio 2.249; 95% confidence interval 1.293–3.912; P = 0.004) and both acid regurgitation and heartburn (odds ratio 2.330; 95% confidence interval 1.392–3.901; P = 0.001) were independent risk factors for GERD recurrence. EQ-5D scores were more improved in patients with CR than in those without CR, and worsened more during follow-up in patients with recurrence than in those without recurrence. Conclusions We should achieve complete symptom relief and attempt to prevent recurrence in GERD patients to improve their HRQoL.
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Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Woon Shin
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, Gangneung Asan Hospital, Ulsan University College of Medicine, Gangneung, Korea
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hyun Soo Kim
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Chong-Il Sohn
- Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Nyeun Kim
- Department of Internal Medicine, Yeungnam University Hospital, Daegu, Korea
| | - Hyeung Cheol Moon
- Department of Internal Medicine, Kwangju Christian Hospital, Gwangju, Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Tavakkoli A, Sayed BA, Talley NJ, Moshiree B. Acid and non-acid reflux in patients refractory to proton pump inhibitor therapy: Is gastroparesis a factor? World J Gastroenterol 2013; 19:6193-6198. [PMID: 24115816 PMCID: PMC3787349 DOI: 10.3748/wjg.v19.i37.6193] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 07/14/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine whether an increased number and duration of non-acid reflux events as measured using the multichannel intraluminal impedance pH (MII-pH) is linked to gastroparesis (GP).
METHODS: A case control study was conducted in which 42 patients undergoing clinical evaluation for continued symptoms of gastroesophageal reflux disease (both typical and atypical symptoms) despite acid suppression therapy. MII-pH technology was used over 24 h to detect reflux episodes and record patients’ symptoms. Parameters evaluated in patients with documented GP and controls without GP by scintigraphy included total, upright, and supine number of acid and non-acid reflux episodes (pH < 4 and pH > 4, respectively), the duration of acid and non-acid reflux in a 24-h period, and the number of reflux episodes lasting longer than 5 min.
RESULTS: No statistical difference was seen between the patients with GP and controls with respect to the total number or duration of acid reflux events, total number and duration of non-acid reflux events or the duration of longest reflux episodes. The number of non-acid reflux episodes with a pH > 7 was higher in subjects with GP than in controls. In addition, acid reflux episodes were more prolonged (lasting longer than 5 min) in the GP patients than in controls; however, these values did not reach statistical significance. Thirty-five patients had recorded symptoms during the 24 h study and of the 35 subjects, only 9% (n = 3) had a positive symptom association probability (SAP) for acid/non-acid reflux and 91% had a negative SAP.
CONCLUSION: The evaluation of patients with a documented history of GP did not show an association between GP and more frequent episodes of non-acid reflux based on MII-pH testing.
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Individualized therapy for gastroesophageal reflux disease: potential impact of pharmacogenetic testing based on CYP2C19. Mol Diagn Ther 2012; 16:223-34. [PMID: 22873740 DOI: 10.1007/bf03262211] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The main therapeutic agent for gastroesophageal reflux disease (GERD) is a proton pump inhibitor (PPI). Plasma levels and the acid inhibitory effect of PPIs depend on the activity of cytochrome P450 (CYP) 2C19, which is polymorphic. Genotypes of CYP2C19 are classified into three groups: rapid metabolizers (RMs: *1/*1), intermediate metabolizers (IMs: *1/*X), and poor metabolizers (PMs: *X/*X), where *1 and X represent the wild type and the mutant allele, respectively. RMs include ultra-rapid metabolizers, who possess the CYP2C19*17 allele. The pharmacokinetics and pharmacodynamics of PPIs differ among different CYP2C19 genotype groups. Plasma PPI levels and intragastric pH values during PPI treatment are lowest in the RM group, intermediate in the IM group, and highest in the PM group. These CYP2C19-genotype-dependent differences in the pharmacokinetics and pharmacodynamics of PPIs influence the healing and recurrence of GERD during PPI treatment, suggesting the need for CYP2C19 genotype-based tailored therapy for GERD. CYP2C19 pharmacogenetics should be taken into consideration for the personalization of PPI-based therapy. However, the clinical usefulness of CYP2C19 genotype testing in GERD therapy should be verified in clinical studies.
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Furuta T, Sugimoto M, Shirai N. Individualized therapy for gastroesophageal reflux disease: potential impact of pharmacogenetic testing based on CYP2C19. Mol Diagn Ther 2012. [PMID: 22873740 DOI: 10.2165/11634960-000000000-00000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The main therapeutic agent for gastroesophageal reflux disease (GERD) is a proton pump inhibitor (PPI). Plasma levels and the acid inhibitory effect of PPIs depend on the activity of cytochrome P450 (CYP) 2C19, which is polymorphic. Genotypes of CYP2C19 are classified into three groups: rapid metabolizers (RMs: *1/*1), intermediate metabolizers (IMs: *1/*X), and poor metabolizers (PMs: *X/*X), where *1 and X represent the wild type and the mutant allele, respectively. RMs include ultra-rapid metabolizers, who possess the CYP2C19*17 allele. The pharmacokinetics and pharmacodynamics of PPIs differ among different CYP2C19 genotype groups. Plasma PPI levels and intragastric pH values during PPI treatment are lowest in the RM group, intermediate in the IM group, and highest in the PM group. These CYP2C19-genotype-dependent differences in the pharmacokinetics and pharmacodynamics of PPIs influence the healing and recurrence of GERD during PPI treatment, suggesting the need for CYP2C19 genotype-based tailored therapy for GERD. CYP2C19 pharmacogenetics should be taken into consideration for the personalization of PPI-based therapy. However, the clinical usefulness of CYP2C19 genotype testing in GERD therapy should be verified in clinical studies.
