Gastroesophageal Reflux Disease Medication Research Articles

Overlapping approach Proton Pump Inhibitors/Nux vomica-Heel as new intervention for gastro-esophageal reflux management: Delphi consensus study.

Gastro-esophageal reflux disease (GERD) may affect the upper digestive tract; up to 20% of population in Western nations are affected by GERD. Antacids, histamine H2-receptor antagonists, and Proton Pump Inhibitors (PPIs) are considered the referring medications for GERD. Nevertheless, PPIs must be managed carefully because their use, especially chronic, could be linked with some adverse effects. An effective and safe alternative pharmacological tool for GERD is needed. After the identification of potentially new medications to flank PPIs, it is mandatory to revise and improve good clinical practices even through a consensus process. To optimize diagnosis and treatment guidelines for GERD through a consensus based on Delphi method. The availability of clinical studies describing the action of the multicomponent/multitarget medication Nux vomica-Heel, subject of the consensus, is the basic prerequisite for the consensus itself. A modified Delphi process was used to reach a consensus among a panel of Italian GERD specialists on the overlapping approach PPIs/Nux vomica-Heel as a new intervention model for the management of GERD. The Voting Consensus group was composed of 49 Italian Medical Doctors with different specializations: Gastroenterology, otolaryngology, geriatrics, and general medicine. A scientific committee analyzed the literature, determined areas that required investigation (in agreement with the multiple-choice questionnaire results), and identified two topics of interest: (1) GERD disease; and (2) GERD treatment. Statements for each of these topics were then formulated and validated. The Delphi process involved two rounds of questioning submitted to the panel experts using an online platform. According to their routinary GERD practice and current clinical evidence, the panel members provided feedback to each questionnaire statement. The experts evaluated 15 statements and reached consensus on all 15. The statements regarding the GERD disease showed high levels of agreement, with consensus ranging from 70% to 92%. The statements regarding the GERD treatment also showed very high levels of agreement, with consensus ranging from 90% to 100%. This Delphi process was able to reach consensus among physicians in relevant aspects of GERD management, such as the adoption of a new approach to treat patients with GERD based on the overlapping between PPIs and Nux vomica-Heel. The consensus was unanimous among the physicians with different specializations, underlying the uniqueness of the agreement reached to identify in the overlapping approach between PPIs and Nux vomica-Heel a new intervention model for GERD management. The results support that an effective approach to deprescribe PPIs through a progressive decalage timetable (reducing PPIs administration to as-needed use), should be considered. Nux vomica-Heel appears to be a valid opportunity for GERD treatment to favor the deprescription of PPIs and to maintain low disease activity together with the symptomatology remission.

Postoperative outcomes for sleeve gastrectomy patients with positive pH-defined GERD.

Gastroesophageal reflux disease (GERD) is a possible side effect of sleeve gastrectomy (SG). However, procedure selection for patients with GERD and risk factors for morbidity after bypass surgeries is complex. For patients with a preoperative GERD diagnosis, literature related to worsening postoperative symptoms is discordant. This study evaluated the effects of SG on patients with pre-operative GERD confirmed through pH testing. University Hospital, United States. This was a single-center case-series. SG patients with preoperative pH testing were compared based on DeMeester scoring. Preoperative demographics, endoscopy results, need for conversion surgery, and changes in gastrointestinal quality of life (GIQLI) scores were compared. Two-sample independent t-tests assuming unequal variances were used for statistical analysis. Twenty SG patients had preoperative pH testing. Nine patients were GERD positive; median DeMeester score 26.7 (22.1-31.15). Eleven patients were GERD negative, with a median DeMeester score of 9.0 (4.5-13.1). The two groups had similar median BMI, preoperative endoscopic findings and use of GERD medications. Concurrent hiatal hernia repair was performed in 22% of GERD positive vs. 36% of GERD negative patients, (p = 0.512). Two patients in the GERD positive cohort required conversion to gastric bypass (22%), while none in the GERD negative cohort did. No significant postoperative differences were noted in GIQLI, heartburn, or regurgitation symptoms. Objective pH testing may allow the differentiation of patients who would be higher risk for need for conversion to gastric bypass. For patients with mild symptoms, but negative pH testing, SG may represent a durable option.

