GERD_PPT copyGERD_PPT copy GERD_PPT copy

gerd

1. Mechanism Of Action: •The PPIs are lipophilic weak bases ( pKa 4–5) and, after intestinal absorption, diffuse readily across lipid membranes into acidified compartments ( eg , the parietal cell canaliculus). • forms a covalent disulfide bond with the H+/K+- ATPase, irreversibly inactivating the enzyme. •This will eventually decrease the ability of the H+/K+- ATPase,to pump hydrogen ions into the gastric lumen thereby increasing gastric pH. •PPIs inhibit both fasting and meal-stimulated secretion because they block the final common pathway of acid secretion, the proton pump.

2. ADVERSE EFFECTS:   PPIs should be prescribed at the lowest effective dose   A minor reduction in oral cyanocobalamin absorption occurs during proton-pump inhibition.   Increases in gastric bacterial concentrations are detected in patients taking PPIs, which is of unknown clinical significance.

3. DRUG INTERACTIONS : Omeprazole may inhibit the metabolism of clopidogrel, warfarin, diazepam, and phenytoin. Esomeprazole also may decrease metabolism of diazepam. Lansoprazole may enhance clearance of theophylline. Rabeprazole and pantoprazole have no significant drug interactions.

4. -Because of the short half-lives of PPIs, clinically significant drug interactions are rare. -PPIs could reduce clopidogrel activation (and its antiplatelet action) in some patients o meprazole esomeprazole lansoprazole dexlansoprazole

5. RECOMMENDATIONS: A clinical diagnosis of GERD can be made if the typical symptoms of heartburn and or regurgitation are present, The diagnosis of GERD can be arrived without the aid of upper endoscopy procedure. Patients who present with chest pain, even if suspected to be GERD-related, should undergo an appropriate cardiovascular risk stratification before initiating empiric PPI therapy Standard dose PPI once daily for eight weeks , taken 30 minutes before morning meal, is the cornerstone of therapy for erosive esophagitis. Weight reduction and elevation of head of the bed may contribute to symptom improvement. If eight weeks of standard once daily PPI treatment achieved only a partial relief of symptoms, administer the same PPI twice daily or switch to a different PPI.  

6. When symptoms relapse after standard GERD treatment, on demand or intermittent PPI therapy is suggested for NERD (non erosive reflux disease) while, continuous PPI treatment is recommended for moderate to severe erosive esophagitis. During maintenance therapy, prescribe the lowest effective dose of PPI.   Alginate-antacid combination is recommended for relief of episodic and postprandial reflux symptoms.a Intermittent H2-receptor blockers may be given as alternative to patients intolerant to PPIs. Long-term administration of PPI is safe; however, careful consideration is needed in patient groups at risk for complications .

7. Empiric Management of such patients can be initiated as long as alarm signals are not present. ALARM SIGNALS ( must not be more than 5 years } dysphagia esophageal carcinoma odynophagia, nocturnal choking weight loss; abdominal mass anemia; recurrent frequent vomiting hematemesis; chest pain

8. PROTON PUMP INHIBITORS RECOMMENDED DOSE: 1 OMEPRAZOLE 20–40 mg qd 2 ESOMEPRAZOLE 20–40 mg qd 3 LANSOPRAZOLE 30 mg qd 4 DEXLANSOPRAZOLE 30–60 mg qd 5 RABEPRAZOLE 40 mg qd 6 PANTOPRAZOLE 20 mg qd IV PROTON PUMP INHIBITORS AVAILABLE RECOMMENDED DOSE: Omeprazole 40mg IV Esomeprazole 40mg IV Pantoprazole 40mg IV

9. In the presence of typical GERD symptoms, chronic cough, laryngitis and asthma may be considered extraesophageal manifestations of GERD .

10. Potassium Competitive Acid Blockers: P-CAB ( Vonoprazan ) bind reversibly to K+ ions and block the H+, K+ ATPase enzyme, thus preventing acid production short duration of action and hepatotoxicity. - Tegoprazan (CJ-12420) is a newer P-CAB with a potential to treat GERD

11. APPROVAL STATUS: Revaprazan was developed in Korea and was the first P-CAB approved. It is also available in India. Vonoprazan was developed by Takeda; it was approved in Japan in February 2015 for the treatment of acid-related diseases Tegoprazan was approved for the treatment of erosive esophagitis (EE) and NERD in Korea in July 2018. The drugs vonoprazan and revaprazan are currently not available outside Asia, Europe and the United States