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Affiliation(s)
- Takahisa Furuta
- Center for Clinical Research, Hamamatsu University School of Medicine, Hamamatsu, Japan.
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Dackus GHE, Loffeld SMLA, Loffeld RJLF. Use of acid suppressive therapy more than 10 years after the endoscopic diagnosis of reflux esophagitis with specific emphasis to trademark and generic proton pump inhibitors. J Gastroenterol Hepatol 2012; 27:368-71. [PMID: 21777284 DOI: 10.1111/j.1440-1746.2011.06855.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Reflux esophagitis needs maintenance therapy. Data on comparison between trademark and generic medications are not available. Complaints and use of acid-suppressive therapy 10 years after diagnosis were determined. METHODS A total of 672 patients with esophagitis between 1998 and 2000 were reviewed. Patients received a questionnaire regarding the use of acid-suppressive therapy, dosage, compliance and satisfaction. The use of trademark and generic medications was assessed. The presence of reflux complaints was assessed via a questionnaire, and a symptom score was calculated using a five-point Likert scale. RESULTS A total of 208 patients returned the questionnaire, of whom 161 (78%) used acid-suppressive therapy. Of the patients still on therapy, 72% (n = 116, group 1) had reflux complaints, while the remaining 45 patients (28%, group 2) were in remission. There was no difference in sex, age, or severity of the initially diagnosed reflux esophagitis. Patients in group 1 were significantly less compliant and satisfied compared to patients from group 2 (73% vs 96% and 83% vs 100%, P < 0.001, respectively). An equal number of patients in both groups used trademark and generic medications (P = not significant). The presence of reflux complaints, as well as the symptom score, showed no difference between users of trademark or generic medication. CONCLUSION More than 10 years after the diagnosis, 22% of patients stopped using acid-suppressive therapy. Only a minority (28%) were in clinical remission, associated with significantly higher satisfaction and compliance to therapy, as compared to their symptomatic counterparts. There was no difference in effect and usage of trademark versus generic medication preparations.
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Affiliation(s)
- Gwen H E Dackus
- University of Maastricht, Medical School, Maastricht, the Netherlands
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The long-term follow-up of patients with endoscopically diagnosed reflux oesophagitis with specific emphasis to complaints. Eur J Gastroenterol Hepatol 2011; 23:1122-6. [PMID: 21934510 DOI: 10.1097/meg.0b013e32834b8d18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Patients with gastroesophageal reflux disease (GERD) need long-term treatment with acid-suppressive therapy. Data on long-term follow-up are very rare. For this reason, a study was performed to detect complaints many years after diagnosis. PATIENTS AND METHODS All patients diagnosed with reflux oesophagitis in the years 1998-2000 were included. In the summer of 2010, they received a questionnaire with four different lists of questions pertaining to reflux complaints and use of medication. Severity and frequency were scored on 5-point and 6-point Likert scales, respectively; the GerdQ, a symptom activity index, and the gastrointestinal symptom-rating scale were also used. RESULTS Complaints were reported by 130 patients (63%); the majority of these, 115 (88%), used acid suppressive therapy. Only 78 patients were in clinical remission, with or without therapy. The respondents with complaints were divided into two groups. Group 1: all patients with reflux complaints using acid suppressive therapy. Group 2: all patients with complaints without medication. Patients in group 1 were significantly older at the time of the endoscopic diagnosis compared with patients of group 2, and patients in group 1 had a hiatal hernia more often (P<0.001). There was no difference in the overall symptom or the frequency score per patient between both groups, with a mean of 5.97 versus 6.8 and 13.4 versus 13.8 respectively. However, heartburn, nausea, acid regurgitation, epigastric pain, dysphagia and nocturnal complaints showed a significantly higher prevalence in patients of group 2. Scores for specific complaints were significantly lower in group 2 and there was no difference between the GerdQ, the symptom activity index and the gastrointestinal symptom-rating scale. CONCLUSION Despite effective therapy, only 37% of the patients are in complete remission. However, the individual symptom score is rather low. Patients without medication more often have reflux complaints but lower severity scores. Patients who still had complaints and used medication had a hiatal hernia significantly more often.
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Canadian Digestive Health Foundation Public Impact Series: gastroesophageal reflux disease in Canada: incidence, prevalence, and direct and indirect economic impact. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2010; 24:431-4. [PMID: 20652158 DOI: 10.1155/2010/296584] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Canadian Digestive Health Foundation initiated a scientific program to assess the incidence, prevalence, mortality and economic impact of digestive disorders across Canada. The current article presents the updated findings from the study concerning gastroesophageal reflux disease - a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications (Montreal definition).