Assessing the diagnostic significance of pH studies in symptomatic patients within the Saudi community: a cohort investigation

Background: pH is a crucial physiological factor in diagnosing groups of diseases related to the gastrointestinal tract. This study delves into the critical role of pH measurement in diagnosing gastrointestinal diseases among symptomatic patients in the Saudi community. The research aims to classify patients based on pH levels, ultimately examining the impact of these findings on patient management and outcomes. Methods: A cohort observational study was conducted; a simple random sample technique was approached. The study population included 130 participants aged between 18 and 70 years. Data were collected from June to July 2021 from a specialized gastroenterology medical Center in Riyadh, receiving patients from different regions of Saudi Arabia (Human Clinic). Results: The study involved 130 participants and examined sociodemographics, clinical characteristics, and the association of symptoms and chronic diseases with pH DeMeester scores in gastroesophageal reflux disease (GERD) diagnosis. The study includes 43.8% female and 56.2% male; 76.9% had chronic diseases; 63.8% reported having GERD; 36.9% had irritable bowel syndrome (IBS); 13.1% were smokers; 84.6% were nonsmokers; 68.5% used GERD medications; 92.3% reported dyspepsia; and 37.7% had high pH scores, 41.5% had normal scores, and 20.8% had severe scores. Most associations between variables and pH scores were not statistically significant, indicating a complex relationship. Conclusion: The study showed a diverse participant profile with a high prevalence of chronic diseases, GERD, and IBS. Although the majority reported dyspepsia and used GERD medications, the associations between symptoms, chronic diseases, and pH DeMeester scores were not statistically significant, highlighting the complex nature of these relationships. Further research is needed to explore additional factors influencing pH scores and improve diagnostic accuracy.

The Effect of Laparoscopic Sleeve Gastrectomy on Symptoms of Gastroesophageal Reflux Disease.

Background Laparoscopic sleeve gastrectomy (LSG) is a common bariatric procedure for weight loss. LSG is becoming prevalent worldwide because it is a relatively simple procedure with high efficacy. Reduced intraabdominal pressure may improve gastroesophageal reflux disease (GERD) symptoms and reduce the GERD medication needed following LSG. However, the main long-term drawback of LSG is the development of de novo GERD. Therefore, we conducted this study to determine the relationship between GERD symptoms and LSG. Methods We conducted a retrospective chart review involving 390 patients who underwent LSG. Study participants were evaluated for GERD symptoms six months before and three, six, and nine months after the procedure, and proton-pump inhibitors (PPIs) were used to control the symptoms. Participants were distributed into two groups: one group for patients with GERD symptoms (36.1%) and one group for asymptomatic patients (62.8%). We collected demographic data and assessed PPI use in both groups after three, six, and nine months postoperatively. Data were collected using Microsoft Excel (Microsoft Corporation, Redmond, WA) and analyzed using IBM SPSS Statistics for Windows, Version 20.0(Armonk, NY: IBM Corp.). We compared data using the student's t-test for independent groups. The quantitative data were summarized using mean and standard deviation (SD), and p < 0.05 was considered statistically significant. Results Of the 390 participants who underwent LSG, 83.8% were women (n=327)and 16.2% were men (n=63), with a median age of 42 ± 11.9 years. PPI use was statistically significantly greater after LSG (34.1%) than before LSG (24.6%, p=0.019). The difference in PPI use between symptomatic and asymptomatic groups was not statistically significant three months after LSG. Conclusions Our study focuses on using PPI after LSG due to GERD symptoms. We found GERD symptoms improved three months following LSG, but de novo GERD symptoms occurred nine months after the surgery. Health providers need to discuss with their patients the potential outcomes of the surgery and manage patient expectations. Physicians should work with their patients to assess whether the benefits of bariatric surgery in controlling overweight-associated conditions, such as blood pressure, diabetes,sleep apnea, and weight loss, outweigh the risk of GERD symptoms and PPI use.

Evidence-based treatment recommendations for gastroesophageal reflux disease during pregnancy: A review.

