Clinical Management Course Acid Peptic Diseases Clinical Management Course February 2007 Walter Smalley, MD MPH

Acid - Peptic Diseases Drugs Antacids H2RAs (“H-2 blockers”) Proton Pump Inhibitors (PPI’s) Selective COX-II inhibitors Conditions Covered Heartburn Gastroesophageal Reflux (GERD) Peptic Ulcer Disease H. Pylori NSAIDs 1

Antacids Immediate effect on gastric pH Effect is short-lived Typical dose 30-60 cc Frequent use may cause diarrhea

H-2 Receptor Antagonists Inhibit H-2 receptors (competitive inhibition) Partially inhibit acid production Relatively safe drugs Less effective than PPI’s Less expensive than PPI’s Available over the counter: at prices more expensive than prescription costs 5

Cimetidine : Safety Considerations Brand name Tagamet Induces cytochrome p450 system Drug interactions with coumadin, theophylline, dilantin and others Rarely clinically relevant But “why not use ranitidine” Confusion in the elderly Thrombocytopenia 7

H2 blockers : No difference in efficacy within group 8

Proton Pump Inhibitors Raise gastric pH to > 5 for several hours Binds covalently to H+/K+ pump Prodrugs: bioavailable at acid pH Maximal effectiveness After several doses When taken before meals After a long fast (Prior to breakfast)

Proton Pump Inhibitors Omeprazole (generic cost about 80% of prescription costs ) Immediate release omeprazole Lansoprazole Rabeprazole Pantoprozole – oral and IV form Esomeprazole Very effective, no important predictable differences in efficacy Very expensive ($2-4/day) ~ $1 per day generic

Case 1 35 year old healthy man Occasional heartburn Occurs only with large meals, EtOH ingestion No dysphagia

Heartburn : Summary How soon does the patient want relief ? How long does it need to last ? How much are they willing to pay ? 41

Heartburn : Summary Prevention Antacids are effective immediately in reducing acid - work for 1-2 hours H2-blockers are effective in 1-2 hours - they work for > 6-8 hours Available over the counter 40

Case 1 Consider not eating large meals Consider PRN antacids Consider OTC H2 blockers On the horizon ? Immediate release omeprazole – Direct to consumer marketing Marginal benefit vs other PPIs

Case 2 50 yo with frequent nocturnal heartburn No dysphagia Trial of lifestyle modification only minimally effective Antacids ineffective

GERD: When to perform diagnostic tests Endoscopy Dysphagia Weight loss Age > 50 Failure of medical therapy Motility : prior to fundoplication pH monitoring: might resolve diagnostic uncertainty in absence of esophagitis

Gastroesophageal Reflux Reflux of gastroduodenal contents Acid ( gastric) Alkaline (biliary, pancreatic) Decreased lower esophageal sphincter (LES) tone Decreased rate of gastric emptying Increased intra-abdominal pressure Decreased salivary clearance 2

GERD: Lifestyle Modification weight loss, avoid tight-fitting clothes NPO 3-4 hours before bedtime elevate head of bed 8'' avoid foods and drugs that decrease LES pressure or gastric emptying rate fat, EtOH, tobacco , peppermint, garlic, onions, chocolate, Ca++channel blockers, nitrates, theophylline, antidepressants No strong RCT evidence to support important effect of lifestyle modification 3

Case 2 50 yo with frequent nocturnal heartburn No dysphagia Trial of lifestyle modification only minimally effective Antacids ineffective EGD - distal esophageal erosions

Antacids: temporary relief H2-antagonists: GERD : Overview Antacids: temporary relief H2-antagonists: high (“double”) doses, frequent dosing Prokinetics: as effective as H2RA’s Metoclopramide Proton pump inhibitors: most effective most expensive 4

GERD: H2-antagonists NO BETWEEN - DRUG DIFFERENCES IN EFFICACY symptomatic relief < 60 - 70% cases endoscopic improvement < symptomatic relief higher doses (>2X ulcer doses) improve efficacy slightly 6

