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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Developing Effective Strategies in the Management of Acid-Related Disorders


GOAL
To provide physicians with the most recent information on new advances in the treatment of acid-related disorders.

TARGET AUDIENCE
This activity is designed for gastroenterologists and primary care physicians. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Identify and assess the symptoms of gastroesophageal reflux disease (GERD) occurring in children.
  • Recognize new and emerging treatment options available for the long-term management of GERD.
  • Evaluate data supporting new treatment strategies aimed at reducing gastrointestinal adverse effects in patients requiring analgesia for arthritis.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: March 15, 2003. Expiration date: March 15, 2005.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from TAP Pharmaceutical Products Inc.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

Full Disclosure Policy Affecting CME Activities:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. Faculty Advisors and Participating Faculty reported the following:

PROGRAM DIRECTOR

    Anthony Kalloo, MD
    Associate Professor of Medicine
    Director, Gastrointestinal Endoscopy
    The Johns Hopkins Hospital
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Kalloo reports having no financial or advisory relationships with pharmaceutical companies related to this activity.

PARTICIPATING FACULTY

    William D. Chey, MD, FACP, FACG
    Associate Professor of Medicine
    University of Michigan Medical Center
    Ann Arbor, Michigan
    • Dr Chey reports receiving grant/research support from AstraZeneca Pharmaceuticals LP and Janssen Pharmaceutical Products LP; and serving as a consultant to and/or receiving honoraria from AstraZeneca Pharmaceutical Products LP, GlaxoSmithKline, Novartis Corporation, and TAP Pharmaceutical Products Inc.

    Benjamin D. Gold, MD
    Associate Professor of Pediatrics and Microbiology
    Director, Division of Pediatric Gastroenterology and Nutrition
    Department of Pediatrics
    Emory University School of Medicine
    Atlanta, Georgia
    • Dr Gold reports serving as a consultant to and on the speakers bureau for AstraZeneca Pharmaceuticals LP and TAP Pharmaceutical Products Inc.

    David A. Peura, MD, FACP, FACG
    AProfessor of Medicine
    Associate Chief of Gastroenterology and Hepatology
    University of Virginia Health Sciences Center
    Gastroenterology Division
    Charlottesville, Virginia
    • Dr Peura reports receiving honoraria from and serving as a speaker for AstraZeneca Pharmaceuticals LP, Merck and Company, TAP Pharmaceutical Products Inc, and Wyeth.

Notice:
In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity contains reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty members have disclosed that their articles have referenced the following unlabeled/unapproved uses of drugs or products:

Lansoprazole and Omeprazole — Dr Gold

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Developing Effective Strategies in the Management of Acid-Related Disorders
Anthony Kalloo, MD*

Gastroesophageal reflux disease (GERD) is a disorder of lower esophageal sphincter relaxation that permits passage of larger than normal amounts of gastric and/or duodenal contents and excessive acid exposure through the gastric cardia into the esophagus. This exposure may result in symptoms of heartburn and in the development of erosive esophagitis, occasionally producing changes to the esophageal and gastric tissue that may be precursors of adenocarcinoma. Specifically, complications of GERD may include erosion, but also esophageal ulcer, stricture (manifested by dysphagia), replacement of normal epithelial tissue with abnormal cells (Barrett's epithelium), and extra-esophageal complications such as asthma.1

Normally, the lower esophageal sphincter relaxes prior to esophageal peristalsis to allow food to pass into the stomach, and then contracts to prevent regurgitation back into the esophagus, thus propelling food in one direction through the digestive tract. The lower esophageal sphincter usually remains closed after eating. However, multiple factors are believed to contribute to the development of GERD, including transient but inappropriately timed lower esophageal sphincter relaxations, decreased resting tone of this sphincter, ineffective esophageal clearance, delayed stomach emptying, and inadequate amounts of saliva than are necessary to help neutralize these acidic contents when they are refluxed.2

While GERD may cause a multitude of symptoms—some of which are not normally associated with the gastrointestinal (GI) tract—such as cough and wheezing, heartburn is the primary symptom associated with GERD. Heartburn affects an estimated 25 million individuals on a daily basis and 60 million individuals report symptoms of heartburn monthly. Furthermore, approximately half of all patients with GERD have esophagitis. Aside from experiencing self-reported decreased quality of life, work productivity, and overall sense of well-being, studies have documented that these individuals face as much as an 11-fold increased risk of esophageal cancer than asymptomatic persons.3 Thus, prompt and accurate diagnosis (primarily via endoscopy and pH monitoring), as well as effective treatment aimed both at elimination of symptoms and permanent healing of esophagitis to minimize serious sequelae, are the goals of the primary care clinician in the long-term management of GERD.

This issue of Advanced Studies in Medicine focuses on GERD as well as management of acid-related disorders in older individuals taking aspirin and/or nonsteroidal anti-inflammatory medications (NSAIDs) for arthritis and primary cardioprotection. This issue also includes information related to the growing prevalence and magnitude of acid-related pathology in all segments of the population, from infants to elderly people. With respect to GERD, the similarities and differences between pediatric and adult patients in terms of presenting symptoms and treatment options are discussed.

For children, it is suggested that lifestyle changes and pharmacotherapy with proton pump inhibitors (PPIs) should be attempted prior to surgical intervention with fundoplication. Early detection and intervention in pediatric patients may prevent a lifetime of complications.

Similarly, for adult patients, medical therapy with a PPI has been demonstrated in studies to be superior to both surgical intervention via laparoscopic or traditional fundoplication and to newer endoscopic techniques that avoid surgery. The evidence supporting greater benefit with this class of medications as compared with histamine type-2 receptor antagonists (H2RAs), prokinetic agents, or prostaglandin analogues will be reviewed for the adult patient.

Finally, this issue will address how to minimize the common adverse effects associated with NSAID use. The patient who requires NSAID therapy for the treatment of chronic inflammatory conditions such as arthritis is usually elderly and also at risk for a cardiovascular event. The combination of low-dose aspirin for cardioprotection and NSAID use significantly increase the incidence of GI bleeding. The use and prescribing of GI-protective medications will be discussed and, specifically, the risks of NSAID use in patients who have already experienced a serious adverse effect along with the role of medications such as H2RAs, PPIs, and selective cyclooxygenase-2 inhibitors to prevent recurrence of symptoms and complications, and to promote healing.

Acid-related disorders increase morbidity and mortality, significantly impact quality of life, and pose an immense financial burden, especially in the treatment of infants and elderly patients. Thus, it is encouraging that pharmacotherapy with PPIs offers a promising solution without the risks, recovery time, and costs associated with surgery. Yet, endoscopic interventions for GERD need to be perfected, and a greater understanding of GERD is necessary for more effective diagnosing, treatment, and perhaps even prevention of this condition that afflicts more than 20 million Americans today.

REFERENCES

1. Gastroesophageal reflux disease. Available at: http://www.hopkins-gi.org. Accessed January 28, 2003.
2. Introduction to GERD. Available at:http://www.gerd.com. Accessed December 10, 2002.
3. Richter JE, Kahrilas PJ, Sontag SJ, Kovacs TO, Huang B, Pencyla JL. Comparing lansoprazole and omeprazole in onset of heartburn relief: results of a randomized, controlled trial in erosive esophagitis patients. Am J Gastroenterol. 2001;96:3089-3098.

*Associate Professor of Medicine, Director, Gastrointestinal Endoscopy, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.