Gastroesophageal reflux disease (GERD) occurs in approximately two-thirds of all pregnancies. Around 25% of pregnant women experience heartburn daily. Symptomatic GERD usually presents in the first trimester and progresses throughout pregnancy. The treatment goal is to alleviate heartburn and regurgitation without jeopardizing the pregnancy or its outcome. An English language electronic literature search of MEDLINE, EMBASE, and Cochrane Reviews was undertaken to identify randomized controlled trials, observational studies, management recommendations and reviews of GERD and its treatment during pregnancy. The search period was defined by the date of inception of each database. The treatment in a pregnant GERD patient should follow the step-up approach, starting with lifestyle modification as the first step. If heartburn is severe, medication should be started after consultation with a physician (Recommendation Grade C). The preferred choice of antacids is calcium-containing antacids (Recommendation Grade A). If symptoms persist with antacids Sucralfate can be introduced at a 1g oral tablet, 3 times daily (Recommendation Grade C). Followed by histamine-2 receptor antagonist (Recommendation Grade B). Inadequate control while on histamine-2 receptor antagonist and antacid may mandate a step-up to proton pump inhibitors along with antacids as rescue medication for breakthrough GERD (Recommendation Grade C). This article presented the treatment recommendations for pregnant women with typical GERD, based on the best available evidence.

Low Prevalence of Endoscopic Screening for Barrett's Esophagus in a Screening-Eligible Primary Care Population.

Despite societal recommendations supporting Barrett's esophagus (BE) screening, it is unknown what proportion of eligible patients is screened in primary care. We assessed the proportion of BE screening- eligible patients evaluated in the primary care setting receiving upper esophagogastroduodenoscopy (EGD) and identified factors associated with undergoing EGD. This was a retrospective study of BE screening-eligible patients, as defined by the American College of Gastroenterology's BE guidelines, in a multipractice healthcare network consisting of 64 internal medicine practices and 94 family medicine (FM) practices. The proportion undergoing EGD, prevalence of BE and esophageal adenocarcinoma (EAC) in this group, and patient and provider factors associated with undergoing EGD were assessed. Multivariable logistic regression was performed to identify independent predictors of undergoing EGD. Of 1,127 screening-eligible patients, the mean age was 65.2 ± 8.6 years; 45% were obese; and 61% were smokers. Seventy-three percent were seeing FM; 94% were on proton pump inhibitors; and 44% took ≥1 gastroesophageal reflux disease (GERD) medication. Only 39% of patients (n = 436) had undergone EGD. The overall prevalence of BE or EAC was 9.9%. Of 39 (9%) referred for BE screening as the primary indication, BE/EAC prevalence was 35.1%. Factors associated with increased odds of having EGD were symptomatic GERD despite treatment (odds ratio [OR] 12.1, 95% confidence interval [CI] 9.1-16.3), being on ≥1 GERD medication (OR 1.4, 95% CI 1.0-1.9), and being an FM patient (OR 1.5, 95% CI 1.1-2.1). In this large, primary care population, only 39% of screening-eligible patients underwent EGD. Most of the examinations were triggered by refractory symptoms rather than screening referrals, highlighting a need for improved dissemination and implementation of BE screening.

Patient- and physician-reported satisfaction with gastroesophageal reflux disease (GERD) treatment in Chinese clinical practice.

The aim of this study was to assess the level of satisfaction with currently prescribed medications for gastroesophageal reflux disease (GERD) in patients and physicians in China. Physicians across China were invited to complete physician surveys concerning factors affecting the prescription of medication for GERD and their satisfaction through an online questionnaire. The enrolled physicians invited the first five GERD patients who visited them on the same day to complete online patient surveys concerning the satisfaction with medications for GERD and its influencing factors. In total, 334 physician surveys (response rate 36.82%) and 1409 patient surveys (86.07%) were analyzed. Over half (62.57%) the physicians recommended taking a proton pump inhibitor (PPI) twice daily and the majority (88.02%) recommended taking a PPI for 1 week to 3months. Factors affecting the prescription were how much it could improve quality of life (84.73%), followed by safety, medication compliance, and efficacy. Approximately 30% of patients reported taking a PPI twice daily and 47.20% reported taking a PPI for 1week to 3months. Factor affecting patients' adherence to medications was safety (64.30%), followed by medical insurance, efficacy and convenience. Approximately one-third of physicians and patients did not report "satisfied" or "very satisfied" with medications for GERD, including 10.51% of patients and 12.87% of physicians reporting "dissatisfied" or "very dissatisfied." One-third of GERD patients and physicians were not satisfied or very satisfied with medications for GERD. Novel medications may help optimize the management of GERD.