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Tsoukali E, Sifrim D. The role of weakly acidic reflux in proton pump inhibitor failure, has dust settled? J Neurogastroenterol Motil 2010; 16:258-64. [PMID: 20680164 PMCID: PMC2912118 DOI: 10.5056/jnm.2010.16.3.258] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 06/15/2010] [Accepted: 06/24/2010] [Indexed: 12/11/2022] Open
Abstract
Patients that do not respond satisfactorily to standard proton pump inhibitor (PPI) treatment have become the most common presentation of gastro-esophageal reflux disease (GERD) in third referral gastrointestinal practices. The causes of refractory GERD include lack of compliance with treatment, residual acid reflux and weakly acidic reflux, esophageal hypersensitivity and persistent symptoms not associated with reflux. A role for weakly acidic reflux in symptom generation has been proposed since the availability of impedance-pH monitoring. The possible mechanisms by which persistent weakly acidic reflux might contribute to persistent symptoms in patients under PPI treatment may include esophageal distension by increased reflux volume, persistent impaired mucosal integrity (ie, dilation of intercellular spaces) and/or esophageal hypersensitivity to weakly acidic reflux events. To establish a definite role of weakly acidic reflux in refractory GERD, outcome studies targeting this type of reflux are still lacking. Treatment strategies to reduce the number or effect of weakly acidic reflux could involve drugs that decrease transient lower esophageal sphincter relaxations (ie, baclofen or similar), improve oesophageal mucosa resistance or visceral pain modulators. Finally, anti-reflux surgery can be considered, only if a clear symptom-weakly acidic reflux association was demonstrated.
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Affiliation(s)
- Emmanouela Tsoukali
- Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, UK
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Furuta T, Sugimoto M, Shirai N, Ishizaki T. CYP2C19 pharmacogenomics associated with therapy of Helicobacter pylori infection and gastro-esophageal reflux diseases with a proton pump inhibitor. Pharmacogenomics 2008; 8:1199-210. [PMID: 17924835 DOI: 10.2217/14622416.8.9.1199] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Proton pump inhibitors (PPIs), such as omeprazole, lansoprazole and rabeprazole, are metabolized by CYP2C19 in the liver. There are genetic differences in the activity of this enzyme. Genotypes of CYP2C19 are classified into three groups, rapid metabolizer (RM: *1/*1), intermediate metabolizer (IM: *1/*X) and poor metabolizer (PM: *X/*X) (*1 and 'X' represent the wild-type and mutant allele, respectively). The pharmacokinetics and pharmacodynamics of PPIs differ among three different CYP2C19 genotype groups. Plasma PPI levels and intragastric pHs during PPI treatment in the RM group are lowest, those in the IM group come next, and those in the PM group are highest of the three groups. These CYP2C19 genotypic differences in pharmacokinetics and pharmacodynamics of PPIs influence the healing and eradication rates for the gastro-esophageal reflux disease and Helicobacter pylori infection by PPI-based regimens. Recently, the CYP2C19 genotype-based tailored therapy for H. pylori infection has been found to be effective. CYP2C19 pharmacogenetics should be taken into consideration for the personalization of a PPI-based therapy.
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Affiliation(s)
- Takahisa Furuta
- 1Hamamatsu University School of Medicine, Center for Clinical Research, 1-20-1, Handa-Yama, Higashi-Ku, Hamamatsu, 431-3192, Japan.
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Abstract
Patients who are unresponsive to 4-8 weeks' treatment with PPIs twice daily might have so-called refractory GERD. The first investigation these patients should undergo is upper endoscopy to exclude a diagnosis of peptic ulcer disease or cancer and identify the presence of esophagitis. The presence of esophagitis in these patients is suggestive of a pill-induced injury, an autoimmune skin disease involving the esophagus, eosinophilic esophagitis or, less likely, a hypersecretory syndrome or a genotype that confers altered metabolism of PPIs. Refractory reflux syndromes associated with normal endoscopy findings are more problematic to diagnose and further testing may be required, including prolonged 48 h pH testing, impedance measurements (for nonacid reflux), esophageal manometry and gastric function tests. For patients with refractory GERD who do not have esophagitis, possible etiologies include nocturnal gastric acid breakthrough, nonacid GER, missed GER or other diseases such as achalasia, gastroparesis or functional heartburn.
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Gené E, Calvet X, Azagra R, Gisbert JP. [Seven or ten days? Cost-effectiveness study on the duration of H. pylori treatment in primary care]. Aten Primaria 2006; 38:555-62. [PMID: 17198608 PMCID: PMC7669186 DOI: 10.1157/13095927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Accepted: 04/24/2006] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To determine through an economic evaluation study whether it is cost-effective to extend treatment of dyspeptic patients from 7 to 10 days, distinguishing between functional dyspepsia, unexamined dyspepsia, and ulcer disease. DESIGN Cost-effectiveness study by means of a decision 3 comparing direct costs per patient cured with 2 strategies: a) 7 days treatment versus b) 10 days. Two-year study in the National Health System. SETTING Primary care. PARTICIPANTS One-hundred patients with peptic ulcer, functional dyspepsia, or unexamined dyspepsia who received treatment for H pylori infection. INTERVENTIONS H pylori eradication treatment with a proton pump inhibitor, clarithromycin, and amoxycillin for 7 or 10 days. Measurement variable: incremental cost per patient cured. RESULTS In peptic ulcer patients, the incremental cost per patient cured on extending the eradication treatment from 7 to 10 days was euro147 (95% CI, 121.3-162.7), whereas in patients with functional or unexamined dyspepsia, it was -euro39.8 (95% CI, -28.5 to -60.7) and -euro27.3 (95% CI, -14.92 to -52.72), respectively. The sensitivity analysis showed that the efficacy of eradication treatment (7 vs 10) was the factor that most affected the stability of the results. CONCLUSIONS Seven days is the most cost-effective duration of the triple therapy for eradicating H pylori in ulcer patients. However, 10 days is more cost-effective in functional dyspepsia patients or those with no prior endoscope diagnosis.
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Affiliation(s)
- Emili Gené
- Servei d'Urgències, Hospital de Sabadell, Corporació Parc Taulí, Barcelona, España.
