MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE

Introduction
Gastroesophageal reflux disease (GERD)
Abnormal reflux of gastroduodenal contents Leads to variety of clinical symptomps quality of life

Clinical manifestations of GERD

Typical symptoms Heartburn Regurgitation Atypical symproms Esophageal Dysphagia Odynophagia Extra esophageal Epigastric pain Dyspepsia Globus Ear pain Hoarseness Complications Esophageal Esophagitis Peptic ulcer Bleeding Perforation Stenosis Extra esophageal Dental injury Otitis media Pharyngitis Laryngitis Laryngeal cancer

Chronic cough Brachyesopha Pneumonia gus Asthma Nocturnal sweats Barrets carcinoma Interstitial fibrosis

A variety of approaches to the therapy of GERD have been suggested.

Majority of GERD patients, with or without esophagitis, require sustained acid suppression, which can be consistently and safely achieved with proton pump inhibitors (PPIs)

It is widely agreed that PPIs are the treatment of choice for GERD treatment, whether for short term or maintenance therapy

Recognizing typical and atypical symptoms of GERD

Diagnosis of GERD based on typical

symptoms of heartburn or regurgitation. Both patients and physicians can misinterpret symptoms.

 Atypical symptoms such as chronic cough,

ear pain and hiccup can further confound the diagnosis of GERD Once GERD is suspected, it is advisable to carry out a single endoscopy to exclude any possibility of Barretts esophagus.

For patients who do not respond to standard therapy, 24-h pH-metry is recommended in difficult cases.
With these available methods and a good questionnaire to conduct a thorough history, diagnostic

sensitivity is approximately 90%

Comparison of proton pump inhibitors

PPIs are the treatment of choice for GERD patients

In order to compare the effects of different PPI doses in decreasing gastric acidity and increasing intergastric pH above 3 99 patients with duodenal ulcer were administered either omeprazole 10 mg, 20 mg or 40 mg o.d
After 4 weeks of treatment Acid inhibition and ulcer healing Dose dependent response : 10 mg : 42% 20 mg: 79% 40 mg: 94%

Another study
Pantoprazole 40 mg o.d VS Omeprazole

Multiple Unit Pellet System (MUPS) 40 mg o.d in GERD patients. Have comparable healing rates. After 4 weeks treatment : Pantoprazole : 78% Omeprazole : 76% After 8 weeks treatment : Pantoprazole : 95% Omeprazole : 95%

Another study
Pantoprazole 40 mg o.d >< Esomeprazole 40

mg o.d in 227 patients with reflux esophagitis.

Clinical efficacy : Equivalent
The overall healing rates in the intentions to treat group were the same, and in per protocol groups there was a 5% greater response for pantoprazole. Similar results were also found for daytime and nighttime syndrom reduction within 4 weeks of treatment of the 40 mg dose of both drugs in 217 patients with moderate to severe GERD.

CHOOSING THE APPROPIATE DOSE

 A higher PPI dose good results & cost

effective in antypical GERD symptoms Severe case & extraesophageal manifestations.

3 placebo-controlled studies of PPIs (in astmatic

patient) omeprazole 40 mg b.i.d or q.i.d improvement > 3 months of treatment (it longer than the standart treament 8 weeks)

 Reduced dose of PPIs good results & cost

effective. Controlled trials PPIs proven to be superior to H2 receptor antagonist (H2RAs) both in controlling symptoms and inducing healing of mucosal lesions.* *(low dose of PPIs >< high dose H2RAs)

Pantoprazole 20 mg o.d Ranitidine 150 mg b.i.d

Ranitidine 300 mg b.i.d Placebo

Clearly Superior PANTOPRAZOLE

TOLERABILITY PROFILE OF PPIS

 PPIs extremely save short & long term use. Tolerability studies a similar rate of drug-

related side effects for all the PPIs.

Aes pantoprazole 40 mg (prevent relaps of

reflux esophagitis) 7%.

 Interactions PPIs with metabolism of other

drugs different each other.

Pantoprazole not interfering with the

cytochrome P450 system indicated in patients with co-prescriptions of drugs that are metabolized by these liver enzymes.
Pantoprazole no interactions with any other

drugs preferable option GERD with comorbidity & co-medication.

CONCLUSION

 GERD & its clinical manifestations common

problems that bring large number of patients to physicians everyday.

PPIs mainstay of the treatment of GERD with

or without esophagitis.
PPIs save & cost effective both short &

long treatment of GERD

== EQUIPOTENCY ==
Esomeprazole 40 mg
Pantoprazole 40 mg

Omeprazole 40 mg

SHOWN

PANTOPRAZOLE

No Pharmacological interactions with any drugs

The choice treatment for GERD with comorbidity

Thank You for Your Attention,