Medical Management of Obesity as it Affects Reflux

Gastroesophageal reflux disease (GERD) is common among the American population and increasing in prevalence, with obesity being implicated as one of the strongest risk factors for its development. Little is known about the effects of currently prescribed anti-obesity medications on GERD symptoms. This review aims to explore the current literature on FDA-approved and off-label anti-obesity pharmacotherapy with respect to their influence on GERD and interactions with commonly prescribed GERD medications.

PGI20 Diagnosis and Treatment Patterns of Gastroesophageal Reflux Disease in China: A Retrospective Real-World Study

This study sought to assess real-world diagnostic practices, treatment patterns, treatment effectiveness, and cost of gastroesophageal reflux disease (GERD) in China, which are currently limited. Retrospective data of patients with a GERD diagnosis were pooled from Electronic Medical Records across 11 hospitals (10 provinces) in China (January 2015 to December 2017). Primary outcomes included GERD patient characteristics, trends in hospital department visits, symptom types, and treatment patterns. Secondary outcomes included the proportion and grade of erosive esophagitis (EE), mucosal healing rate, healthcare resource utilization and associated costs. Descriptive analyses and Wilcoxon rank-sum test are performed. 71,904 patients (48.1% male; mean (SD) age, 49.28 years) with a GERD diagnosis were identified, of which 65.6% were diagnosed and treated in a gastrointestinal department. GERD subtypes identified were non-erosive reflux disease (NERD;82.8%), EE (15.5%), and Barrett’s esophagitis (1.7%). Los Angeles A-B comprised the majority of EE (93.8%, n=1396/1488). Typical, atypical, and extraesophageal symptoms occurred in 62.7%, 48.3% and 12.1% of GERD patients, respectively. Approximately, 16.4% of GERD patients underwent endoscopic examination. Proton pump inhibitors (PPIs) were the most prescribed medication for GERD (95.6%), followed by gastroprokinetic agents (57.3%). Furthermore, 75.8% of PPIs were prescribed in combination regimens (74.1% with gastroprokinetic agents, 6.5% with mucosal protectants and 2.9% with H2 antagonists). The EE mucosal healing rate after standard treatment regimens was 50% in EE patients who has two endoscopic results within 12 weeks. Overall, median cost per outpatient visit was significantly higher for gastrointestinal vs. non-gastrointestinal departments (¥424.6 vs. ¥387.82; p<0.01). NERD was the most common subtype in GERD patients in China. Low endoscopy (to diagnose GERD) and mucosal healing rates in EE were observed. PPI combination treatment was the most prescribed regimen, suggesting inadequate symptom control with PPI monotherapy.

Estimate of Refractory Reflux Disease in the United States: Economic Burden and Associated Clinical Characteristics.

To update the estimate of the prevalence of refractory gastroesophageal reflux disease (GERD) in the United States, and to assess the clinical and economic differences between patients with and without refractory GERD. GERD affects 18% to 28% of the US population, with nearly 40% of GERD patients presenting with refractory symptoms despite ongoing therapy. Retrospective analysis of the IBM MarketScan databases between January 2011 and June 2018. Inclusion criteria were prescription fill and subsequent refill of a proton pump inhibitor or H2-receptor antagonist (earliest claim=index date), diagnosis of GERD 60 days preceding and/or following index, continuous insurance enrolment for 12 months preceding/following index, and absence of prior GERD diagnosis or GERD medication. We derived refractory GERD symptom scores for all patients on the basis of a previously published algorithm. Health care costs and comorbidities were assessed for all patients and compared between those with and without refractory GERD. In total, 399,017 GERD patients qualified for the study; 103,654 (26%) met our definition of having indications of refractory GERD symptoms. Patients with refractory GERD symptoms reported significantly higher rates of hiatal hernia (25.1% vs. 5.9%), esophagitis (37.3% vs. 11.8%), esophageal stricture (11.3% vs. 1.5%), and dysphagia (26.8% vs. 7.1%; P<0.01 for each). The refractory GERD symptoms cohort incurred ~$10,000 greater health care costs per patient per year compared with patients without refractory GERD symptoms ($26,057±$58,948 vs. $15,285±$39,307; P<0.01). Refractory GERD symptoms were associated with a substantial increase in health care costs. Treatments aimed at improving refractory GERD symptoms may mitigate symptom burden, potentially reducing health care expenditure.