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Recent developments in the pathophysiology and therapy of gastroesophageal reflux disease and nonerosive reflux disease. Curr Opin Gastroenterol 2005. [PMID: 15930988 DOI: 10.1097/01.mog.0000166657.09968.4b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Gastroesophageal reflux disease is a very common disorder. Proton pump inhibitors are the highly successful mainstay of medical gastroesophageal reflux disease treatment. However, some limitations of proton pump inhibitor therapy continue to drive studies that aim at better understanding and managing manifestations of gastroesophageal reflux disease. This review summarizes recent progress in our understanding of the pathophysiology and treatment of gastroesophageal reflux disease. RECENT FINDINGS Recent studies have demonstrated a potential role of increased gastric acid secretion in gastroesophageal reflux disease, a factor largely neglected during the last decade. Failure to respond adequately to proton pump inhibitor therapy has been attributed to diagnostic inaccuracy, to nocturnal acid breakthrough, to ongoing non-acid reflux and to esophageal hypersensitivity. The relevance of nocturnal acid breakthrough has been recently challenged. Transient lower esophageal sphincter relaxations are a major mechanism of gastroesophageal reflux disease; inhibition of transient lower esophageal sphincter relaxations is a potentially important therapeutic target. Recent studies have focused on GABA receptor stimulation using baclofen or sodium valproate. The role of esophageal body peristalsis in the clearance of reflux events has been questioned. Endoscopic antireflux therapies aim at perendoscopic reinforcement of the antireflux barrier as a novel therapeutic approach to gastroesophageal reflux disease. At present, long-term and controlled data are scarce. Recent observations have challenged the long-term efficacy of surgical antireflux therapy. SUMMARY Increased understanding of the pathophysiology of gastroesophageal reflux disease may lead to new or improved treatments. Major advances have been made in the role of gastric acid secretion, the control of transient lower esophageal sphincter relaxations and mechanisms underlying esophageal hypersensitivity. Recent studies have highlighted some shortcomings of proton pump inhibitor therapy and of antireflux surgery. Novel approaches are treatments aimed at decreasing transient lower esophageal sphincter relaxations and endoscopic antireflux procedures. Large-scale controlled studies are lacking for both treatments.
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Calabrese C, Bortolotti M, Fabbri A, Areni A, Cenacchi G, Scialpi C, Miglioli M, Di Febo G. Reversibility of GERD ultrastructural alterations and relief of symptoms after omeprazole treatment. Am J Gastroenterol 2005; 100:537-42. [PMID: 15743348 DOI: 10.1111/j.1572-0241.2005.40476.x] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Dilation of intercellular spaces (DIS) of human esophageal epithelium, evident at transmission electron microscopy (TEM), is an early marker of damage caused by gastroesophageal reflux, but its reversibility after therapy has not been investigated. AIM To evaluate whether omeprazole can induce the healing of DIS. METHODS Thirty-eight symptomatic patients, 22 with nonerosive reflux disease (NERD) and 16 with erosive esophagitis (EE), classified on the basis of 24-h pH monitoring, were enrolled. During upper gastrointestinal endoscopy, six biopsies from apparently normal mucosa were taken within the lower 5 cm of the esophagus for histological and TEM analysis. One hundred computer measurements were taken on TEM photomicrographs of the specimens in each patient. After 3 months of omeprazole 40 mg/die a further endoscopy with biopsies was performed. In patients with persistent heartburn and/or incomplete ultrastructural recovery of esophageal epithelium, a new endoscopy was performed after 3 more months of treatment. RESULTS After 3 months of therapy, 35 patients (92.1%) showed a complete recovery of DIS and resolution of heartburn. Three patients required 3 more months of therapy because of an incomplete recovery of the epithelium correlated with sporadic heartburn. Healing of the mucosa was achieved in two patients, whereas one had an incomplete recovery of DIS with persistent heartburn. CONCLUSIONS Three and six months of omeprazole therapy led to a complete recovery of DIS in 92.1% and 97.4% of cases, respectively. No significant differences of DIS between NERD and EE were noted. Complete recovery of DIS was accompanied by regression of heartburn in all cases.
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Affiliation(s)
- Carlo Calabrese
- Dipartimento di Medicina Interna e Gastroenterologia, Sezione di Anatomia Patologica, Università di Bologna, Italy
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16
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Marko D, Calvet X, Ducons J, Guardiola J, Tito L, Bory F. Comparison of two management strategies for Helicobacter pylori treatment: clinical study and cost-effectiveness analysis. Helicobacter 2005; 10:22-32. [PMID: 15691312 DOI: 10.1111/j.1523-5378.2005.00288.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND First-line proton pump inhibitor-based triple and quadruple therapies for Helicobacter pylori eradication present similar levels of efficacy. Cross-over treatment (quadruple following triple failure, and triple following quadruple failure) seems the most sensible approach to treatment failures, but the two strategies -'quadruple first' versus 'triple first'- have not been previously compared. The aims of our study were to assess the usefulness and the cost-effectiveness of the two treatment strategies. MATERIAL AND METHODS Forty-nine out of 344 patients included in a previous study comparing triple therapy - 7 days of omeprazole, amoxicillin and clarithromycin twice a day - with quadruple therapy - 7 days of omeprazole twice a day, plus tetracycline, metronidazole and bismuth subcitrate three times a day - failed initial treatment and were assigned to cross-over therapy. Cure was determined by urea breath test. A decision analysis was performed to compare the two eradication strategies. RESULTS Intention to treat cure rates were 46% (10/22 patients; 95% CI 24-68%) for second-line triple therapy and 63% (17/27 patients; 95% CI 42-81%) for second-line quadruple therapy. Per protocol cure rates were 71% and 85%, respectively. Intention to treat cure rates were 87% (95% CI 81-92%) for the 'triple first' versus 86% (95% CI 80-91%) for the 'quadruple first' strategy (p = .87). The 'quadruple first' strategy was more cost-effective. The incremental cost of 'triple first' strategy per person was 19 in the low-cost area and 65 US dollars in the high-cost area. CONCLUSIONS The effectiveness of 'triple first' and 'quadruple first' strategies is similar, although the latter seems slightly more cost-effective.
