Cologuard Where It Fits In

Cologuard Screening test for colorectal cancer FIT-DNA : composite of tests :(1) hemoglobin (2) molecular assays for DNA mutations (3) methylation biomarkers

Colorectal Neoplasms DNA shed into stool may reveal genetic mutations (KRAS) and epigenetic changes

Test Procedure Patient collects a stool sample in a special collection kit No dietary or medication restrictions Kit mailed back in 72 hours or less Repeat testing every 3 years (if negative) If positive, refer for colonoscopy

Who is a Candidate? Average risk patients Should not be used if: (1) history of colonic adenomas or cancer (2) history of IBD (3) family history of colon cancer/ Lynch Syndrome/FAP

Effectiveness Sensitivity (confirmed by colonoscopy) for CRC 92% Not affected by CRC stage or location of lesion Specificity for CRC was 87% Significance of a (+) Cologuard followed by a (-) colonoscopy is unknown

Colonoscopy “Gold Standard”-but not a perfect test prep needed and complications possible “Miss rate” of 2% with large adenomas (>10mm), 25% <5 mm

Positive Cologuard Changes screening colonoscopy to diagnostic colonoscopy

Proton Pump Inhibitors

Potential Risks of PPI’s Proton pump inhibitors have been used on millions of patients since Prilosec was introduced in the USA in 1989

PPI’s Changed GI Medicine

Mechanism of Action Binds to the H-K- ATPase on the luminal surface of the parietal cell Most effective after a prolonged fast and when the parietal cell is stimulated after a meal

Clinical Uses GERD-especially erosive esophagitis Peptic ulcer disease Eradication of H. pylori Zollinger-Ellison syndrome Prevention NSAID ulcers

Potential Adverse Effects Increased risk of Clostridium difficile infection Calcium malabsorption and fracture risk Pneumonia Dementia Death

Kidney Disease and PPI’s PPI’s can cause acute interstitial nephritis Weak association with PPI’s and chronic kidney disease (CKD)

Potential Malabsorption Iron malabsorption Magnesium malabsorption Vitamin B12 malabsorption

Why Use PPI’s Inhibit gastric acid secretion much more effectively than H2 RA’s Once-daily dosing decreases gastric acid secretion by 66%

Shortest Duration/< Dose

Any Clinical Difference? rabeprazole omeprazole esomeprazole lansoprazole pantoprazole

PPI’s and H2 Blockers H2RA’s suppress acid much less effectively, but work more quickly- better for prn use Taking them at the same time renders the PPI less effective