GERD : Prokinetic Agents Metoclopramide As effective as H2RAs Adverse reactions: fatigue, lethargy, extrapyramidal symptoms occur in 10% - 30%. 9

Case 2 Continue lifestyle modification Trial of H2 blockers at high doses

Case 3 Patient #2 returns after 8 week trial of H2 blockers Therapy only minimally effective

GERD : Proton Pump Inhibitors Causes healing and resolution of symptoms in 80% of patients with disease resistant to H2-blockers Expensive, single source drugs ($ 2 - 4 / day) Over the counter more expensive than prescription Not on Wal-mart list Generic omeprazole still > $1 per day 12

Case 3 Proton pump inhibitor

Case 4 Patient from Case 3 returns Symptoms well controlled on omeprazole Symptoms recur immediately after stopping drug “Hates taking meds”

GERD: Anti - Reflux Surgery Indications: patient preference over drug treatment young patients with severe esophagitis difficult to dilate strictures recurrent esophageal ulcers GER-respiratory/ENT syndromes 80 - 90% of cases have some improvement 13

GERD: Anti - Reflux Surgery Side effects: about 10 % cases "gas bloat" dysphagia strictures other Usually won’t work if PPI’s don’t work 14

Utilization of GERD pharmaceuticals in patients treated medically and surgically Acid suppression days per quarter Most fundoplication patients end up taking some acid meds after operation Khaitan et al, Arch Surgery 2003

Endoscopic therapies for GERD Stretta: radiofrequency destruction of GEJ myenteric plexus Endoscopic Plication: sewing gastric cardia mucosa to augment GEJ Injection of GEJ with plastic (removed from market) All should be considered experimental at this point

Case 4 Consider anti reflux procedure Weighing potential benefits of not taking medication vs. risk of side effects from surgery (probably 1- 3% in experienced hands)

Case 5 40 yo with epigastric pain

“ALARM FEATURES” unexplained weight loss anorexia early satiety vomiting progressive dysphagia odynophagia bleeding anemia jaundice abdominal mass lymphadenopathy family history of upper GI cancer history of peptic ulcer, previous gastric surgery or malignancy. ACG dyspepsia management guidelines

Case 5 40 yo with epigastric pain Relieved with meals No clinical signs of bleeding No vomiting Reasonable approaches Empiric trial of acid suppression “Test and treat” for H pylori Refer for endoscopy

Case 5 40 yo with epigastric pain 8 week trials of PPI fails EGD : duodenal ulcer H pylori positive no NSAIDs confirmed

Ulcer Disease : Basic Concepts H. pylori is associated with GU and DU NSAID use is associated with GU and DU Most ulcers are not the result of excess acid Acid suppression aids in healing ulcers Prior to the H pylori era: most of the cost of ulcer disease had been in “maintenance” therapy 15

H pylori : Concepts H pylori infection is chronic Prevalence in US adults = 50 - 80% Lifetime risk of ulcer disease = 10% Associated with chronic gastritis - a histological diagnosis H pylori is a risk factor for gastric adenocarcinoma 16

H pylori - Diagnosis EGD – Biopsy for histology and CLO Breath Tests – commercially available big hassle Serology – widely available, followup is problematic (positivity persists months after eradication) Stool antigen test: problem = it’s stool. 17

H pylori. treatment - Efficacy For treatment of duodenal ulcer > gastric ulcer Eradication of H.pylori alone = treatment with H2-blockers alone For preventing recurrent duodenal ulcer: Eradication of H.pylori >> continuous H2-blocker therapy Marginal (if any) benefit in treating non ulcer dyspepsia 18

H pylori. treatment - Options Many different regimens No "standard of care" Best therapy yet to be determined Big problems compliance resistance Current (2/07) favorite combination Amoxicillin, PPI, Clarithromycin Metrondazole, PPI, Clarithromycin 20