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Affiliation(s)
- Dritana Marko
- Centre de Recerca d'Economia del Benestar, Parc Científic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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Nayyar AK, Royston C, Bardhan KD. Oesophageal acid-peptic strictures in the histamine H2 receptor antagonist and proton pump inhibitor era. Dig Liver Dis 2003; 35:143-50. [PMID: 12779067 DOI: 10.1016/s1590-8658(03)00021-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM We present a survey on the incidence, demography and natural history (re-dilatation rates) of patients with oesophageal acid-peptic stricture seen between 1977 and 1995. PATIENTS AND METHODS Prospective, cohort observational study. Stricture severity was graded mild, moderate or severe (needing forcible dilatation with bougies). Most were treated with histamine H2 receptor antagonists or proton pump inhibitors, and were followed up by serial check endoscopy. RESULTS A total of 156 of 7429 (2%) reflux patients had stricture: mild, n=56; moderate, n=25; severe, n=75. The prevalence of reflux disease is rising, paralleled by an increase in the number of patients with stricture; hence the incidence of stricture is unchanged: 1977-1982, 1.8% (18/986); 1983-1989, 2.4% (61/2595); 1990-1995, 2% (77/3848). Demography: mean age 68 years; mean length of reflux history 6.4 years; 15% on non-steroidal anti-inflammatory drugs/aspirin; 18% with Barrett's metaplasia. Mean follow-up: 5.6 years. OUTCOME of the 75 with severe stricture, 36 (48%) needed forcible dilatation only once, and 39 more often (13 twice, nine three times), most within 2 years. Only six of these patients need > or = 6 re-dilatations. CONCLUSION The incidence of stricture is low and remains unchanged, despite the increased prevalence of reflux disease. Most patients have a good prognosis, only half needing further forcible dilatation, mainly within the first 2 years.
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Affiliation(s)
- A K Nayyar
- Rotherham General Hospitals NHS Trust, Rotherham, South Yorkshire S60 2UD, UK
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Prasad M, Rentz AM, Revicki DA. The impact of treatment for gastro-oesophageal reflux disease on health-related quality of life: a literature review. PHARMACOECONOMICS 2003; 21:769-790. [PMID: 12859219 DOI: 10.2165/00019053-200321110-00002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Gastro-oesophageal reflux disease (GORD) is common in the general population and is diagnosed based on patient-reported symptoms and clinical tests. Although clinical tests are available, significant percentages of patients report symptoms of heartburn and reflux despite negative endoscopies, and 24-hour pH tests are not often used by primary-care physicians in diagnosis. Consequently, patient-reported symptoms and health-related QOL (HR-QOL) are important in assessing treatment outcome. HR-QOL is significantly impaired in patients with GORD, and HR-QOL is associated with symptom severity and changes in GORD-related symptoms. The objective of this literature review is to examine the impact of pharmacological treatment on HR-QOL in patients with GORD. Generic and disease-specific HR-QOL measures have been used in clinical trials to evaluate the impact of GORD on patient functioning and well-being. The Psychological General Well-Being (PGWB) Index and the 36-Item Short-Form Health Survey (SF-36) have been used in several clinical trials of treatment for GORD and have consistently shown that HR-QOL improves with successful therapy. These trials have been conducted primarily with two pharmacological agents, omeprazole and ranitidine. On the Heartburn-specific Quality of Life questionnaire, patients treated with ranitidine reported better HR-QOL after treatment compared with placebo therapy. In two clinical trials where omeprazole and ranitidine were compared, patients treated with omeprazole reported significantly better HR-QOL (based on the PGWB Index) than those treated with ranitidine; however, 2 other trials did not detect significant differences between the treatments. Results from clinical trials using disease-specific measures (Gastrointestinal Quality of Life Index [GIQLI] and Heartburn-specific Quality of Life questionnaire) demonstrate similar findings, supporting the association between treatment-related symptom resolution and improvements in HR-QOL. The GIQLI was used in a trial comparing pantoprazole and ranitidine, where results favoured pantoprazole therapy. Several studies have demonstrated that resolution of GORD symptoms is associated with improvement in HR-QOL. Although there is evidence that treatment for GORD does improve symptoms and HR-QOL outcomes, further research is needed to more completely understand the value of medical therapy for GORD.