Decreasing Inappropriate Use of Antireflux Medications by Standardizing Gastroesophageal Reflux Disease Management in NICU.

A multidisciplinary team developed evidence-based clinical practice guidelines (CPG) for GERD management. Process improvement included developing a GERD management algorithm, electronic order sets, and education for all providers. Multiple plan-do-study-act cycles done. Implementation of standardized GERD management guideline, decreased the overall use of antireflux medications from baseline, 15.1%-6.8% [χ2 (1, N = 1259) = 12.98, P < 0.001]. There was elimination of GERD medication use in preterm from baseline of 19.3% [χ2 (1, N = 220) = 12.18, P < 0.001]. The most frequently used GERD medication was lansoprazole, with an incorrect initial dosing rate of 55.0% that deceased to zero [χ2 (1, N = 33) = 10.73, P = 0.001]. Appropriate testing with PH probe with 24-hour multichannel impedance was observed (17.1%-28.0%) identifying patients with correct GERD diagnosis [χ2 (1, N = 101) = 1.41, P = 0.236]. Length of stay for GERD patient's improved from a median of 89-53 days. Standardizing clinical management leads to best practices for GERD management with appropriate diagnostic testing, eliminating incorrect medication dosing, and improved patient safety with value-based outcomes.

Antiemetic Prescription Fills in Pregnancy: A Drug Utilization Study Among 762,437 Pregnancies in Norway.

ObjectiveTo determine antiemetic prescription fill patterns during pregnancy in Norway, with special focus on the use of ondansetron and recurrent use in subsequent pregnancies.MethodsWe conducted a population-based registry study based on data from the Medical Birth Registry of Norway linked to the Norwegian Prescription Database for 762,437 pregnancies >12 gestational weeks ending in live or non-live births between 2005 and 2017. Prescription fills of medications used for nausea and vomiting of pregnancy were summarized in treatment pathways to determine drug utilization patterns. Logistic regression analyses were used to estimate associations between maternal and pregnancy characteristics and antiemetic prescription fills.ResultsThe prescription fill rate for antiemetic medication during pregnancy was 7.6%. However, prescription fill rates were 35.5% in the second pregnancy after filling an antiemetic prescription in the first pregnancy and 53.5% for women who filled antiemetic prescriptions in the previous 2 pregnancies. Among pregnancies with antiemetic prescription fills, 62.2% were dispensed metoclopramide, 28.2% meclizine, and 17.2% promethazine. First-line treatment started with monotherapy in 97.4% of these pregnancies, which was the only treatment received in 78.7%. Prescriptions for ondansetron were filled in 0.3% of pregnancies, with 76.9% being initially filled in the first trimester. Ondansetron as first-line prescription medication and/or use in the first trimester was associated with proxies for more severe nausea and vomiting of pregnancy, including a diagnosis of hyperemesis gravidarum, multiple gestations, a higher obstetric comorbidity index, and concomitant use of medication for gastroesophageal reflux disease and nervous system medications. Women who filled an antiemetic prescription in their first pregnancy were less likely to have subsequent pregnancies than women who did not fill an antiemetic prescription in their first pregnancy (OR 0.93, 95% CI 0.90–0.96).ConclusionComplex patterns of antiemetic prescription fills in pregnancy may mirror the challenge of optimal management of nausea and vomiting of pregnancy in clinical practice, especially for women with severe symptoms.

The interrelationship between xerogenic medication use, subjective oral dryness and tooth wear