Peptic Ulcer: Treatment Outcomes 28

Case 5 QD H2 blockers, or proton pump inhibitor Amoxicillin 1000 BID Treatment with acid suppression QD H2 blockers, or proton pump inhibitor Treat H pylori Amoxicillin 1000 BID Clarithromycin 500 BID Omeprazole 20 BID

Case 6 65 yo male with osteoarthritis with recent ulcer On ibuprofen 1800 mg per day Ulcer has healed H pylori negative

NSAIDs and Ulcers - Concepts Higher doses ---> greater risk Long time users still have increased risk after 12 months Absolute risk is high about one ulcer hospitalization per 100 person years in the elderly About 2/3 of ulcers in NSAID users are due to the NSAID use By far our most important complication of pharmaceutical use 22

NSAIDs and PUD : Treatment Stop NSAIDs Acid suppression Drug Healing at 6 - 8 weeks Omeprazole > 90% H2-Blockers 70-90% Misoprostol 70-90% Sucralfate not effective 23

NSAIDs and Ulcers - Prevention Does the patient really need NSAIDs ? objective = pain control NSAIDs do not prevent progression in osteoarthritis little evidence demonstrating superiority of NSAIDs over acetaminophen in osteoarthritis patients. No NSAID is "safe". 24

NSAIDs and Ulcers - Prevention Misoprostol - a synthetic PGE analog Prevents GU and DU Expensive therapy - for prevention. Debate on cost effectiveness continues. Side effects: diarrhea (10%), abdominal pain (10 - 20%) Causes spontaneous abortions - do not use in potentially fertile women 25

NSAIDs and Ulcers - Prevention H-2 blockers at high doses may be reliable preventive agents for DU prevention Misoprostol is very effective in preventing ulcers in clinical trials. PPI’s are as probably as effective as misoprostol and better tolerated Eradicating H pylori is helpful in preventing recurrence (RCT evidence)

Selective COX-II Inhibitors: COXIBs Celecoxib, rofecoxib, valdecoxib, etoricoxib and lumiracoxib NO more effective than traditional NSAIDs Potential benefit is GI safety Still have renal toxicity, other toxicities ? Large trials demonstrate decreased ulcer rate Decrease of about 50% Do high-risk patients still need acid suppression ? Risk of cardiac events has led to the removal of rofecoxib and valdecoxib

Results from a polyp prevention trial

Case 6 narcotics non-narcotics physical therapy topical therapy Consider alternatives to NSAIDs narcotics non-narcotics physical therapy topical therapy Consider misoprostol Consider acid suppression with PPI For now would not consider any COXIB drugs left on the market

Peptic Ulcer Disease Stop NSAIDs. Acid suppression acutely Test for H pylori and treat if present. 27

Case 7 75 yo admitted with hematemesis, shock Intubated for airway protection (NPO) EGD reveals gastric ulcer with visible vessel Treatment with heater probe controls bleeding

Acid Suppression There is evidence that acid suppression may decrease rebleeding rates, surgical rates, and hospital days There is no evidence that it saves lives (studies would have to be huge) Most IV PPI data is based on trials using IV OMEPRAZOLE which is not available in the US Most studies involved bleeding ulcers requiring endoscopic therapeutic interventions (injection therapy or heater probe)

Lancet 2005 Proton pump inhibitor (IV or PO) Moderate effects on: reduced rebleeding (table left) OR 0.46, 95%CI 0.33 to 0.64 NNT =12 surgery OR 0.59 95%CI 0.46 to 0.76 NNT = 20 treatment had no significant effect on mortality OR 1.11, 95%CI 0.79 to 1.57 NNT = incalculable Lancet 2005

PPI’s Summary In the select group of patients who require endoscopic therapy the few published studies demonstrated potential advantage for IV Omeprazole In our settings most endoscopies will be done quite early - there is little advantage in starting IV PPI’s prior to EGD in most cases Oral PPIs may have some protective effect compared to placebo

Case 7 Start IV Pantoprazole (80 mg bolus followed by 8 mg per hour) Start PPI of choice after patient is taking oral meds