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Calvet X, Gené E, López T, Gisbert JP. What is the optimal length of proton pump inhibitor-based triple therapies for H. pylori? A cost-effectiveness analysis. Aliment Pharmacol Ther 2001; 15:1067-76. [PMID: 11421884 DOI: 10.1046/j.1365-2036.2001.01031.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Triple therapy with a proton pump inhibitor, clarithromycin and amoxicillin is widely used for H. pylori infection. The appropriate length of treatment remains controversial. AIM To determine whether length of treatment has an impact on the cost-effectiveness of triple therapy. METHODS The study took the form of a cost-effectiveness analysis spanning 2 years. The perspective was societal and the setting, ambulatory care. Subjects were Helicobacter pylori-positive patients with a duodenal ulcer. The triple therapy trials spanned 7, 10 or 14 days and the main outcome measures were cost per patient and marginal cost for additional cured patient calculated for a low cost-of-care setting (Spain), for a high-cost setting (USA), and for two follow-up strategies: (i) systematic 13C-urea breath test after eradication; (ii) clinical follow-up, breath-test if symptoms recurred. RESULTS Base-case analysis showed that for both the 13C-UBT and the clinical follow-up branches, lowest costs were obtained with 7-day schedules both in Spain and the USA. Sensitivity analysis showed that in Spain, 10-day therapies would have to increase 7-day cure rates by 10-12% to become cost-effective. In contrast, in the USA only a 3-5% increase was needed. The corresponding figures for 14-day therapy were 25-35% and 8-11%, respectively. CONCLUSIONS Seven-day therapies seem the most cost-effective strategy. However, in high-cost areas the differences were less evident.
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Affiliation(s)
- X Calvet
- Servei de Medicina, Corporació Sanitària Parc Taulí, Sabadell, Spain Servicio de Aparato Digestivo, Hospital de la Princesa, Madrid, Spain.
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20
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Jones R, Bytzer P. Review article: acid suppression in the management of gastro-oesophageal reflux disease--an appraisal of treatment options in primary care. Aliment Pharmacol Ther 2001; 15:765-72. [PMID: 11380314 DOI: 10.1046/j.1365-2036.2001.00985.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Gastro-oesophageal reflux disease (GERD) is one of the most common conditions presenting to the primary care physician. Despite progress in understanding and treatment of the disease, strategies for capitalizing on these advances are less well developed. In many practices, H2-receptor antagonists still remain the most widely prescribed treatment for GERD, despite the availability of the more effective acid-suppressant proton pump inhibitors. This review examines the relative efficacies of acid-suppressant drugs in minimizing oesophageal acid exposure and outlines the evidence for the superiority of proton pump inhibitors over standard-dose H(2)-antagonists in symptom relief, erosion healing and prevention of relapse in GERD. Current prescribing patterns and considerations for the general practitioner are also examined. The availability and impact of over-the-counter H(2)-antagonists on the treatment of GERD and their relative cost-effectiveness vs. proton pump inhibitors are also addressed. A hierarchy of drug efficacy (full-dose proton pump inhibitor > half-dose proton pump inhibitor > high-dose H(2)-antagonist > standard-dose H(2)-antagonist or prokinetic) applies in principle to all GERD patients, (with or without oesophagitis). The most effective initial therapy for GERD is also likely to be the most cost-effective one, if treatment failure leads to higher utilization of medical resources. The application of these recommendations to the management of non-endoscoped GERD, endoscopy-negative GERD and low-grade oesophagitis as well as higher grade oesophagitis is also reviewed.
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Affiliation(s)
- R Jones
- Department of General Practice and Primary Care, Guy's, King's and St Thomas' School of Medicine, London, UK.
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21
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Abstract
A study was carried out in a group of patients in whom reflux esophagitis was diagnosed 4.5-7.5 years previously in order to assess current complaints and use of medication. A questionnaire was mailed to all patients in whom reflux esophagitis was diagnosed. Patients were asked about the presence of reflux complaints. Use of medication was assessed (continuous, intermittent, or on demand). In the 3-year period, reflux esophagitis was diagnosed in 312 patients (195 men, 117 women, mean age 59.6 years, range 17-96 years). The questionnaire was mailed to 246 patients, of whom 172 (70%) responded. Of these, 146 (85%) used acid-suppressive therapy. One hundred and eight (74%) used drugs on a daily basis, 31 on demand and 19 prophylactically in order to prevent the occurrence of reflux complaints. Despite the use of medication, patients suffered significantly more often from reflux complaints than did individuals who did not use any medication. It is concluded that the majority of patients (85%) still use acid-suppressive therapy and, in 74% of cases, on a daily basis. Maintenance therapy cannot prevent clinical relapse.
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Affiliation(s)
- H D Boom
- Department of Internal Medicine, De Heel Zaans Medisch Centrum, Zaandam, The Netherlands
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22
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Abstract
The introduction of laparoscopic anti-reflux surgery has led to a renewed interest in the operative treatment of gastro-oesophageal reflux disease (GORD). Three groups of patients can be identified who are particularly suited to laparoscopic anti-reflux surgery. Failure to respond to medical treatment has been historically the main determinant for those referred for anti-reflux surgery. With the availability of modern anti-secretory drugs most patients with chronic GORD can control their symptoms adequately by these means. Even effective medical therapy, however, is not without problems. In many patients rapid and consistent relapse of symptoms and oesophagitis occurs on cessation of therapy. Some of these patients do not want to be reliant on a form of medication that has yet to firmly establish its record for safety over many years of continued use. A second readily identifiable group of patients are those who are often described as 'volume refluxers'. They are bothered by persistent fluid regurgitation despite adequate control of their heartburn with acid suppressive drugs. Third there are those individuals who develop oesophageal strictures and those with Barrett's oesophagus and concomitant reflux symptoms and also those with respiratory complications associated with presumed aspiration of gastric juice into the pharynx and into the respiratory tree. The low morbidity associated with laparoscopic surgery that has been achieved in the best modern series means that the pendulum may swing back to surgery and therefore it is even more important that the right operation (fundoplication) is done for the right patient. Failure to create an adequate crural repair behind the wrap is associated with a risk of early post-operative para-oesophageal herniation and proximal wrap migration. The question of tailored anti-reflux surgery based on the pre-operative motor function of the body of the oesophagus is widely applied, although the scientific basis for these selective approaches is rather weak. Partial fundoplication seems to be associated with very low rates of dysphagia and of gas bloat. Assessment of the post-operative result should ideally be done by an independent observer and should consider not only traditional outcome measures but also the impact of surgery on the quality of the patient's life. Investigations on the cost effectiveness of these surgical therapeutic strategies suggest important benefits of surgery, which should be incorporated into the clinical decision process when assessing different long-term management alternatives for patients with chronic GORD.
