1. High Value Care: GERD Sheetal Sharma, MBBS Assistant Professor of Clinical Medicine Associate Director of Endoscopic Quality Section of Advanced Therapeutic Endoscopy Division of Gastroenterology, Hepatology and Nutrition

2. High-Value, Cost-Conscious Health Care for GERD Discuss Management of GERD Emerging Controversies PPI long-term use and Osteoporosis Plavix interactions Management of Barrett’s Esophagus OBJECTIVES

3. GERD is one of the most common GI disorders encountered by Gastroenterologists. Definition: GERD is a term applied to pathological symptoms suggestive of reflux or regurgitation with/without esophageal inflammation Symptoms may not be present for pathological reflux to occur. Montreal Classification (Consensus) Mild symptoms > 2 days/week Moderate/Severe >1 day/week Gastroesophageal Reflux Disease (GERD) High-Value, Cost-Conscious Health Care for GERD

4. Epidemiology : 10-20% Prevalence in Western World 5% Asia Men: Woman 8:1 ratio of Esophageal Adenocarcinoma Greater risk of Barrett’s (Independent risk factor) Woman Greater incidence of Non-erosive reflux disease (NERD) GERD High-Value, Cost-Conscious Health Care for GERD

5. Clinical Features Heartburn/Dyspepsia Regurgitation Dysphagia Odynophagia; less commonly Water brash Globus sensation Nausea Bloating/Belching Epigastric Pain GERD High-Value, Cost-Conscious Health Care for GERD

6. Exclude Cardiac etiologies Dysphagia Odynophagia Weight loss Recurrent Vomiting GI bleeding Anemia Red Flags High-Value, Cost-Conscious Health Care for GERD

7. Diagnosis Typical symptoms; Treat with PPI Barium Radiographs: No Upper Endoscopy Family History Red Flags Refractory Diagnosis of GERD High-Value, Cost-Conscious Health Care for GERD

8. Diagnosis Ambulatory pH monitoring Prior to therapeutic endoscopy or surgery Diagnosis in question H.pylori: Not routinely needed in GERD patients Diagnosis of GERD High-Value, Cost-Conscious Health Care for GERD

9. Weight Loss Association between BMI and GERD Weight gain BMI Associated with Barrett’s Esophagus Medical Management of GERD High-Value, Cost-Conscious Health Care for GERD

10. Head above bed Avoidance of late night meals before bedtime 8 week course of PPI therapy for symptoms and erosive esophagitis PPI used 30-60min prior to the first meal PPI safe in pregnancy if clinically indicated Prokinetic use requires prior diagnostic evaluation Medical Management of GERD High-Value, Cost-Conscious Health Care for GERD

11. Initial Therapy Step up vs Step-down options Mild/intermittent Symptoms Lifestyle/Dietary changes Data suggests benefit as noted by pH monitoring or GERD symptoms Medical Management of GERD High-Value, Cost-Conscious Health Care for GERD

12. Antacids Magnesium, Aluminum, and Calcium containing agents Action 5 minutes Duration 30-60 minutes Alginates Sucralfate Medical Management of GERD High-Value, Cost-Conscious Health Care for GERD

13. H2 Receptor Antagonists Good for prn use Tachyphylaxis can occur in 2-6 weeks Limits use Limited use for erosive esophagitis Medical Management of GERD High-Value, Cost-Conscious Health Care for GERD

14. PPI Those failing twice daily H2RA Erosive Esophagitis Severe GERD symptoms More effective than H2RA regardless of severity of GERD and esophagitis Length of therapy Life long in Severe esophagitis Barrett’s Esophagus Medical Management of GERD High-Value, Cost-Conscious Health Care for GERD

15. PPI Titration down to lowest effective dose. Recurrent titration is worthwhile Addition of lifestyle modifications are needed Medical Management of GERD High-Value, Cost-Conscious Health Care for GERD

16. Benefits of Upper Endoscopy Primary tool to evaluate the esophageal mucosa. Erosive Esophagitis Barrett’s Esophagus Rings/Strictures Eosinophilic Esophagitis Upper Endoscopy High-Value, Cost-Conscious Health Care for GERD

17. Reflux Esophagitis

18. Reflux Esophagitis and Peptic Stricturing

19. Refractory GERD Reasons Proper dosing 30 minutes prior to breakfast Compliance 30% of those with GERD are compliant at 6 months Functional Heartburn Non-acid Reflux Bile Reflux Eosinophilic Esophagitis Refractory GERD High-Value, Cost-Conscious Health Care for GERD

20. Refractory GERD Functional Esophageal symptoms Commonly refractory to increasing PPI dosing pH studies fail to show acid reflux Recent meta-analysis/reviews suggest benefit from TCA and SSRI in modulating pain/discomfort in these patients Refractory GERD High-Value, Cost-Conscious Health Care for GERD

21. PPI and Clopidogrel Initial in vivo studies in combination with retrospective evaluations seemed to indicate that PPI decrease effectiveness of Clopidogrel FDA in 2009 issued warning about concurrent use of PPI and Clopidogrel and increased cardiovascular events Several studies, including recent one in NEJM from 2010 note that PPI helped to prevent GI bleeding in those on Clopidogrel Controversies High-Value, Cost-Conscious Health Care for GERD

22. PPI and Clopidogrel Current data does not support idea that PPI and Clopidogrel interact in a meaningful clinical manner No significant increase in cardiovascular events as first suspected Controversies High-Value, Cost-Conscious Health Care for GERD

23. PPI and Osteoporosis Principal is that decreased gastric acid levels will decrease calcium release from calcium salts and proteins Meta-analysis in 2011 suggests that risk has been overstated, but that a small but significant increased risk in hip fractures Case Control studies suggest that PPI with additional risk factor is true risk for osteoporosis Controversies High-Value, Cost-Conscious Health Care for GERD

24. Barrett’s Esophagus Chronic acid reflux, and only potentially malignant complication of GERD Barrett’s found in 5-15% of those having endoscopy for GERD Incidence of Esophageal Cancer is 0.5% yearly in those with Barrett’s Controversies High-Value, Cost-Conscious Health Care for GERD

25. Barrett’s Treatment Barrett’s without dysplasia Q3-5 year surveillance Barrett’s with low-grade dysplasia Q1 year surveillance Possible eradication Barrett’s with high-grade dysplasia Eradication recommended Q3months if no eradication Controversies High-Value, Cost-Conscious Health Care for GERD

26. Barrett’s Esophagus

27. Barrett’s Treatment Radiofrequency Ablation Indicated for Barrett’s with dysplasia Several sessions required Follow is needed long-term Controversies High-Value, Cost-Conscious Health Care for GERD

28. Barrett’s Esophagus with Radiofrequency Ablation (RFA)

29. Treatment for GERD Multi-modal treatment plan Primary is lifestyle modification PPI therapy titrated to lowest effective dose In those with significant symptoms, most benefits typically outweigh real and potential risks of long-term use of PPI No clinically significant interaction between PPI and Clopidogrel Eradicate Barrett’s with dysplasia Summary High-Value, Cost-Conscious Health Care for GERD

30. Katz et.al AJG 2013 Focks et.al Heart 2012 Kwok et.al Int J Card 2013 Corley et.al Gastro 2010 Ngamruengphong et.al. AJG 2011 Spechler et.al Gastro 2011 References High-Value, Cost-Conscious Health Care for GERD

31. THANK YOU Sheetal.Sharma@osumc.edu 614-293-6255(Phone) GHN Barrett’s/Early Esophageal Cancer Clinic at Martha Morehouse High-Value, Cost-Conscious Health Care for GERD