ObjectiveTo investigate the association between xerogenic medication use and tooth wear among American adults and whether this association can be explained by subjective oral dryness. MethodsWe used data from 3578 adults who participated in the National Health and Nutritional Examination Survey (NHANES). Tooth wear was clinically determined using the modified Tooth Wear Index. Information on xerogenic medication use, subjective oral dryness (amount of saliva in mouth and feeling the mouth dry when eating) and potential confounders (sociodemographic factors, dental insurance coverage, gastroesophageal reflux disease medication use and soft drinks intake) were self-reported. The associations among xerogenic medication use, subjective oral dryness and tooth wear were assessed in regression models adjusting for confounders. ResultsAdults taking xerogenic medication had greater odds of reporting too little amount of saliva and feeling the mouth dry when eating. In addition, participants taking one and multiple (two or more) xerogenic medications had, respectively, 1.53 (95 % CI: 1.01−2.32) and 1.44 (95 % CI: 0.62−3.33) greater odds of having tooth wear than those taking no xerogenic medications. In a regression model including all explanatory variables, the association of xerogenic medication use with tooth wear was fully attenuated whereas subjective oral dryness (amount of saliva in mouth but not feeling the mouth dry when eating) remained positively associated with prevalence of tooth wear. Similar findings were obtained with long-term use of xerogenic medication (in the past month and for three or more years). ConclusionCurrent (last month) use of xerogenic medication was associated with the presence of tooth wear. This association was accounted for by subjective indicators of oral dryness. Clinical significanceDentists should be familiar with the possible connection between patient’s medical prescription and tooth wear. Changing prescriptions to non-xerogenic alternatives, whenever possible, could improve patients’ oral condition. The findings also suggest that patients may recognise, through the perception of dry mouth, when medication is placing them at risk.

The Effect of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease.

The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD. To examine the effects of LSG on GERD symptoms. One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL). For the entire group, mean weight loss, %TWL, and reduction in BMI were 79 pounds, 28.1%, and 12.7kg/m2 respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL. These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.

Outcomes and Safety of Blenderized Tube Feedings in Pediatric Patients: A Single Center's Experience.

Recently, significant interest from families and healthcare providers has arisen to use blenderized tube feedings (BTF). Although many institutions are providing this nutritional option, literature documenting outcomes and safety is lacking. A retrospective chart review was performed on pediatric patients receiving BTF at Rutgers-Robert Wood Johnson University Hospital between January 2013 and April 2017. Demographic data and dietary information before and after BTF were collected. Reasons for diet initiation, symptoms, and anthropometrics were recorded. Adverse events and outcomes were assessed through physician documentation and relevant medication changes. Thirty-five patients (24 boys) received BTF. Age at initiation of BTF ranged from 1 to 19 years (mean 8.3 +/- 5.8 [SD] years). Length of follow-up ranged from 1 to 45 months (mean 15 +/- 12.2 months). The most common reason for starting BTF was gastroesophageal reflux disease (GERD) (N = 32). Almost all patients were on medications for GERD, constipation, or gastrointestinal dysmotility before starting BTF (N = 33). Majority of patients had improvement in relevant symptoms (N = 20); 13 of 33 patients on gastrointestinal medications were able to wean or stop medication(s). BMI z scores did not differ before and after BTF initiation (P = 0.558). No serious life-threatening adverse events were found. Our data suggest that BTF is a safe dietary intervention that may improve gastrointestinal symptoms in pediatric patients. Further prospective studies are needed to compare safety and efficacy of BTF and commercial formulas in pediatric patients.

Gastroesophageal Reflux Disease Medication Cost Saving after Bariatric Surgery

Welsh, Leonard K. MD; Davalos, Gerardo MD; Jara, Ramon Diaz MD; Cordova, Andres Narvaez MD; Portenier, Dana MD, FACS; Guerron, Daniel A. MD Author Information

Prenatal use of medications for gastroesophageal reflux disease and early childhood fracture risk.

Gastroesophageal reflux disease is a common condition in pregnancy and is often managed with medications. Specific medications have been linked to osteoporosis and fragility fracture in older adults. This study assessed whether maternal use of antireflux medications is associated with early childhood fracture. TRICARE beneficiaries during pregnancy were retrospectively identified using the Military Health System Data Repository and pharmacy data. Mother and infant data were linked; children with continuous enrollment for the first 5years of life were included. Differences in the children's fracture risk were analyzed through multivariate analysis, adjusting for region, rank, and military branch of service. A total of 378150 patients comprised the final cohort with 3.3% (n=12479) prescribed antireflux medications during pregnancy. A significant decrease in fracture rate was found among children of women who were prescribed antireflux medications during pregnancy compared with those who were not (0.8% vs 1.2%, RR=0.70, 95% CI 0.58-0.85). There was no difference in fracture risk between histamine type 2 receptor antagonists and proton pump inhibitors. A significantly increased fracture incidence was seen in pregnancies with multiple gestations (RR=1.38, 95% CI 1.04-1.85). There was no identified difference in fracture risk for women with gestational diabetes, preeclampsia, preterm or low birthweight, chronic hypertension, induction, or breech presentation when compared to women without these conditions. We found no increase in early childhood fracture risk with maternal antireflux medication use. This suggests that prenatal exposure to antireflux medications does not affect fetal bones to a clinically significant extent.