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Affiliation(s)
- L Lundell
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, S-413 45, Sweden
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23
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Abstract
Gastro-oesophageal reflux disease (GORD) is a highly prevalent condition in Western countries; at least 20% of the population have weekly symptoms. The incidence appears to be rising in the West and in some developing countries. Heartburn, based on a carefully elicited history, is reasonably specific for identifying GORD if it is a predominant complaint. Symptoms, however, appear to correlate poorly with oesophagitis; hence, severe symptoms do not indicate there is greater oesophageal damage. Only one-third to one-half of patients with GORD undergoing endoscopy have oesophagitis. GORD is usually a chronic disease but one-third may lose their symptoms over time. An ill-defined subset of patients over time may progress to develop abnormal acid exposure or oesophagitis, or both, when none existed at baseline. GORD has a significant negative impact on quality of life to the same degree as other chronic medical conditions, but impairment in quality of life is independent of oesophagitis.
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Affiliation(s)
- S Nandurkar
- Department of Medicine, University of Sydney, Penrith, NSW 2751, Australia
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24
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Gené E, Calvet X, Azagra R. Diagnosis of Helicobacter pylori after triple therapy in uncomplicated duodenal ulcers--a cost-effectiveness analysis. Aliment Pharmacol Ther 2000; 14:433-42. [PMID: 10759623 DOI: 10.1046/j.1365-2036.2000.00735.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The cost-effectiveness of determining Helicobacter pylori status after treatment remains to be established. AIM To determine the benefit of post-treatment assessment of H. pylori eradication in patients with uncomplicated duodenal ulcer. MATERIALS AND METHODS A decision analysis was performed in patients with uncomplicated duodenal ulcer who were H. pylori-positive and had received eradication therapy. A decision tree was devised to compare the costs per patient of two different strategies: (a) systematic performance of post-treatment urea breath test and new treatment if positive; and (b) clinical follow-up, 13C-urea breath test if dyspeptic symptoms recurred and eradication treatment if the test was positive. RESULTS Post-eradication 13C-urea breath test was notably more expensive than clinical follow-up, both in a low-cost per care setting (197 vs. 132 Euros) and in a high-cost per care (614 vs. 340 US $) scenario. This conclusion remained stable for a wide range of variations of the variables included in the decision tree (e.g. cure rates of eradication treatment, cost of the urea breath test or sensitivity, and specificity of urea breath test to detect eradication). CONCLUSION In patients with uncomplicated duodenal ulcer, evaluation of eradication after H. pylori treatment markedly increases costs with no clear improvement in results and therefore should not be performed routinely.
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Affiliation(s)
- E Gené
- Servei de Medicina, Corporació Sanitària del Parc Taulí, Sabadell, Spain
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Goetzel RZ, Ozminkowski RJ, Meneades L, Stewart M, Schutt DC. Pharmaceuticals--cost or investment? An employer's perspective. J Occup Environ Med 2000; 42:338-51. [PMID: 10774502 DOI: 10.1097/00043764-200004000-00002] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Employers are becoming increasingly concerned about rising pharmaceutical costs. Are improved health and cost outcomes achieved as a result of increasing pharmaceutical costs? One should approach this issue with a holistic view that considers the overall impact that disease conditions have on health and productivity. To illustrate, we first identified the "top ten" most expensive physical and mental health concerns facing American businesses, using data from over 60 firms from the 1996 MarketScan Private Pay Fee-For-Service Research Database. For some of these top ten conditions, the literature already addresses the drug cost versus investment issue, with mixed results. For conditions in which uncertainty prevails and for other high-cost conditions, empirical analyses should address the drug cost versus investment issue to minimize the risk of a penny-wise and pound-foolish payment/coverage policy. A similar strategy should be applied to individual corporate diagnostic assessments.
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Affiliation(s)
- R Z Goetzel
- MEDSTAT Group, Inc, Washington, D.C. 20008, USA.
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Dammann HG, Burkhardt F, Wolf N. The effects of oral rabeprazole on endocrine and gastric secretory function in healthy volunteers. Aliment Pharmacol Ther 1999; 13:1195-203. [PMID: 10468701 DOI: 10.1046/j.1365-2036.1999.00545.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
AIM To evaluate the short-term effects of rabeprazole 20 mg on endocrine parameters, in particular serum testosterone and cortisol, and on 24 h intragastric pH, H+ activity and nocturnal gastric acid secretion. METHODS In this double-blind, two-period crossover study, 12 healthy young male volunteers were randomly given oral rabeprazole 20 mg o.m. or placebo for 14 days. There was a washout period of at least 1 week between the two studies. The effects of rabeprazole and placebo on cortisol and testosterone (primary criteria), and on tri-iodothyronine, thyroxine, 17beta-oestradiol, thyroid-stimulating hormone, thyroxine-binding protein, parathyroid hormone, insulin, glucagon, rennin, aldosterone, follicle-stimulating hormone, luteotrophic hormone, prolactin, somatotrophic hormone, dehydroepiandrosterone, cortisol-binding globulin and urinary 6-beta hydroxycortisol were compared. Intragastric 24 h pH, 24 h H+ activity and nocturnal gastric acid secretion were determined by pH probe and gastric aspiration. RESULTS Rabeprazole produced no clinically relevant effects on endocrine function as assessed by measurement of serum testosterone, circadian serum cortisol levels, ACTH-stimulated serum cortisol levels and 17 other endocrine function tests. Rabeprazole significantly increased the 24 h median pH values compared to placebo (on Days 7 and 14 median values ranged from 3.92 to 6.88 with rabeprazole and from 1.48 and 4.22 with placebo, P < 0.001) and significantly decreased the integrated 24 h H+ activity (AUC08--08) from 343 mmol/L/h with placebo to 44 mmol/L/h with rabeprazole (P < 0.001). Following cessation of dosing, intragastric pH levels decreased and H+ activity increased, but acid secretion did not recover completely during the next 72 h. The mean value for nocturnal gastric acid secretion on Days 7 and 8 was 36 mmol/6 h with placebo and 5.6 mmol/6 h with rabeprazole (P < 0.001). Rabeprazole was well tolerated. CONCLUSION Rabeprazole did not influence endocrine function in healthy young male volunteers during short-term dosing. Rabeprazole substantially increased intragastric pH over a 24 h period and significantly decreased intragastric acidity and nocturnal gastric acid secretion.
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Affiliation(s)
- H G Dammann
- Klinische Forschung Hamburg, Wissenschaftliches Institut, Hamburg, Germany
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Van Rensburg CJ, Honiball PJ, Van Zyl JH, Grundling HD, Eloff FP, Spies SK, Simjee AE, Theron I, Fischer R, Louw JA. Safety and efficacy of pantoprazole 40 mg daily as relapse prophylaxis in patients with healed reflux oesophagitis-a 2-year follow-up. Aliment Pharmacol Ther 1999; 13:1023-8. [PMID: 10468676 DOI: 10.1046/j.1365-2036.1999.00573.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Pantoprazole is a benzimidazole derivative which selectively inhibits the proton pump H+, K+-ATPase, necessary for the final step in gastric acid secretion. AIM To assess safety and efficacy of oral pantoprazole (40 mg o.d.) used as a prophylaxis against relapse in patients with healed reflux oesophagitis during an open-label, 2-year study. METHODS Outpatients (n=157) with healed stage II or III reflux oesophagitis (Savary-Miller classification) were enrolled into a long-term, multicentre maintenance study. Endoscopy was performed at entry into the study, after 12 and 24 months, or when disease-specific symptoms occurred on more than three consecutive days. Symptoms were assessed at 3-monthly intervals. Endoscopically confirmed relapses (at least stage I) were evaluated as treatment failures. RESULTS Of the 178 adverse events, experienced by 88 (56%) patients (intention-to-treat population), 12 (7%) were assessed by the investigators as possibly related to the study medication. Median serum gastrin levels increased from a baseline of 46 ng/L to 90 ng/L, reaching a plateau after 9 months. For the intention-to-treat population the endoscopic remission rates after 12 and 24 months were 87% and 76%, respectively (Life-Table survival analysis, Kaplan-Meier). CONCLUSION Pantoprazole 40 mg proved to be safe and efficacious during a 2-year prophylaxis treatment in patients with healed reflux oesophagitis.
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Affiliation(s)
- C J Van Rensburg
- Gastroenterology Units of University of Stellenbosch, South Africa.
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Jones RH, Baxter G. Lansoprazole 30 mg daily versus ranitidine 150 mg b.d. in the treatment of acid-related dyspepsia in general practice. Aliment Pharmacol Ther 1997; 11:541-6. [PMID: 9218080 DOI: 10.1046/j.1365-2036.1997.00179.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM To compare lansoprazole 30 mg daily with ranitidine 150 mg b.d. in the treatment of acid-related dyspepsia in general practice. METHODS In a double-blind, parallel group, randomized, mutlicentre study conducted in 32 general practices in the UK, 213 patients were randomized to receive lansoprazole 30 mg daily, and 219 to receive ranitidine 150 mg b.d., for 4 weeks. All patients had experienced symptoms of reflux-like or ulcer-like dyspepsia on at least 4 of the 7 days prior to the study; 75% had experienced dyspepsia in the past, and 74 of the lansoprazole patients and 77 of the ranitidine patients had documented histories of acid-related disorders, investigating by either radiology or endoscopy. RESULTS After 2 weeks 55% of the lansoprazole patients and 33% of the ranitidine group were symptom-free (P = 0.001, chi 2 = 7.12) with corresponding 4-week figures of 69% and 44%, respectively (P = 0.001, chi 2 = 18.03). Similar figures were found at both 2 and 4 weeks for daytime and night-time heartburn and epigastric pain scores; in the lansoprazole group, at 4 weeks, 80% of patients were free of daytime heartburn and 81% of night-time epigastric pain, compared with 55% (P = 0.001, chi 2 = 15.44) and 65% (P = 0.01, chi 2 = 6.10) in the ranitidine group. CONCLUSION Superior symptom relief for patients presenting with ulcer-like and reflux-like symptoms in general practice is provided by lansoprazole 30 mg daily compared with ranitidine 150 mg twice daily.
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Affiliation(s)
- R H Jones
- Department of General Practice, UMDS (Guy's and St Thomas's), London, UK
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