Erythromycin and Reflux Events in Premature Neonates: A Randomized Clinical Trial.

Gastroesophageal reflux disease (GERD) in premature neonates may manifest as apnea, bradycardia, growth failure, aspiration, or feeding intolerance. Erythromycin ethylsuccinate (EES), is often used as a pro-kinetic in the management of GERD, despite lack of evidence or safety from randomized controlled trials. We sought to study the efficacy of enteral EES at a dose of 50 mg · kg · day in decreasing the frequency of gastroesophageal reflux events as determined by pH-multichannel intraluminal impedance (pH-MII) monitoring. In a randomized, double-blind, placebo-controlled trial, eligible premature neonates with clinical signs of GERD underwent 24-hour pH-MII monitoring. If >5 reflux events were identified on pH-MII, then subjects were randomized to receive either EES or placebo. Repeat 24-hour pH-MII was performed on day 7 of study treatment and compared to initial pH-MII. Forty-three premature neonates were enrolled. Of those, 31 neonates were randomized, 15 to EES and 16 to placebo with a median (IQR) pretreatment total reflux events per 24 hours of 23 (16-40) and 29 (12-40), respectively. Day 7 total events per 24 hours decreased by 4 events in the EES group to 19 (15-33) and by 10 events in the placebo group to 19 (11-26) (P = 0.09). There were no differences in pretreatment and day 7 acidic and nonacidic reflux, proximal reflux, total or percent reflux time, median or longest bolus clearance time, or nurse-reported apnea events between groups. Enteral EES did not decrease reflux events on 24-hour pH-MII at the dose studied. Therefore, it may be ineffective in the treatment of GERD in premature neonates.

Asthma medication usage is significantly reduced following bariatric surgery.

Asthma is an important healthcare problem affecting millions in the United States. Additionally, a large proportion of patients with asthma suffer from obesity. These patients exhibit poor asthma control and reduced therapy response, increasing utilization of healthcare resources. Pulmonary symptoms improve after bariatric surgery (BS), and we hypothesized that asthma medication usage would decrease following BS. A retrospective data analysis was performed in adult patients from a single institution's database. Patients with obesity using at least one asthma medication pre-operatively who underwent BS were studied for up to 3-years post-operation. Poisson generalized linear mixed models for repeated measures were used to evaluate the effects of time and procedure type on the number of asthma medication. Bariatric patients with at least one prescribed asthma medication (mean 1.4 ± 0.6) were included (n = 751). The mean age at time of operation was 46.8 ± 11.6years, mean weight was 295.9 ± 57lbs, and mean body mass index (BMI) was 49 ± 8.2kg/m2; 87.7% were female, 33.4% had diabetes, 44.2% used gastroesophageal reflux disease (GERD) medication, and 64.4% used hypertension medication. The most common procedure was Roux-en-Y gastric bypass (79%), followed by sleeve gastrectomy (10.7%), adjustable gastric banding (8.1%), and duodenal switch (2.3%). The mean number of prescribed asthma medications among all procedures decreased by 27% at 30days post-operation (p < 0.0001), 37% at 6months (p < 0.0001), 44% at 1year (p < 0.0001), and 46% at 3years (p < 0.0001) after adjusting for risk factors. No significant differences in medication use over time between procedure types were observed. In the adjusted analysis, the mean number of asthma medications was 12% higher in patients using at least one GERD medication (p = 0.015) and 8% higher with 10-unit increase in pre-operative BMI (p = 0.006). BS significantly decreases asthma medication use starting 30days post-operation with a sustained reduction for up to 3years.

Proton pump inhibitor non-responsive gastroesophageal reflux disease: unraveling an enigma?

Gastroesophageal reflux disease (GERD) affects 10–20% of adults in Western countries (1,2) and 13% of Americans use medications for GERD at least twice weekly (3). In the USA alone, it is estimated that the annual direct and indirect costs incurred due to GERD is approximately $10 billion (4).